Die aseptische Caputnekrose nach Schenkelhalsfraktur bei Jugendlichen und ihre Beziehung zum Perthesschen Krankheitsbild

Ohne Zusammenfassung     

Konservative und operative Therapie der Klavikulaschaftfrakturen

Nonoperative treatment, e.g. with a sling or a figure-of-eight bandage, has so far been considered to be the gold standard for midshaft clavicle fractures even when substantial displacement has been present. However, more recent studies have shown poorer results following nonoperative treatment of dislocated clavicle fractures compared with operative treatment. The main reasons are a higher nonunion and shortening rate of displaced midshaft fractures, which often result in poor functional outcome and low patient satisfaction. Operative methods, e.g. locking plates or intramedullary fixation technique have proven to have much better outcome in the treatment of midshaft clavicle fractures with displacement and comminution than conservative methods. Adults with a displaced midshaft fracture have for example a nonunion rate of up to 15% after conservative therapy whereas it is 2–3% after operative treatment. The traditional view that clavicular midshaft fractures no matter what grade of dislocation and what type of fracture should be treated conservatively is no longer valid today. Instead possible complications and risks of the conservative and operative treatment always have to be taken into account and weighed individually for therapy decision-making in the clinical routine. The analysis of current studies shows that patients with dislocated comminuted fractures benefit from surgery.     

Fractures of the scapula

The scapula connects the arm with the chest wall and is therefore of great importance for a free range of shoulder of motion. For a long-term scapular fractures had been treated predominantly conservative. However, clinical studies of the past decades revealed that some fracture patterns deserve operative treatment to prevent unfavorable functional outcome and chronic state of pain. Scapular fractures are predominantly acquired during high-energy trauma and these patients' presents with a mean of 3.9 associated injuries in the emergency department. Injuries to the head, chest and ipsilateral upper extremity are most common. As some of these injuries are possibly life threatening they are treated first. Scapular fractures are only very seldom surgical emergencies. Therefore they are treated during the phase of reconvalescence in polytraumatized patients. Decision-making should be based on a thoroughgoing diagnostics, including conventional x-rays and a CT-scan, epically in cases of glenoid neck or cavity fractures. All fracture patterns should be identified to there full extend and put into the context of the scapular suspensory complex. The OTA lately presented a new and comprehensive system for classification of the scapular fractures. It is divided in two levels. Level one for the general orthopedic or trauma surgeon and Level two for the advanced upper Extremity or Shoulder surgeon. This classification scheme allows an easy access to understanding of the severity and prognostics of scapular fractures. As a general guideline surgery is indicated if a double disruption of the Scapula suspensory system, a relevant malposition or dysintegrity of the glenoid (articular surface) or a displacement of the lateral column is present.     

Suture anchors or transglenoidal sutures for arthroscopic repair of isolated SLAP-2 lesions? A matched-pair comparison of functional outcome and return to sports

Purpose

Presumably, the technique of SLAP refixation has significant influence on outcome. This study analyzes and compares functional outcome and return to sports after arthroscopic suture anchor (SA) and arthroscopic transglenoidal suture (TS) repair of isolated SLAP-2 lesions.

Methods

Twenty-four competitive amateur athletes constituted the two treatment groups of this retrospective matched-pair analysis. In the SA group (n = 12), the mean age was 39.1 years (±12.0) and the mean follow-up period was 4.0 years (±0.6). In the TS group (n = 12), the mean age was 33.8 years (±12.0) and the mean follow-up period was 3.7 years (±0.9). The minimum follow-up period was 2.0 years. Primary outcome measures were the absolute constant-score (CS), the subjective shoulder value (SSV) as well as the ability to return to sports.

Results

The mean CS in the SA group was 91.6 (±5.5) compared to 81.3 (±15.5) in the TS group (p = 0.04). The mean SSV after SA repair was 96.9 (±4.6) compared to 80.0 (±20.8) after TS repair (p = 0.01). Both scores showed significantly higher standard deviations within the TS group (p < 0.05). Twelve of eighteen patients (67 %) were able to return to their overhead sports without restrictions (5/9 in the SA group and 7/9 in the TS group; p > 0.05). Fourteen of twenty-four patients (58 %) achieved their preinjury sports levels (8/12 in the SA group and 6/12 in the TS group; p > 0.05).

Conclusions

Superior objective and subjective shoulder function was obtained following arthroscopic SA repair compared to arthroscopic TS repair of isolated SLAP-2 lesions. In addition, results of SA repair were more predictable. However, nearly half of the athletes did not achieve full return to sports regardless of the applied technique of refixation.     

