Osteosynthese dislozierter intraartikulärer Kalkaneusfrakturen

Objective

Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints.

Indications

Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment.

Contraindications

High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse).

Surgical technique

Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types.

Postoperative management

The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6–12 weeks depending on fracture severity and bone quality.

Results

Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4?%) of postoperative hematoma, 2 (1.7?%) superficial and 5 (4.3?%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8?%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Gelenkerhaltende Korrekturen bei Fehlheilungen im Chopart-Gelenk

Background

Injuries to the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted and therefore, not adequately treated at initial presentation. Malunion results in a loss of essential joint function and a three-dimensional malalignment leading to considerable impairment of global foot function and a rapid development of painful posttraumatic arthritis.

Methods

If no symptomatic arthritis is present, joint displacement or non-union may be subject to secondary anatomical reconstruction and internal fixation. Bone grafting becomes necessary in cases of non-union or partial avascular necrosis (AVN) of the navicular bone. In most cases joint destruction will have lead to manifest posttraumatic arthritis requiring fusion of the affected joint. Arthrodesis is always combined with axial realignment. Rebalancing of the medial and lateral foot columns is of utmost importance.

Results

We have treated 16 patients with joint-preserving correction of the Chopart joint: 6 of the navicular bone, 3 of the talar head, 3 of the anterior calcaneal process, 2 of the cuboid and 2 with combined malunions. Two female patients aged 50 and 67 years developed AVN of the navicular bone and required talonavicular fusion and one patient with a nonunion of the anterior calcaneal process needed a second revision surgery to achieve union. The average American Orthopaedic Foot and Ankle Society (AOFAS) score of 12 patients increased from 37 preoperatively to 77 at follow-up after an average of 2 years.

Conclusion

Joint-preserving corrections are generally possible for all four bony components of the Chopart joint in carefully selected cases of malunited fractures and fracture dislocations.     

Osteosynthese zentraler Talusfrakturen

Objective

Anatomic reduction of talar neck and body fractures with axial realignment and restoration of the articular surfaces of the talus.

Indications

Displaced talar neck and body fractures.

Contraindications

High perioperative risk, soft tissue infection, neurogenic osteoarthropathy.

Surgical technique

Reduction of the axial alignment of the talus and its joints via bilateral approaches according to the preoperative CT-based planning. A medial malleolar osteotomy may be necessary to approach the talar dome. The blood supply via the deltoid ligament and the sinus tarsi has to be respected. Manipulation of the main fragments with K-wires introduced temporarily; a mini-distractor is helpful in restoring the length. Internal fixation is tailored to the individual fracture pattern, including conventional and headless screws, bioresorbable pins, lost K-wires, and/or minifragment plates. Joint transfixation for 6 weeks to ensure ligamentous healing if instability persists after internal fixation. With severe soft tissue damage, temporary tibiometatarsal external fixation is applied until soft tissue consolidation.

Postoperative management

Range of motion exercises of the ankle and subtalar joints starting postoperative day 2 except for cases with joint transfixation. Partial weight bearing of 20 kg for 10–12 weeks. Use of a cast or walker for 6 weeks followed by intensive active and passive range of motion exercises of the ankle and subtalar joints.

Results

Over 8 years 79 fractures of the talar neck and body were treated. In all, 43 patients with 45 talar neck (n?=?30) and body (n?=?15) fractures were re-examined clinically and radiologically (mean follow-up 3 years). Definite treatment consisted of open reduction and screw fixation of the talus in 41 cases and small plate fixation in 2 cases supplemented by temporary external fixation for 1–3 weeks in 12 cases. At follow-up, the Maryland Foot Score averaged 86.1 and the AOFAS Ankle/Hindfoot Score averaged 78.9. The Hawkins classification was of prognostic value in talar neck fractures. The functional results and the rate of avascular necrosis (AVN) were unaffected by the time to definite internal fixation. AVN was observed in 11 cases (24?%); with only partial AVN involving less than one third of the talar body in 8 of these patients. Due to complete AVN with collapse of the talar dome, 3 patients (6.7?%) required fusion. Signs of posttraumatic arthritis of the tibiotalar or subtalar joint were seen in 21 cases (47?%). The rate of symptomatic posttraumatic arthritis correlated with the occurrence of total AVN, but not with partial AVN.     

