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- Klinik und Poliklinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie (Chirurgische Klinik II) (26)
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The coronal unicondylar fracture of the distal femur (AO 33-B3) is a rare intraarticular injury within the weight bearing area of the knee, initially described by Albert Hoffa in 1904. We report an unusual combination of a Hoffa fracture with lateral patellar dislocation in a young adult. Our patient sustained the injury by a sudden twist of his leg during sports. He presented clinically with knee swelling, dislocation of the patella, and localized tenderness; unable to bare weight. After plane radiograph confirmed the injury, manual reduction of the patella was done by hyperextension of the knee and medialward pressure. Afterwards, a CT scan and MRI were conducted. The injury was surgically treated with lag-screws, locking-plate and MPFL-reconstruction.
Background
The Goutallier Classification is a semi quantitative classification system to determine the amount of fatty degeneration in rotator cuff muscles. Although initially proposed for axial computer tomography scans it is currently applied to magnet-resonance-imaging-scans. The role for its clinical use is controversial, as the reliability of the classification has been shown to be inconsistent. The purpose of this study was to compare the semi quantitative MRI-based Goutallier Classification applied by 5 different raters to experimental MR spectroscopic quantitative fat measurement in order to determine the correlation between this classification system and the true extent of fatty degeneration shown by spectroscopy.
Methods
MRI-scans of 42 patients with rotator cuff tears were examined by 5 shoulder surgeons and were graduated according to the MRI-based Goutallier Classification proposed by Fuchs et al. Additionally the fat/water ratio was measured with MR spectroscopy using the experimental SPLASH technique. The semi quantitative grading according to the Goutallier Classification was statistically correlated with the quantitative measured fat/water ratio using Spearman’s rank correlation.
Results
Statistical analysis of the data revealed only fair correlation of the Goutallier Classification system and the quantitative fat/water ratio with R = 0.35 (p < 0.05). By dichotomizing the scale the correlation was 0.72. The interobserver and intraobserver reliabilities were substantial with R = 0.62 and R = 0.74 (p < 0.01).
Conclusion
The correlation between the semi quantitative MRI based Goutallier Classification system and MR spectroscopic fat measurement is weak. As an adequate estimation of fatty degeneration based on standard MRI may not be possible, quantitative methods need to be considered in order to increase diagnostic safety and thus provide patients with ideal care in regard to the amount of fatty degeneration. Spectroscopic MR measurement may increase the accuracy of the Goutallier classification and thus improve the prediction of clinical results after rotator cuff repair. However, these techniques are currently only available in an experimental setting.
Background
Tibial head depression fractures demand a high level of fracture stabilization to prevent a secondary loss of reduction after surgery. Elderly individuals are at an increased risk of developing these fractures, and biomechanical investigations of the fractures are rare. Therefore, the aim of this study was to systematically analyze different types of osteosyntheses in combination with two commonly used bone substitutes.
Methods
Lateral tibial head depression fractures were created in synthetic bones. After reduction, the fractures were stabilized with eight different treatment options of osteosynthesis alone or in combination with a bone substitute. Two screws, 4 screws and a lateral buttress plate were investigated. As a bone substitute, two common clinically used calcium phosphate cements, Norian® Drillable and ChronOS™ Inject, were applied. Displacement of the articular fracture fragment (mm) during cyclic loading, stiffness (N/mm) and maximum load (N) in Load-to-Failure tests were measured.
Results
The three different osteosyntheses (Group 1: 2 screws, group 2: 4 screws, group 3: plate) alone revealed a significantly higher displacement compared to the control group (Group 7: ChronOS™ Inject only) (Group 1, 7 [p < 0.01]; group 2, 7 [p = 0.04]; group 3, 7 [p < 0.01]). However, the osteosyntheses in combination with bone substitute exhibited no differences in displacement compared to the control group. The buttress plate demonstrated a higher normalized maximum load than the 2 and 4 screw osteosynthesis. Comparing the two different bone substitutes to each other, ChronOS™ inject had a significantly higher stiffness and lower displacement than Norian® Drillable.
Conclusions
The highest biomechanical stability under maximal loading was provided by a buttress plate osteosynthesis. A bone substitute, such as the biomechanically favorable ChronOS™ Inject, is essential to reduce the displacement under lower loading.
Purpose
Displaced midshaft clavicular fractures can be treated conservatively as well as operatively by titan elastic nail (TEN) or plate fixation. This survey was performed to evaluate the clinical results of each treatment method and elaborate advantages or possible complications of each modality.