Traumatische Verletzungen des Sternoklavikulargelenks

Traumatic injuries of the sternoclavicular joint occur rarely and are mainly caused by an indirect trauma mechanism with high kinetic energy. Anterior dislocation is much more common than posterior dislocation, which may be associated with life-threatening injuries. The CT scan is the diagnostic tool of choice for accurate assessment of the injury and coexisting pathologies. The primary goal in anterior and posterior dislocations is an early closed reduction. In cases of redislocation after closed reduction of an anterior dislocation we recommend primary joint reconstruction on the basis of an individual therapeutic concept. Posterior dislocations often cannot be reduced by closed means. Then open reconstruction and stabilization are performed. Chronic instabilities should only be addressed surgically in cases of persistent pain and/or functional deficit. Resection of the medial clavicula represents an effective treatment option in post-traumatic sternoclavicular joint arthritis provided that the costoclavicular ligaments are intact or will be reconstructed during surgery. Physeal injuries of the medial clavicle can occur until an approximate age of 25. Closed reduction of dislocated physeal injuries is attempted. After reposition non-operative treatment in general leads to a good functional outcome. Posteriorly dislocated physeal injuries often cannot be reduced by closed means. In these cases good function can be expected after open stabilization.     

Traumatic injuries of the sternoclavicular joint

Traumatic injuries of the sternoclavicular joint occur rarely and are mainly caused by an indirect trauma mechanism with high kinetic energy. Anterior dislocation is much more common than posterior dislocation, which may be associated with life-threatening injuries. The CT scan is the diagnostic tool of choice for accurate assessment of the injury and coexisting pathologies. The primary goal in anterior and posterior dislocations is an early closed reduction. In cases of redislocation after closed reduction of an anterior dislocation we recommend primary joint reconstruction on the basis of an individual therapeutic concept. Posterior dislocations often cannot be reduced by closed means. Then open reconstruction and stabilization are performed. Chronic instabilities should only be addressed surgically in cases of persistent pain and/or functional deficit. Resection of the medial clavicula represents an effective treatment option in post-traumatic sternoclavicular joint arthritis provided that the costoclavicular ligaments are intact or will be reconstructed during surgery. Physeal injuries of the medial clavicle can occur until an approximate age of 25. Closed reduction of dislocated physeal injuries is attempted. After reposition non-operative treatment in general leads to a good functional outcome. Posteriorly dislocated physeal injuries often cannot be reduced by closed means. In these cases good function can be expected after open stabilization.     

Tendinosis calcarea der Schulter

Calcific tendonitis of the shoulder joint is one of the essential causes of shoulder pain and generally affects middle-aged men and women. The etiology of calcific tendonitis differs from degenerative rotator cuff lesions. It concerns a self-limiting disorder in the vital, functioning rotator cuff with a high spontaneous healing potential, which progresses in phases. Thus, there is a precalcification phase, a calcification phase, and a postcalcification phase, which finally ends in a restitutio with spontaneous resolution of the calcium deposit. The resorption of the deposit can be incomplete or can be interrupted during any phase of the evolution cycle. This can lead to symptomatic persistence of a residual calcium deposit or to so-called postcalcific tendonitis with continuing shoulder pain, despite x-ray having confirmed complete resorption of the calcium deposit. The precise radiological association of the calcification to a specific phase of the cyclic course of calcific tendonitis is not possible so far, so that a reliable classification of the stage of the illness in daily clinical practice can not be achieved. The recommended imaging methods for calcific tendonitis are x-rays in a.p. and outlet view including, where appropriate, scans in internal and external rotation as well as sonography. However, it is often not possible to identify a calcium deposit based on the x-ray morphological characteristics of specific radiological classifications (e. g., according to Gärtner or the French Society of Arthroscopy, SFA). From our point of view initially conservative therapy for a minimum of 6 months is recommended. Negative prognosis factors, which increase the probability of the conservative therapy being ineffective, include anterior subacromial localization of the calcification (corresponding to the sector classification), bilateral occurrence, medial subacromial extension, and a large calcification volume. If pain persists, arthroscopic removal of the calcium deposit is the method of choice. With the so-called quadrant technique, based on a preoperatively performed ultrasound examination, it is possible to reliably and fast identify the location of the deposit. Arthroscopic removal of the calcification should in general not be combined with subacromial decompression; it is more important to achieve sufficient elimination of the calcium deposit for a good clinical result. Complete removal of the calcium deposit should be avoided, in case this is only achievable by accepting considerable damage of the rotator cuff, because there is a particularly high spontaneous resorption rate of any possible remaining calcifium deposit immediately after surgery.