Publications by authors named "Konrad Mader"

28 Publications

  • Page 1 of 1

A cost-effectiveness analysis of reverse total shoulder arthroplasty compared to locking plates in the management of displaced proximal humerus fractures in the elderly. The DelPhi trial.

J Shoulder Elbow Surg 2022 Jun 30. Epub 2022 Jun 30.

Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway.

Aim: To evaluate the cost-effectiveness of surgical treatment with reversed total shoulder arthroplasty (RTSA) compared to open reduction and internal fixation (ORIF) with a locking plate for patients 65-85 years old with a displaced proximal humerus fracture.

Methods: A cost-utility analysis (CUA) was conducted alongside a multicenter randomized controlled trial, taking a health care perspective. A total of 124 patients with displaced proximal humerus fractures were randomized to treatment with RTSA (n=64) or ORIF (n=60) during a two-year period. The outcome measure was quality-adjusted life years (QALYs) derived from the generic questionnaire 15D in an intention to treat population. The results were expressed as incremental cost-effectiveness ratios (ICERs), and a probabilistic sensitivity analysis was done to account for uncertainty in the analysis.

Results: At 2 years, 104 patients were eligible for analyses. The mean QALY in the RTSA group was 1.24 (95% CI 1.21-1.28) and 1.26 (95% CI 1.22-1.30) in the ORIF group. The mean cost was higher in the RTSA group with mean cost of 36.755 € (€ 17 654 - € 55 855) compared to 31.953 € (€ 16 226 - € 47 279) in the ORIF group. Using ICER, ORIF was the dominant treatment. When using a probabilistic sensitivity analysis with 1000 replications, the plots were centered around origo. This indicates that there is no significant difference in cost or effect.

Conclusion: In the cost-utility analysis of treatment of displaced proximal humeral fractures, there were no difference between RTSA and ORIF.
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http://dx.doi.org/10.1016/j.jse.2022.05.022DOI Listing
June 2022

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study.

Eur J Trauma Emerg Surg 2022 Jun 25. Epub 2022 Jun 25.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Purpose: Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living.

Methods: A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files.

Results: The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination.

Conclusion: A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.
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http://dx.doi.org/10.1007/s00068-022-02013-xDOI Listing
June 2022

Morphology of the acromioclavicular-joint score (MAC).

Arch Orthop Trauma Surg 2022 Apr 5. Epub 2022 Apr 5.

Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Admiralitätstrasse 3-4, 20459, Hamburg, Germany.

Introduction: To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection.

Materials And Methods: In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width < 2 mm in conjunction with an AC angle > 12°. A scoring system consisting of the measured morphologic factors was developed.

Results: Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%.

Conclusion: Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone.

Level Of Evidence: Level IV, retrospective diagnostic study.
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http://dx.doi.org/10.1007/s00402-022-04407-3DOI Listing
April 2022

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial.

J Bone Joint Surg Am 2020 Mar;102(6):477-485

Division of Orthopaedic Surgery (A.N.F., T.M.W., J.E.M., and T.F.), and Division of Radiology and Nuclear Medicine, Department of Musculoskeletal Radiology (A.C.K.), Oslo University Hospital, Oslo, Norway.

Background: Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.

Methods: The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.

Results: There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19).

Conclusions: At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.01071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508281PMC
March 2020

Current and Future Concepts for the Treatment of Impaired Fracture Healing.

Int J Mol Sci 2019 Nov 19;20(22). Epub 2019 Nov 19.

Clinic of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.

Bone regeneration represents a complex process, of which basic biologic principles have been evolutionarily conserved over a broad range of different species. Bone represents one of few tissues that can heal without forming a fibrous scar and, as such, resembles a unique form of tissue regeneration. Despite a tremendous improvement in surgical techniques in the past decades, impaired bone regeneration including non-unions still affect a significant number of patients with fractures. As impaired bone regeneration is associated with high socio-economic implications, it is an essential clinical need to gain a full understanding of the pathophysiology and identify novel treatment approaches. This review focuses on the clinical implications of impaired bone regeneration, including currently available treatment options. Moreover, recent advances in the understanding of fracture healing are discussed, which have resulted in the identification and development of novel therapeutic approaches for affected patients.
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http://dx.doi.org/10.3390/ijms20225805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6888215PMC
November 2019

Radial head resection and hemi-interposition arthroplasty in patients with multiple hereditary exostoses: description of a new surgical technique.

