Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

Purpose

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

Material and methods

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

Results

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

Conclusion

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.     

Winkelstabile Plattenosteosynthese am proximalen Humerus

Because of the high complication rate and the correspondingly poor outcome in some cases, the problem of how best to treat fractures of the proximal humerus remains unsolved. This clinical study was designed to compare results of internal fixation with a fixed-angle plate and those obtained by conventional methods of internal fixation, with the intention of finding when this new procedure is really indicated. The fixed-angle plating procedure has sometimes been too generously used, even in osteoporotic four-part fractures, in addition to which it involves some specific technical problems, so that the complication rate is comparable to those of established procedures. The clinical outcome measured with the ASES score suggests that the clinical results can be expected to improve when correct indications for the new method are insisted upon.     

Minimalinvasive Plattenosteosynthese am proximalen Humerus

Proximal humerus fractures are one of the most common fractures which mainly occur in older patients. Historically these fractures had been treated mainly conservatively, but today a more anatomic reduction is advocated particularly of the tubercles with early functional aftercare. Besides the commonly used open deltapectoral approach, a minimally invasive anterolateral deltoid-splitting approach can be used even for proximal diaphyseal fractures for percutaneous plate fixation.     

Navigierte Osteosynthese des proximalen Femurs

Screw position in femoral head has been considered the most important predictive factor for mechanical failure in pertrochanteric osteosynthesis, and correct positioning is assisted by fluoroscopic control. Although fluoroscopy leads to precise and reproducible results, it is associated with scattered radiation to the patient and surgical staff. Computer-assisted surgery (CAS) may be an alternative in means of achieving precise screw insertion with a low radiation dose. We designed a laboratory study in which artificial proximal femora were submitted to insertions of a dynamic hip screw (DHS) and an anti-rotational screw (ARS). Three set-ups were tested: (1) conventional implantation with two simultaneous C-arms using a guide wire; (2) drilling and implantation controlled by CAS solely with a 3.2-mm drill bit, then insertion of a guide wire and drilling for the dynamic hip screw; (3) after navigated drilling (3.2 mm) a fluoroscopic control was performed. Five variables were used comparing methods and surgeons: operation time, radiation time, tip-apex distance (TAD), and the insertion neck-shaft angles of DHS and ARS. Considering TAD as a precision parameter, CAS led to screw insertion as accurate as with fluoroscopic control, with a reduction of radiation time up to 93%.     

Frakturen des proximalen Humerus

Trauma und Berufskrankheit - Bei 4–5% aller Frakturen handelt es sich um proximale Humerusfrakturen, begünstigend wirkt v. a. die Osteoporose. Aus diesem Grund ist unter...     

Komplikationen der Nagelosteosynthese am proximalen Humerus

In a prospective outcome study, 76 of 116 patients were examined 1 year after reduction and internal fixation of a dislocated humeral head fracture with an antegrade straight intramedullary nailing system using angular and sliding stable interlocking screws. Of these patients, 77% had three- or four-segment fractures according to the Neer classification. The mean absolute Constant-Murley score 1 year after trauma was 70.0±19.7 points. During the observation period, 51 complications occurred in 44 of 76 patients; of these 44 patients, only 27 required therapeutic interventions. The highest frequency of complications was apparent in those with Neer IV fractures (73.7%), while those with Neer III and Neer IV/III fractures had complication rates of 50% and 52.5%, respectively. Patients without complications showed good or excellent functional results, ranging from 78% to 96% (relative Constant-Murley score of the contralateral noninjured side). In patients with complications, the relative Constant-Murley score ranged from 51% to 65%. Despite the high complication rate, the antegrade angular and sliding stable interlocking nail can be considered effective for treating dislocated humeral head fractures. Modifications of the surgical technique for stabilizing the tubercles (additional suture cerclage fixation of fragmented tubercles) and a polyetheretherketone (PEEK) insert in the proximal segment of the nail to prevent the fixation screws from backing out can substantially decrease some of the most frequent complications.     