Gelenkerhaltende Korrektur fehlverheilter Kalkaneusfrakturen

Background

Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis.

Methods

Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint.

Results

While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects.

Conclusion

In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.     

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain

Purpose

Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment.

Methods

Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded.

Results

During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4–24) and 24 (range 16.8–24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups.

Conclusion

In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.     

Treatment for calcaneal malunion

Background

Pain, limping, and deformity are the most common complications following calcaneal malunion which results from non-operative treatment for calcaneal fractures.

Objective

To introduce the experience of treating calcaneal fracture malunion.

Method

Between December 2009 and April 2011, eleven patients with calcaneal malunion were treated operatively. Age of patients ranged between 23 and 40 years with an average 28.7. All of them were followed up with a mean 13.5 (9–18 months). Eight of them were right-sided and the other three were left-sided. All of them were male. The mechanism of trauma was fall from a height in all patients. All of them were treated non-operatively since the prime trauma. According to Stephens and Sanders classification, all of cases were type II. The extended lateral calcaneal “L” approach was used in all cases. Lateral wall exostectomy and peroneal tendons are decompressed below the tip of the lateral malleolus and in situ subtalar bone block arthrodesis was done.

Result

The mean of American Orthopedic Foot and Ankle Society and pain score systems score was improved from 33 (19–44 points) preoperatively to 69 (42–83 points) postoperatively. The reported complications were superficial wound infection in two cases (18.18 %) and reflex sympathetic dystrophy in three cases (27.27 %).

Conclusion

Calcaneal lateral wall exostectomy, peroneal tenolysis and subtalar joint arthrodesis is an efficient method to treat calcaneal malunion type II after calcaneal fracture by reshaping the calcaneal contour and recovering the hind foot function.

Level of evidence

IV.     

Fracture of the talar neck associated with a compression fracture of the calcaneocuboid joint in a 5-year-old child: a case report

Objective

The objectives of this present case study are to report a rare combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in a 5-year-old child and to describe its radiological features, surgical treatment and clinical outcome.

Case summary

A 5-year-old male boy was injured in a car accident in which his left foot underwent one of the tires. On arrival at the hospital, a displaced talar neck fracture associated both with a cuboid fracture and compression of the articular surface of the cuboid at the calcaneocuboid join was identified. Fractures were fixed surgically. Leg was protected with a below-knee plaster split immobilization and non-weight-bearing for 5 weeks. After that period, the patient initiated a rehabilitation protocol with active and passive motion exercises.

Discussion

Fractures and fracture dislocations at the mid-tarsal joint have an important impact on the global foot function because malunion can result in post-traumatic arthritis and three-dimensional deformities of the foot. If a cuboid compression fracture is not reduced properly, it can result in the shortening of the lateral column with the development of an abduction, pronation and flat foot deformity. A talar neck fracture, if unreduced, can result in medial column displacement and rotational dislocation of the talar head, leading to a subluxation in the talonavicular joint with severe restriction of foot function. With early surgical treatment and open reduction and internal fixation, our patient recovered from the accident without having symptoms of pain, avascular necrosis, postoperative foot deformities or neurovascular deficits.

Conclusions

The combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in children usually requires correct diagnoses and early treatment with anatomic reduction and internal fixation to prevent severe post-traumatic deformities.

Level of evidence

V.     

Treatment of traumatic subtalar arthritis with interpositional arthroplasty with tensor fascia lata or fat

Objective

The aim of this study was to evaluate the results of interpositional arthroplasty with tensor fascia lata or fat as a treatment for traumatic subtalar joint arthritis after a fracture of the calcaneus.

Methods

From August 2006 to March 2008, 22 patients with traumatic subtalar joint arthritis were enrolled in this study. Tensor fascia lata was implanted for 7 patients who previously underwent surgery with the extensive lateral approach. Fat was implanted for 15 patients who were previously managed with conservative or percutaneous fixation. All the patients were followed up for more than 1 year, and the results were evaluated retrospectively.