J Pediatr Orthop B 2018 Jul;27(4):289-295

Department of Orthopaedic, Trauma, and Spine Surgery, Section Upper Extremity, Asklepios Klinik Altona, Hamburg, Germany.

Multiple hereditary exostoses (MHE) are a rare disorder characterized by the growth of bony protrusions. Elbow involvement is found in a considerable number of patients and varies from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of symptoms, for example, pain, functional impairment, and cosmetic concerns. Several types of surgical procedures, therefore, can be offered, ranging from excision of symptomatic osteochondromas to challenging reconstructions. In this paper, we will discuss the essential basics of visualizing, planning, and treatment options of forearm deformities in MHE. In more detail, we will describe our current surgical technique as a salvage procedure for Masada type II forearm deformities in patients with MHE.
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http://dx.doi.org/10.1097/BPB.0000000000000496DOI Listing
July 2018

Multiple osteochondromas (MO) in the forearm: a 12-year single-centre experience.

Strategies Trauma Limb Reconstr 2016 Nov 13;11(3):169-175. Epub 2016 Oct 13.

Section Upper Extremity, Department of Orthopaedic, Trauma and Spine Surgery, Asklepios Klinik Altona, 22763, Hamburg, Germany.

Multiple osteochondromas (MO) are a rare autosomal dominant disorder characterized by the presence of osteochondromas located on the long bones and axial skeleton. Patients present with growth disturbances and angular deformities of the long bones as well as limited motion of affected joints. Forearm involvement is found in a considerable number of patients and may vary from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of problems and symptoms e.g., pain, functional impairment, loss of strength and cosmetic concerns. Several surgical procedures are offered from excision of symptomatic osteochondromas to challenging reconstructions of forearm deformities. We describe visualizing, planning and treating these forearm deformities in MO and, in particular, a detailed account of the surgical correction of Masada type I and Masada type II MO forearm deformities.
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http://dx.doi.org/10.1007/s11751-016-0267-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069205PMC
November 2016

Complex forearm deformities: operative strategy in posttraumatic pathology.

Obere Extrem 2015 14;10(4):229-239. Epub 2015 Oct 14.

Orthopædic Department, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Complex posttraumatic forearm deformities have a significant impact on the integrity of the upper extremity leading to pain, instability in both the proximal and/or distal radioulnar articulation, and reduced range of forearm motion. Corrective osteotomy or more advanced procedures for malunited fractures or other posttraumatic deformities of the upper extremity, especially in the forearm are challenging procedures. In this review we will discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the pathway from preoperative planning to the actual deformity correction surgery, either with one-stage correction or using gradual lengthening with external fixation ("callotasis techniques") and finally the functional outcome we can expect for our patients. In addition we will analyze the modern computer-assisted techniques available to date.
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http://dx.doi.org/10.1007/s11678-015-0341-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579473PMC
October 2015

[Distraction arthrodiatasis in elbow stiffness].

Oper Orthop Traumatol 2009 Dec;21(6):521-32

St. Vinzenz-Hospital Köln, Akademisches, Lehrkrankenhaus der Universität zu Köln, Köln, Germany.

Objective: Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation are of utmost importance for planning any surgical intervention for elbow stiffness. Most activities of daily living are possible, if the elbow has a range of motion of 100 degrees (30-130 degrees of flexion, Morrey's arc of motion).

Indications: Stiff elbow, usually defined as less than 30 degrees extension or less than 130 degrees flexion.

Contraindications: Poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection, acute articular infection.

Surgical Technique: Current operative techniques, such as closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure.

Postoperative Management: If indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved.

Results: In 14 children and adolescents the results after 5 years showed an increase of preoperative range of motion from 37 degrees to 108 degrees (flexion/extension; 75-130 degrees ) postoperatively.
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http://dx.doi.org/10.1007/s00064-009-2002-2DOI Listing
December 2009

Treatment of displaced proximal fifth metatarsal fractures using a new one-step fixation technique.

J Trauma 2010 Jan;68(1):122-5

Department of Orthopedics, Traumatology, Hand and Reconstructive Surgery, St. Vinzenz-Hospital, Cologne, Germany.