Stabilitätsmessungen bei Osteosynthesen am proximalen Femur

Zusammenfassung In einer vergleichenden Untersuchung wurde die Biegebelastbarkeit stabiler und instabiler pertrochanterer und subtrochanterer Frakturmodelle nach Osteosynthesen am Knochenpräparat mit Y-Nägeln, Ender-Nägeln, 130°-Winkelplatten und 95°-Kondylenplatten der AO getestet. Bei den instabilen Bruchformen wurden auch Verbundosteosynthesen mit Knochenzement geprüft.Bei der stabilen Form der pertrochanteren Fraktur ist die Ender-Nagelung mit durchschnittlich 147 kp, die Winkeplatten-Osteosynthese mit ca. 200 kp belastbar.Bei fehlender medialer Abstützung gelingt eine hochbelastbare Osteosynthese mit den geprüften Methoden nur dann, wenn der Defekt am Adam'schen Bogen mit Knochenzement aufgefüllt wird.Die mit mehr als 300 kp belastbare Kondylenplatten-Verbundosteosynthese der instabilen per- und subtrochanteren Fraktur erwies sich bei einmaliger Belastung stabiler als die anderen getesteten Verfahren.Die Versuchsergebnisse sind synoptisch in Tabelle 4 zusammengefaßt.

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Measurements of stability of operative osteosynthesis on the proximal femur

Summary Bending burdening of stable and unstable per- and subtrochanteral fractures after osteosynthesis with Y-nails (Küntscher), Ender-nails, 130°and95° angled plates of the AO were tested in a comparative experimental study. The unstable fractures were also tested after treatment with osteosynthesis and additional application of bone cement in the artificial defect.The essential results were as follows: in the group of stable pertrochanteral fractures the Ender-nails bear in the mean 147 kp, the 130° angle plate 200 kp.In the fracture-group with lacking medial support a highly burdening osteosynthesis could only be achieved by filling up the defects with bone cement.The 95°-angled plate-osteosynthesis combined with bone cement bearing more than 300 kp was superior to the other procedures in the unstable per- and subtrochanteral fractures. In our investigation the stabilizing forces of muscles and fascia have not been taken into consideration.

     

Frakturen des proximalen Humerus

Fractures of the proximal humerus account for 4–5% of all fractures, with the chief predisposing factor being osteoporosis. This means that in view of the present demographic developments we have to expect increasing numbers of these injuries. In most cases good reesults are achieved with a conservative treatment involving immobilization and bandaging of the shoulder, but in about 30% of cases surgery is needed. The surgical operation is difficult because of the complex anatomy and vascularitation. The difficulty is compounded by the usually quite advanced age of the patients and their correspondingly poor bone quality. Achievement of the best possible postoperative result demands accurate classification of the fracture, detailed preoperative planning, adequate knowledge of the anatomy and vascularization of the upper arm region and of the surgical techniques available, and an individually tailored aftertreatment.     

Komplikationen nach Osteosynthese des proximalen Femurs

Background

Fractures of the proximal femur are among the most common fractures of all bones. Currently nearly every trauma surgeon has to be able to treat proximal femur fractures either with osteosynthesis or with a prosthesis. An increase of 200–300?% of fractures of the proximal femur is expected within the next 30 years. In addition an increase of periprosthetic fractures of the proximal and distal femur can be observed. The correct treatment of these complications is a challenging objective for the trauma surgeon.

Objectives

This article provides an overview on complications after osteosynthesis of the proximal femur. It contributes treatment options depending on the implant, the patient specific risk factors and the special problems of postoperative care.

Methods

A selective review of the literature using Pubmed under consideration of experiences gained in the treatment of complications after osteosynthesis of the proximal femur was performed.

Conclusions

Due to the increasing incidence of fractures of the proximal femur on the one hand and complications after operative treatment of these fractures on the other, the trauma surgeon must provide differentiated therapy concepts depending on the individual risk factors of different patients. Moreover, trauma surgeons must know how to treat the potential complications of these procedures.     

Maßnahmen bei fehlgeschlagenen Osteosynthesen am proximalen Femur

Trauma und Berufskrankheit - Fehlgeschlagene Osteosynthesen des proximalen Femurs lassen sich folgenden Problembereichen zuordnen: Implantatassoziierte Probleme beruhen meist auf...     

Komplikationsmanagement nach winkelstabiler Plattenosteosynthese am proximalen Humerus

PURPOSE: In this prospective study, complications observed after angularly stable proximal humerus plate fixation (locking proximal humerus plate) were analysed by deriving specific therapies.PATIENTS: Fifty patients (median age 65 years, range 25-84 years, 39 female, 11 male) with displaced proximal humerus fractures (seven single, 36 double, and seven triple fractures) were evaluated 3, 6, and 12 months after angularly stable plate fixation using a standard protocol.RESULTS: Age- and gender-matched median constant scores 12 months postoperatively showed for the three fracture types 86, 87, and 55 points and complication rates of 14, 19, and 100%, respectively. There were seven primary and seven secondary implant displacements, five humeral head necroses, four osseous malalignments, two nonunions, two deep infections, and one heterotopic ossification. Nine reoperations were required in six patients: implant removal (n=3), reosteosynthesis (n=2), revision because of nonunion (n=2), and deep infection (n=2).CONCLUSIONS: Differentiated analysis of complications and the development of specific prevention and therapeutic strategies considering surgical technique, implant, fracture morphology, and humeral head perfusion minimize the rate of complications observed after angularly stable locking proximal humerus plate fixation.     

