Surgical Treatment − Evidence‐Based and Problem‐­Oriented

Funktionelle Anatomie der Gelenke

Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

/pdf/current-concepts-in-locking-plate-fixation-of-proximal-2eacd6i0et.pdf

Current concepts in locking plate fixation of proximal humerus fractures

Patella fractures can be caused by excessive tension through the extensor mechanism or a direct impact. Non-displaced fractures with an intact extensor mechanism can be treated nonoperatively. Surgical treatment is recommended for fractures that either disrupt the extensor mechanism or have greater than 2 to 3 mm of step-off and greater than 1 to 4 mm of displacement. Tension band fixation is the most commonly employed surgical technique; however, this can be technically demanding, especially in multifragmentary fractures. Symptomatic hardware is the most common complication following operative treatment. Functional impairment remains common after treatment of patella fractures. The purpose of this article is to review current treatment strategies to help optimize the management of patients with such patella fractures.

Current Treatment Strategies for Patella Fractures.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial.

The standard treatment for patella fractures is tension band wiring. However, with tension band wiring anatomical reduction and rigid fixation can be challenging and the clinical outcome after patella fracture is often not satisfying. The purpose of this prospective clinical observation was to evaluate the clinical outcome in patients with patella fractures treated with an angular stable patella plate. Between 2011 and 2015 a total of 67 patients were treated with an angular stable patella plate. Outcome in these patients was evaluated by the Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) and range of motion of the knee joint was assessed. Complete follow up was obtained for 35 patients. In these patients, we found one implant-related complication. None of the patients reported any deficits in extension capabilities. The flexion was on average 127° (SD 21°). The patients classified the function of their knee in daily life on average with 77% (SD 24%) in comparison to their function before the trauma. Only kneeling or squatting was a problem in some patients. In conclusion, angular stable patella plating appears to be a promising alternative treatment for patella fractures. The patella plate provides increased mechanical stability for fracture fixation which appeared to result in a reduction of complications and improvement of functional outcome compared to tension band wiring. Especially patients with a multi-part or comminuted fracture or with osteoporotic bone are likely to benefit from the stability provided by the plate and the locking screws.

Treating patella fractures with a locking patella plate - first clinical results.

Aim of this study was to evaluate prognosis of severely injured patients. All severely injured patients with an Injury Severity Score (ISS) ≥ 50 were identified in a 6-year-period between 2000 and 2005 in German Level 1 Trauma Center Murnau. Data was evaluated from German Trauma Registry and Polytrauma Outcome Chart of the German Society for Trauma Surgery and a personal interview to assess working ability and disability and are presented as average. 88 out of 1435 evaluated patients after severe polytrauma demonstrated an ISS ≥ 50 (6.5%), among them 23% women and 77% men. 66 patients (75%) had an ISS of 50-60, 14 (16%) 61-70, and 8 (9%) ≥ 70. In 27% of patients trauma was caused by motor bike accidents. 3.6 body regions were involved. Patients had to be operated 5.3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% of patients demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLO-chart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% of patients problems with working ability regarding duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability. Even severely injured patients after multiple trauma have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score.

/pdf/outcome-after-severe-multiple-trauma-a-retrospective-v5o4rgcfe4.pdf

Outcome after severe multiple trauma: a retrospective analysis

Objective:To analyze the mechanical stability of locked plating in comparison with tension-band wiring for the fixation of fractures of the patella.Methods:Biomechanical tests were performed on artificial foam patella specimens comparing an angular stable plate and monocortical screws with tension-b

Biomechanical Assessment of Locked Plating for the Fixation of Patella Fractures.

Femoro-patellar complications are one of the most common problems after total knee arthroplasty (TKA). TKA components that reduce patellar loads and preserve physiological patellar kinematics should reduce these problems. Therefore, we evaluated the patellar kinematics and the retro-patellar contact characteristics in both the intact knee and in the TKA-knee. Eight Thiel-embalmed cadaver knees were tested first intact and then after TKA using rotating as well as gliding inlay and with additional patellar resurfacing while flexing the knee from 0° to 100°. During the examination quadriceps and hamstring forces were applied. TKA with additional patellar resurfacing led to an increased retro-patellar pressure, a decreased contact area and an increased lateral movement. Although patellar kinematics could not be changed by using a gliding inlay compared to a rotating inlay, the gliding inlay improved retro-patellar contact characteristics by reducing the pressure and increasing the contact area, especially in higher flexion. The increased retro-patellar pressure together with the increased lateral movement of the patella after TKA may be one important cause for anterior knee pain appearing after TKA. In view of the improved retro-patellar contact characteristics using a gliding inlay this inlay should be preferred, providing that the posterior cruciate ligament is intact.

Influence of total knee arthroplasty on patellar kinematics and contact characteristics

Die ideale Versorgungsstrategie bei proximalen Humerusfrakturen wird kontrovers diskutiert. In dieser Studie wurden mit der proximalen Marknagel- und winkelstabilen Plattenosteosynthese die beiden gangigsten Operationsverfahren miteinander verglichen. Zwischen 03/2009 und 03/2010 wurden 118 Patienten eines uberregionalen Traumazentrums mit verheilter proximaler Humerusfraktur in einer retrospektiven Studie erfasst. Davon wurden 72 Patienten der Jahre 2002–2005 mindestens 3 Jahre nach operativer Stabilisierung einer traumatischen proximalen Humerusfraktur durch Marknagel- oder winkelstabiler Plattenosteosynthese anhand klinischer Untersuchung, Bewertung von „Outcome Scores“ und Rontgenuntersuchung nachuntersucht. Als Funktionsscores wurden der Constant-Murley- und der SF-36-Score angewendet. Nach Neer wurden 31 3-Teile-Frakturen klassifiziert, davon 23 mit PHN und 8 mit winkelstabiler Platte versorgt, und 41 4-Teile-Frakturen, davon 21 mit PHN und 20 mit Platte stabilisiert. Bei 42 Patienten wurden 3 Jahre nach Trauma keine klinischen Symptome mehr festgestellt, bei 30 Patienten dagegen bestanden Schmerzen und/oder Funktionsdefizite. Der durchschnittliche absolute Constant-Murley-Score betrug auf der verletzten Seite 73 Punkte im Vergleich zur Gegenseite mit 88 Punkten. Sowohl die Marknagelosteosynthese als auch die winkelstabile Plattenosteosynthese sind adaquate Behandlungsverfahren fur die Stabilisierung proximaler Humerusfrakturen. Diese Untersuchung zeigt, dass weder der Frakturtyp, noch das Patientenalter, noch die Wahl des Osteosynthesematerials einen signifikanten Einfluss auf die klinisch-funktionellen Langzeitergebnisse haben.

Marknagel- vs. winkelstabile Plattenosteosynthese bei proximalen Humerusfrakturen

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