Background: Fractures of the tuberosity of the fifth metatarsal are common after foot twisting injuries, and operative treatment is recommended in cases of displacement. The purpose of this study was to report the radiologic outcome and clinical results of displaced fractures of the tuberosity of the fifth metatarsal treated using fine-threaded K-wires (FFS).

Methods: In 3 years' time, in a total of 35 cases, patients had an initial fracture displacement of more than 2 mm for isolated extraarticular fractures and an involvement of the cuboidal joint surface of more than 30%. After 15 months to 60 months (mean, 30.6), 32 of these patients participated in a clinical follow-up examination and questionnaire according to a clinical rating system for midfoot fractures. Radiologic outcome measurements were the remaining postoperative intraarticular step off and the healing time.

Results: The mean midfoot scale score was 96.5 points. All the patients returned to prior activities after operative treatment. Seven patients reported minor pain during longer periods of walking. One patient with secondary wound healing experienced frequent pain. Radiologically, in 32 of 35 patients, there was a remaining step off of less than 1 mm and in three patients less than 3 mm. All fractures except one healed within the first 3 months to 6 months.

Conclusion: Operative treatment of displaced proximal fifth metatarsal fractures using the FFS system leads to a good clinical and radiologic outcome. The FFS system provides a new treatment option for this fracture type.
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http://dx.doi.org/10.1097/TA.0b013e3181a8b355DOI Listing
January 2010

Treatment of chronically unreduced complex dislocations of the elbow.

Strategies Trauma Limb Reconstr 2009 Oct 25;4(2):49-55. Epub 2009 Aug 25.

Department of Orthopaedic Surgery, University of Cologne, Joseph-Stelzmann-Str. 9, 50924, Cologne, Germany,

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107 degrees (range, from 100 degrees to 110 degrees ). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.
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http://dx.doi.org/10.1007/s11751-009-0064-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746275PMC
October 2009

Olecranon fracture fixation with a new implant: biomechanical and clinical considerations.

Injury 2009 Jun 24;40(6):618-24. Epub 2009 Apr 24.

Department of Surgery, St. Elisabeth Hospital, Werthmannstrasse 1, D-50935 Cologne, Germany.

Unlabelled: This study aims to describe the first clinical results in the treatment of dislocated olecranon fractures with 2.2-mm, fine-threaded wires with a washer. Furthermore, in the second part of the article, the stability of these new implants has been compared to standard tension band wiring in a sawbone model.

Patients: The radiological and clinical outcomes in 24 patients (mean age: 53.6 years) with 24 isolated Mayo type I and II fractures of the olecranon were evaluated in a prospective study after open reduction and internal fixation (ORIF) with a new fixation device (FFS; Orthofix). The quality of reduction with the implementation of 24 FFS constructions was compared with 24 tension band-wiring procedures performed by six different surgeons in a standard sawbone Mayo type IIa fracture model. Stability was tested in all constructs using a single cycle load to failure protocol (group I), cyclic loading for 300 cycles between 10 and 500 N (group II) and incremental sinusoidal loading from 10 to 200 N with an incremental increase of 10 N per cycle (group III) in a laboratory study.

Results: The Morrey elbow score was excellent in 23 patients and good in one patient, with mean DASH score of 1.6. No implant migration, secondary dislocation or nonunion was observed. In the sawbone model, the quality of reduction was the same with the FFS implants compared to the tension band wiring in the sawbone model. Here, bending moments in all three groups showed no significant difference, whereas displacement at failure was significantly greater in the tension band-wiring group at a single cycle load (p=0.017).

Conclusion: Clinical results were comparable to tension band wiring and stability of the implants in the sawbone model was the same; thus, we conclude that the FFS technique can serve as an alternative treatment option for isolated olecranon fractures.
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http://dx.doi.org/10.1016/j.injury.2009.01.129DOI Listing
June 2009

Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation.

Knee Surg Sports Traumatol Arthrosc 2009 Mar 9;17(3):220-7. Epub 2008 Oct 9.

Institute II for Anatomy, University of Cologne, Joseph-Stelzmann Strasse 9, Cologne 50931, Germany.