Die Fraktur des proximalen Humerus

The incidence of proximal humerus fractures is rising and they constitute the third most frequent fracture in the elderly after femoral fractures in the hip area and radius fractures. They are caused by the age-related increase in osteoporosis. In contrast to young people, low-energy trauma involved in simple falls represents the mechanism that leads to the injury in older people. Numerous authors have introduced systems for the classification of proximal humerus fractures.After a thorough clinical examination of the affected extremity including assessment of circulation, motor function, and sensitivity, attention should be directed toward concomitant injuries, especially in the region of the shoulder girdle and thorax. Advocated imaging consists of anteroposterior and axial views of the affected shoulder. Disagreement over management of this fracture is quite considerable and treatment ranges from a conservative approach through to procedures for minimally invasive plate osteosynthesis, open fixed-angle locked plating, and nailing up to prosthetic replacement.     

Arthroskopische Materialentfernung nach winkelstabiler Plattenosteosynthese am proximalen Humerus

Background

Implant removal is necessary in up to 25% of patients with plate osteosynthesis after proximal humeral fracture. Our new technique of arthroscopic implant removal offers all the advantages of minimally invasive surgery. This study outlines the first results after arthroscopic implant removal in comparison with those of open implant removal.

Material and methods

Twenty patients [median age 64 (30-82) years] had arthroscopic and nine patients [median age 53 (34-76) years] had open implant removal. Median 9.5 months after implant removal subjective patient satisfaction, Constant-Murley Score (CMS) and Simple Shoulder Test (SST) were determined.

Results

Arthroscopic implant removal showed first results comparable to open implant removal. The SST outlined advantages for the arthroscopic technique. In 85% of arthroscopically treated patients concomitant intra-articular lesions were observed.

Conclusion

Arthroscopic implant removal offers all the advantages of minimally invasive surgery and first results comparable to open implant removal. The subjective and objective satisfaction of the patients is high. The technique can be applied and established by all skilled arthroscopic shoulder surgeons.     

Biomechanische Untersuchung der winkelstabilen Plattenosteosynthese am proximalen Humerus

Introduction

Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB®-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model.

Methods

For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded.

Results

Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing.

Conclusion

The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.     

Erfahrungen mit der Alloarthroplastik bei Tumoren und Metastasen des coxalen Femurendes und des proximalen Humerus

Zusammenfassung Es wird über die Ergebnisse von 17 Arthroplastiken des Hüftgelenkes wegen Tumoren oder Metastasen des coxalen Femurendes und 3 Arthroplastiken des Schultergelenkes wegen Tumoren des proximalen Humerus berichtet. Anhand der Fallbeschreibungen wird die Indikation bei malignen, potentiell malignen und benignen Primärtumoren und bei Metastasen besprochen. Es werden Grundsätze zur Konstruktion geeigneter Prothesen für Hüfte und Schulter angeführt, wobei der partielle Gelenkersatz neben dem totalen Gelenkersatz weiterhin seine Berechtigung behält. Während die Resultate der Alloarthroplastik am Hüftgelenk befriedigend sind, mahnen die Ergebnisse des entsprechenden Eingriffes am Schultergelenk noch zur Zurückhaltung.

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Experiences with arthroplasty for tumors and metastases of the proximal femur and humerus

Summary This report describes the results of 17 arthroplasties of the hip joint for tumors or metastases in the proximal part of the femur and 3 arthroplasties of the shoulder joint because of tumors in the proximal humerus. Based on case reports the paper discusses the indication in the case of malignant, potentially malignant and benign primary bone tumors and in the case of metastases. In addition principles for the construction of suitable hip and shoulder prostheses are cited, whereby the partial joint replacement continues to retain its justification beside total replacement. While the results of the hip arthroplasty proved satisfactory, the results of the corresponding operation on the shoulder are less satisfactory and urge to exercise more restraint in the operative indication.