Methods
Between 2008 and 2013, 102 patients were prospectively included in our study—37 patients for conservative treatment with a rucksack bandage for 4 to 6 weeks, 41 patients for plate osteosynthesis, and 24 for intramedullary stabilization with TEN. Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley Score (CMS), and visual analog scale (VAS) for pain and function as well as time of invalidity were recorded over a 1-year period.
Results
The clinical data collected reveals that all three different therapies lead to good or excellent clinical results after 1 year. However, one can observe advantages of operative treatment in comparison to conservative therapy in some characteristics.
Conclusion
Our data shows that there are several indications where operative treatment has advantages compared to conservative treatment. In special fracture types (Robinson 2B1), TEN gives the best results. Plate fixation is extraordinarily sufficient in pain reduction within the first 5 weeks and indicated in more-part fractures (Robinson 2B2). Nevertheless, conservative treatment is always a good and promising way to treat clavicular fractures, so that individual indications and thorough patient informative talks are inevitable.
Background
Suture pretension during tendon repair is supposed to increase the resistance to gap formation. However, its effects on the Bunnell suture technique are unknown. The purpose of this study was to determine the biomechanical effects of suture pretension on the Bunnell and cross-lock Bunnell techniques for tendon repair.
Methods
Eighty porcine hindlimb tendons were randomly assigned to four different tendon repair groups: those repaired with or without suture pretension using either a simple Bunnell or cross-lock Bunnell technique. Pretension was applied as a 10 % shortening of the sutured tendon. After measuring the cross-sectional diameter at the repair site, static and cyclic biomechanical tests were conducted to evaluate the initial and 5-mm gap formation forces, elongation during cyclic loading, maximum tensile strength, and mode of failure. The suture failure mechanism was also separately assessed fluoroscopically in two tendons that were repaired with steel wire.
Results
Suture pretension was accompanied by a 10 to 15 % increase in the tendon diameter at the repair site. Therefore, suture pretension with the Bunnell and cross-lock Bunnell repair techniques noticeably increased the resistance to initial gap formation and 5-mm gap formation. The tension-free cross-lock Bunnell repair demonstrated more resistance to initial and 5-mm gap formation, less elongation, and higher maximum tensile strength than the tension-free Bunnell repair technique. The only difference between the tensioned cross-lock Bunnell and tensioned Bunnell techniques was a larger resistance to 5-mm gap formation with the cross-lock Bunnell technique. Use of the simple instead of cross-lock suture configuration led to failure by suture cut out, as demonstrated fluoroscopically.
Conclusion
Based on these results, suture pretension decreases gapping and elongation after tendon repair, and those effects are stronger when using a cross-lock, rather than a regular Bunnell suture. However, pretension causes an unfavorable increase in the tendon diameter at the repair site, which may adversely affect wound healing.
Background
Barbed suture material offers the possibility of knotless flexor tendon repair, as suggested in an increasing number of biomechanical studies. There are currently two different absorbable barbed suture products available, V-Loc™ and Stratafix™, and both have not been compared to each other with regard to flexor tendon repair. The purpose of this study was to evaluate both suture materials for primary stability under static and cyclic loading in a biomechanical ex vivo model.
Methods
Forty fresh porcine flexor digitorum profundus tendons were randomized in two groups. A four-strand modified Kessler suture technique was used to repair the tendon either with a 3–0 V-Loc™ or 3–0 Stratafix™ without a knot. Parameters of interest were mode of failure, 2-mm gap formation force, displacement, stiffness and maximum load under static and cyclic testing.
Results
The maximum load was 42.3 ± 7.2 for the Stratafix™ group and 50.7 ± 8.8 N for the V-Loc™ group. Thus, the ultimate tensile strength was significantly higher for V-Loc™ (p < 0.05). The 2-mm gap occurred at 24.8 ± 2.04 N in the Stratafix™ group in comparison to 26.5 ± 2.12 N in the V-Loc™ group (n.s.). Displacement was 2.65 ± 0.56 mm in the V-Loc™ group and 2.71 ± 0.59 mm in the Stratafix™ group (n.s.). Stiffness was 4.24 ± 0.68 (N/mm) in the V-Loc™ group and 3.85 ± 0.55 (N/mm) the Stratafix™ group (n.s.). Those measured differences were not significant.
Conclusion
V-Loc™ demonstrates a higher maximum load in tendon reconstruction. The differences in 2-mm gap formation force, displacement and stiffness were not significant. Hereby, the V-Loc™ has an advantage when used as unidirectional barbed suture for knotless flexor tendon repair.