Correct placement of the tibial and femoral bone tunnel is prerequisite to a successful anterior cruciate ligament (ACL) reconstruction. This study compares the resulting radiographic femoral bone tunnel position of two commonly used techniques for arthroscopically assisted drilling of the femoral bone tunnel: the transtibial approach or drilling through the anteromedial arthroscopy portal. The resulting bone tunnel position was assessed in postoperative knee radiographs of 70 patients after ACL reconstruction. Three independent observers identified the femoral bone tunnel and determined its position in the lateral and A-P view. Differences in femoral tunnel position between transtibial and anteromedial drilling were evaluated. In the sagittal plane, significantly more femoral bone tunnels were positioned close to the reference value using an anteromedial drilling technique (86%) when compared to transtibial drilling (57%). Drilling through the transtibial tunnel resulted in a significantly more anterior position of the femoral tunnel. In the frontal plane, femoral bone tunnels which were placed through the anteromedial arthroscopy portal displayed a significantly greater angulation towards the lateral condylar cortex (50.92 degrees ) when compared to transtibial drilling (58.82 degrees ). In conclusion, drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique. Further studies may evaluate if there are any clinical advantages using the anteromedial portal technique.
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http://dx.doi.org/10.1007/s00167-008-0639-2DOI Listing
March 2009

Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail.

Clin Orthop Relat Res 2007 Oct;463:151-6

Department of Orthopaedic Surgery and Traumatology, Isala Clinics, De Weezenlanden Hospital, 8000 GM Zwolle, The Netherlands.

New techniques for tibiotalocalcaneal arthrodesis ideally should improve union rate and reduce the complication rate. The purpose of this study was to evaluate the union rate of tibiotalocalcaneal arthrodesis achieved using an intramedullary nail without formal debridement of the subtalar joint and open or percutaneous debridement of the ankle joint. Consolidation time, complication and satisfaction rates, American Orthopaedic Foot and Ankle Society ankle/hindfoot score, and shoe adaptation were assessed. Fifty patients who had tibiotalocalcaneal arthrodeses with a minimum followup of 12 months (mean, 51 months; range, 12-84 months) were retrospectively reviewed. All patients completed a questionnaire and underwent physical examination and radiographic investigations. Fusion was achieved in all ankles; two subtalar joints did not fuse. The average time of fusion was 20 weeks for both joints. Observed complications were few and the satisfaction rate was 92%. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 70. Tibiotalocalcaneal arthrodesis with a specifically designed retrograde intramedullary nail without formal debridement of the subtalar joint and a choice between open or percutaneous debridement of the ankle is a reliable method to achieve fusion. Opening and debriding the subtalar joint is, in our opinion, not necessary, and percutaneous debridement of the ankle is a good alternative to open debridement.
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October 2007

Four distal radial fracture classification systems tested amongst a large panel of Dutch trauma surgeons.

Injury 2007 Nov 23;38(11):1268-72. Epub 2007 Jul 23.

Department of Orthopaedic Surgery and Traumatology, Isala Clinics, Weezenlanden Hospital, Zwolle, The Netherlands.

Five different radiographs of distal radial fractures were classified according to the AO/ASIF, Frykman, Fernandez and Older systems by 45 observers (trauma surgeons and residents). The same panel classified the same radiographs in a different order 4 months later. Mean interobserver correlation for all cases was fair to moderate according to the Spearman rank test. However, these classifications showed poor correlation with the gold standard as classified by the senior author. All intraobserver agreements demonstrated a moderate kappa agreement (K(w)=0.52) for the AO/ASIF classification and fair for the Frykman (K(w)=0.26), Fernandez (K(w)=0.24) and Older (K(w)=0.27) classifications. When the group was divided according to years of clinical experience (<6 years; >or=6 years), there was poor correlation between experience and consistency amongst all four classifications. In view of these findings, we do not recommend use of these classifications for clinical application because of their questionable reproducibility and reliability.
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http://dx.doi.org/10.1016/j.injury.2007.03.032DOI Listing
November 2007

Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years.

Acta Orthop 2007 Feb;78(1):151-6

Department of Surgery, St. Elisabeth Hospital, Cologne, Germany.

Background: Treatment options in radial head fractures of Mason types III and IV range from open reduction and internal fixation (ORIF) to radial head resection with or without prosthetic replacement.