Results

The Ankle-Hindfoot score by the American Orthopedic Foot & Ankle Society changed from 60.95 to 80.23 (p < 0.05). Visual Analogue Scale pain score decreased from 6.6 to 3.8 (p < 0.05). The results of the circle draw test were excellent in 8 patients, good in 11, and fair in 3 patients without any poor outcomes. The subjective satisfaction of the patients was excellent in 16 patients, good in 4 patients, and poor in 2 patients. In 2 patients with poor satisfaction, symptoms and mobility showed no improvement postoperatively.

Conclusions

Interpositional arthroplasty with tensor fascia lata or fat as a treatment modality of traumatic subtalar joint arthritis could provide good clinical outcome and preservation of range of motion.     

The use of circular fine wire frames for the treatment of displaced intra-articular calcaneal fractures

Background

The treatment of displaced intra-articular calcaneal fractures is still controversial.

Materials and methods

Sixteen consecutive patients admitted at University Hospital with intra-articular fractures were treated with fine wire circular frames and followed up at an average of 160 days from their injuries. We focused on radiological outcome and functional outcome using a patient-based questionnaire.

Results

We had no secondary reconstruction procedures. With the numbers available, the difference between the preoperative values and the follow-up measurements for Böhler’s angle, Gissane’s angle and posterior subtalar joint space was not statistically significant (P = 0.8, P = 0.2, and P = 0.4, respectively). The standardized AAOS FAS ranged from 42 to 96, with a mean of 80 and a standard deviation of 19.

Conclusions

Fine wire circular frame is a good alternative to ORIF in displaced intra-articular calcaneal fractures, yielding good patient function, a high return-to-work rate and a low complication rate.     

évaluation des résultats du traitement fonctionnel et chirurgical des fractures thalamiques du calcanéus : à propos d’une série rétrospective de 304 cas

Introduction

The treatment of thalamic fractures of the calcaneus is often an institutional decision, with no systematic correlation to osteo-chondral lesions. The aim of this retrospective study was to evaluate the results of functional and surgical treatment and to clarify the therapeutic indications based on the thalamic comminution and the position of the thalamic fundamental fracture line.

Materials and methods

It was a retrospective study conducted between 1990 and 2008. The fracture should involve the subtalar joint with an extension possible at the calcaneocuboid joint. Iinitial CT scans were carried out systematically to analyze the chondral lesions and the dysmorphia of the calcaneus bone. Cases were not included if the Kitaoka score was affected by neurological lesion or musculoskeletal sequela.

Results

Two thousand six hundred (and) twenty-four patients or 304 fractures were included. The average time of the revision of results was 39 months. The population was male (78%) with 38% of work-related accident. The treatment was functional in 172 cases, and surgical in 132 cases (89 subtalar arthrodesis with bone reconstruction and 43 osteosynthesis). The parameter ??work-related accident?? degraded the duration of sick leave and the Kitaoka score regardless of the treatment carried out. Subtalar joint osteoarthritis was present in 90% of cases reviewed. The Kitaoka score was correlated with the reconstruction of the calcaneus bone. It was higher in the group of vertical fractures treated by internal fixation or arthrodesis reconstruction versus functional treatment.

Discussion

Review of the literature confirms the importance of the patient parameters (sex, age, secondary benefit) on the final functional outcome. Surgical treatment has a high rate of complications, which requires a selection of the surgical indications in order to improve the Kitaoka score. The high rate of early secondary osteoarthritis of the subtalar joint, noted in a series of literature, is an important argument to advise a subtalar arthrodesis with calcaneus bone reconstruction immediately if the subtalar joint reconstruction seems impossible.

Conclusions

Functional treatment is the best choice for calcaneus fractures, with a global congruency of the subtalar joint. Osteosynthesis seems appropriate for simple fractures with an internal fundamental fracture line associated with a verticalization of a lateral thalamus fragment. Arthrodesis should be reserved for comminuted fractures.     

A new fixation method for Hoffa fracture

Purpose

To investigate the clinical effect of a new fixation method for Hoffa fractures.