Patients: In a prospective study, the radiographic and clinical outcome was evaluated in 23 patients (age median 51 years) with 23 complex radial head fractures median 2 (1-4) years after ORIF using a new fixation device (FFS; Orthofix). 14 Mason type-III fractures with 2 concomitant olecranon fractures and 1 ulnar nerve lesion, and 11 type-IV fractures with 2 olecranon fractures and 2 fractures of the coronoid process were treated. 2 patients were lost to follow-up. In 7 cases of joint instability, an elbow fixator with motion capacity was applied after ORIF of the radial head.

Results: No radial head resection was necessary. No secondary dislocations or nonunion occurred. The Morrey elbow score was excellent in 8 and good in 4 Mason type-III fractures and excellent in 5, good in 3, and fair in 3 Mason type-IV fractures.

Interpretation: Reconstruction of comminuted radial head fractures can be performed with this device and radial head resection can be avoided.
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http://dx.doi.org/10.1080/17453670610013565DOI Listing
February 2007

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents. Surgical technique.

J Bone Joint Surg Am 2007 Mar;89 Suppl 2 Pt.1:26-35

Department of Trauma and Orthopedic Surgery, Hand and Reconstructive Surgery, St. Vinzenz-Hospital, Merheimer Strasse 221-223, D-50733 Cologne, Germany.

Background: Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

Methods: Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees . Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

Results: The mean preoperative arc of total elbow motion was 37 degrees . The mean pronation was 46 degrees , and the mean supination was 56 degrees . After a mean duration of follow-up of thirty-four months, all patients but two had achieved an arc of motion of 100 degrees . The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees ). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees ), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees ). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

Conclusions: Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.
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http://dx.doi.org/10.2106/JBJS.F.01122DOI Listing
March 2007

Treatment of medial malleolar fractures using fine-threaded K-wires: a new operative technique.

J Trauma 2007 Jan;62(1):258-61

Department of Traumatology, Hand and Reconstructive Surgery, St. Vinzenz Hospital, Merheimerstr. 221-223, D-50733 Cologne, Germany.

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http://dx.doi.org/10.1097/01.ta.0000240443.61205.96DOI Listing
January 2007

Treatment of bilateral elbow dislocation using external fixation with motion capacity: a report of 2 cases.

J Orthop Trauma 2006 Jul;20(7):499-502

Department of Surgery, St Elisabeth-Hospital, Cologne, Germany.

Bilateral elbow dislocation is a rare injury and only 11 cases are described in the literature, including 8 patients with isolated ligamentous and 3 patients with an additional osseous injury. We present 2 cases of bilateral posterior elbow dislocations treated with a bilateral hinged elbow fixator with motion capacity to allow for early physiotherapy. Both patients had a high-energy trauma with one who fell off a ladder from a 5 m height and the second from a mountain bike injury during off-road biking. All extremities were neurovascularly intact. In the operating room, severe instability was detected in all 4 elbows: after closed reduction in 3 elbows and open reduction in 1 elbow for a Mason type 4 fracture of the radial head that was internally fixed using fine threaded implants, an elbow fixator with motion capacity was applied in all 4 elbows for a period of 6 weeks. One year after surgery, the active range of motion was 0/10/140 degrees of extension and flexion on the right and 0/0/130 degrees on the left side. The second patient achieved 0/0/125 degrees and 0/10/130, respectively. Pro- and supination was full in both patients. All 4 elbows were stable and there were no radiologic signs of degenerative changes at the 1 year follow-up. Treatment of bilateral elbow dislocation using external fixation with early motion capacity allows for active physiotherapy although maintaining joint stability, thus minimizing complications normally associated with the injury. Using this method resulted in an excellent clinical outcome for both patients.
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http://dx.doi.org/10.1097/00005131-200608000-00009DOI Listing
July 2006

Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents.

J Bone Joint Surg Am 2006 May;88(5):1011-21

Department of Trauma Surgery, Hand and Reconstructive Surgery, St.Vinzenz-Hospital, Merheimer Strasse 221-223, D-50733 Cologne, Germany.

Background: Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

Methods: Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

Results: The mean preoperative arc of total elbow motion was 37 degrees. The mean pronation was 46 degrees, and the mean supination was 56 degrees. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100 degrees. The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

Conclusions: Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.
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http://dx.doi.org/10.2106/JBJS.D.02090DOI Listing
May 2006

Dual mode of signalling of the axotomy reaction: retrograde electric stimulation or block of retrograde transport differently mimic the reaction of motoneurons to nerve transection in the rat brainstem.

J Neurotrauma 2004 Jul;21(7):956-68

Klinik für Unfallchirurgie, Hand- und Wiederherstellungschirurgie, St. Vinzenz Hospital, Köln, Germany.

Axotomy of a peripheral nerve causes a complex central response of neuronal perikarya, astroglia and microglia. The signal initiating this axotomy reaction is currently explained either by deprivation of target-derived trophic factors after interruption of transport (trophic hypothesis) or by electrophysiological disturbances of the axotomized neurons (electric hypothesis). In 108 adult Wistar rats we have compared the time course and intensity of the axotomy reaction in the hypoglossal nucleus after (1) resection of the nerve (permanent axotomy), (2) one-time electric stimulation (intact nerve, brief transient electric disturbance), and (3) colchicine block of transport (intact nerve, prolonged transient loss of trophic factors). Nerve resection activated microglia at 2-35 days post-operation (dpo), elevated GFAP in astrocytes at 3-35 dpo and increased CGRP in motoneurons at 2-15 dpo. Fluorogold prelabeling revealed neurophagocytosis and 25% neuron loss at 25 dpo. Colchicine block similarly activated microglia at 5-35 dpo, elevated GFAP at 7-35 dpo and upregulated CGRP at 7-25 dpo. Neurophagocytosis and 15% motoneuron loss were evident at 25 dpo. Electric stimulation (15 min, 4 Hz, 0.1 msec impulse, 2 mAmp) of the intact nerve activated microglia at 1-10 dpo, elevated astroglial GFAP-expression at 7-35 dpo, and upregulated CGRP at 1-10 dpo, but no neuron death and neurophagocytosis were detected. Hence electric stimulation elicited a faster, shorter-lasting response, but transport block as well as axotomy a slower, longer-lasting response. This suggests a dual mode of signaling: Onset and early phase of the axotomy reaction are triggered by electric disturbances, late phase and neuron death by deprivation of trophic factors.
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http://dx.doi.org/10.1089/0897715041526113DOI Listing
July 2004

Femoral neck fracture in an arthrodesed hip treated by a supracondylar intramedullary locked nail.

J Orthop Trauma 2004 Feb;18(2):116-8

Department of Trauma, Hand and Reconstructive Surgery, St Vinzenz-Hospital, Cologne, Germany.

We describe a case of a femoral neck fracture occurring 51 years after a hip arthrodesis. This rare lesion in an obese woman was treated with a straight supracondylar nail with proximal and distal locking inserted retrograde from the subtrochanteric area into the ileum. Full weight bearing was achieved within 1 week postoperatively, and union was present 3 months following the operation.
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http://dx.doi.org/10.1097/00005131-200402000-00011DOI Listing
February 2004

Calcaneotalotibial arthrodesis with a retrograde posterior-to-anterior locked nail as a salvage procedure for severe ankle pathology.

J Bone Joint Surg Am 2003 ;85-A Suppl 4:123-8

Department of Trauma Surgery, St Vincent-Hospital, Cologne, Germany.

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http://dx.doi.org/10.2106/00004623-200300004-00016DOI Listing
January 2004

Shortening and deformity of radius and ulna in children: correction of axis and length by callus distraction.

J Pediatr Orthop B 2003 May;12(3):183-91

Department of Trauma, Hand and Reconstructive Surgery, St. Vinzenz-Hospital, Cologne, Germany.

Forearm deformities in children and adolescents may be congenital or developmental, or result from trauma; they may cause pain and decreased function of the wrist and hand. In this study we treated seven patients with forearm deformities (10 forearms) by callus distraction of either the radius or ulna using a monolateral external fixator after osteotomy. Target length was achieved in all cases. The results show significant improvement in range of motion of the forearm. All patients were satisfied with the appearance. There were no complications such as pin tract infection or neural impairment. In one case delayed ossification was resolved by alternating distraction and compression. The timing of correction depends on the implications of the deformity for the carpal bones and the function of the other forearm. Monolateral external fixation proved a versatile tool for correction of forearm deformity in children and adolescents, with a low complication rate.
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http://dx.doi.org/10.1097/01.bpb.0000057485.91570.e9DOI Listing
May 2003
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