Methods

We treated eleven patients with Hoffa fracture using the new fixation method (fixation with one screw inserted from the femoral intercondylar notch and two screws inserted from the nonarticular lateral (or medial) surface of the fractured condylar fragment; the two sets of screws were crossed).

Results

After an average follow-up period of 24 months (range 5–28 months), all fractures had healed. The average healing time was 11.6 weeks (range 9–14 weeks). On the version of the Knee Society Score modified by Dr. John Insall in 1993, the average score was 174.6 points (range 125–199 points).

Conclusions

The new fixation method for Hoffa fracture is effective, and may provide a new way to treat Hoffa fractures.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.     

Arthrodese (mit/ohne Korrektur) des oberen und unteren Sprunggelenks

Objective

Restoration of a stable and plantigrade foot in deformities of the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joints.

Indications

Deformities at the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joint. Failed (corrective) arthrodesis of the ankle and subtalar joints. Fused ankle and degeneration of the subtalar joint. Failed total ankle replacement with insufficient substance of talar body and/or degeneration of subtalar joint. Massive hindfoot instability.

Contraindications

Active local infection or relevant vascular insufficiency, possible preservation of the ankle or subtalar joint (relative contraindication).

Surgical technique

Prone position and posterolateral approach to ankle and subtalar joints (alternative supine position/anterior approach; lateral position/lateral approach). Exposition of ankle and subtalar joints and removal of remaining cartilage. Optional corrective osteotomies and/or bone grafting. Correction and optional fixation of the corrected position with 2.0 mm K-wires. Mechanically navigated insertion of a retrograde guide wire in projection of the tibial axis and insertion of a second guide wire through the entry point of the nail lateral and dorsal to the tibial axis. Reaming and insertion of the A3 nail with a distal double bend; one posterior and one lateral, and a proximal bend corresponding to a slight recurvatum. Insertion of locking screws into the calcaneus, talus and tibia (twice with optional static or dynamic locking). Optional compression between calcaneus and talus, and between tibia and talus. Insertion of a drainage and layer-wise closure.

Postoperative management

For the first 6 weeks 15 kg partial weight bearing in an orthosis, followed by full weight bearing in a stable standard shoe.

Results

In October 2010 (n?=?2) and from 15 October 2011 to 13 April 2012 (n?=?26) 28 arthrodeses (with/without correction) with A3 fixation were performed. In all cases, exact nail placement was achieved. Thirteen cases completed follow-up (3–11 months) and showed timely fusion and full mobilization.     

Outcome after proximal femoral fractures during primary total hip replacement by the direct anterior approach

Background

The literature suggests that intraoperative fractures of the greater trochanter and the metaphysis are increased with uncemented stems and the direct anterior approach. This study aims to determine the incidence and assess the functional and radiological outcome after such fractures.

Methods

484 consecutive total hip replacements (THR) (64 ± 12 years) were analyzed. We treated trochanteric fractures conservatively without any further denuding, and secured metaphyseal fissures with cerclages. Postoperative X-rays and at the latest follow-up were compared to assess secondary fracture displacement and stem subsidence. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after 1 year were analyzed. For each patient sustaining a fracture, two patients without fractures were matched in terms of age, body mass index and gender.

Results

13 (2.7 %, 5 male, 68 ± 9 years) patients with intraoperative fractures of the greater trochanter (n = 8) or the metaphysis (n = 5) were analyzed. Consolidation was observed in 7/8 patients sustaining a trochanteric fracture while secondary displacement of the fragment occurred in one case. Stem subsidence was observed in 2/5 cases (5 and 7 mm). Patients who sustained a fracture showed a trend towards poorer WOMAC scores at 1 year postoperatively, compared to patients without fractures. A significantly increased joint stiffness was also observed.

Conclusion

The intraoperative fracture risk in this series of THR through a direct anterior approach was 2.7 %. Trochanteric fractures do heal without primary fixation. Metaphyseal fractures heal well if immediately stabilized with a cerclage.     

Targon® Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

Purpose

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon® FN fixation concept is innovative; two small case series are promising. We present the first larger series.

Methods

We conducted prospective documentation of all Targon® FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

Results

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4 %. Conversion to joint replacement was necessary in 9.6 %. Complication rate was significantly higher in displaced fractures.

Conclusions

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.     

The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation

Background

The Humerusblock NG represents a new semi-rigid angular stable fixation device for minimally invasive stabilization of proximal humeral fractures. This study evaluates the function and stability of the Humerusblock NG and its biomechanical properties on the basis of two different fracture models under cyclic loading.

Methods

Six fresh frozen human humeri were tested in a dynamic shoulder joint abduction motion test bench, simulating abduction between 15° and 45°. A stable wedge fracture with intact medial hinge and an unstable fracture with 5-mm gap were loaded for 500 cycles. Radiological measurement of implant migration was performed.

Results

The stable fracture model showed a slow constant fracture settling. The unstable fracture model showed initial fracture settling with closure of the medial fracture gap during the first 20 cycles. Thereafter, a slow constant settling of the fracture was measured comparable to the stable fracture model. Maximum varus tilt was 3.17° for the stable and 3.68° for the unstable fracture pattern. Radiological analysis showed no change in the tip apex distance and a significant settling of the implants fixation pins in the unstable fracture model. None of the specimen failed during the testing.

Conclusion

The Humerusblock NG allows for angular stable dynamic fixation of two-part proximal humeral fractures. It enables closure of the fracture gap and maintains fracture compression during loading, a concept already established in the stabilization of femoral neck fractures (dynamic hip screw). Clinical trials will be necessary to evaluate the value of this device in daily practice.

Level of evidence

Basic science study.     

Periphere Talusfrakturen

Objective

Open reduction and internal fixation with screw(s) for fragments with sufficient size, and resection of smaller fragments.

Indications

Displaced fragments with (typical) involvement of joint surface.

Contraindications

Active infection and severe peripherial vascular disease.

Surgical technique

Positioning and approach are adapted to the fracture location. Fractures of the talar head and talar shoulders, supine position and anteromedial/-lateral approach. Fractures of the lateral talar process, lateral position on contralateral side and lateral approach. Fractures of the posterior talar process, prone position and posterolateral approach. Fractures of the medial, supine position and medial approach. Open reduction and internal screw fixation. Cartilage-surgical procedures for concomitant chondral defects.

Postoperative management

For the first 6 weeks, 15 kg partial weight bearing without orthosis in a standard shoe. Thrombosis prophylaxis following the local standard during the time of partial weight bearing.

Results

At a specialized orthopedic hospital with a supraregional frequented department for foot and ankle surgery, 8 patients with peripherial talar fractures were treated in 2012 (medial/posterior talar process, each n?=?1, lateral talar process, n?=?2, medial and lateral talar shoulder, each n?=?2). One fragment was fixed with 1–3 screws, and additional cartilage reconstruction with matrix-associated stem cell transplantation was performed in 4 cases (lateral talar process, n?=?2, medial and lateral talar shoulder, each n?=?1). Bony fusion was registered at the 6-week follow-up in all cases. Further follow-up is not completed. Complications have not been registered so far.     

Minimally invasive treatment for pubic ramus fractures combined with a sacroiliac joint complex injury

Purpose

Fractures of the pubic rami due to low energy trauma are common in the elderly, with an incidence of 26 per 100,000 people per year in those aged more than 60 years. The purpose of this study was to evaluate the clinical application of this minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury, including its feasibility, merits, and limitations.

Methods

Fifteen patients with pubic ramus fractures combined with sacroiliac joint injury were treated with the minimally invasive technique from June 2008 until April 2012. The quality of fracture reduction was evaluated according to the Matta standard.

Results

Fourteen cases were excellent (93.3 %), and one case was good (6.7 %). The fracture lines were healed 12 weeks after the surgery. The 15 patients had follow-up visits between four to 50 months (mean, 22.47 months). All patients returned to their pre-injury jobs and lifestyles. One patient suffered a deep vein thrombosis during the peri-operative period. A filter was placed in the patient before the surgery and was removed six weeks later. There was no thrombus found at the follow-up visits of this patient.

Conclusion

The minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury provided satisfactory efficacy.