The calcar screw in angular stable plate fixation of proximal humeral fractures - a case study

<p>Abstract</p> <p>Background</p> <p>With new minimally-invasive approaches for angular stable plate fixation of proximal humeral fractures, the need for the placement of oblique inferomedial screws ('calcar screw') has increasingly been discussed. The purpose of this study was to investigate the influence of calcar screws on secondary loss of reduction and on the occurrence of complications.</p> <p>Methods</p> <p>Patients with a proximal humeral fracture who underwent angular stable plate fixation between 01/2007 and 07/2009 were included. On AP views of the shoulder, the difference in height between humeral head and the proximal end of the plate were determined postoperatively and at follow-up. Additionally, the occurrence of complications was documented. Patients with calcar screws were assigned to group C+, patients without to group C-.</p> <p>Results</p> <p>Follow-up was possible in 60 patients (C+ 6.7 ± 5.6 M/C- 5.0 ± 2.8 M). Humeral head necrosis occurred in 6 (C+, 15.4%) and 3 (C-, 14.3%) cases. Cut-out of the proximal screws was observed in 3 (C+, 7.7%) and 1 (C-, 4.8%) cases. In each group, 1 patient showed delayed union. Implant failure or lesions of the axillary nerve were not observed. In 44 patients, true AP and Neer views were available to measure the head-plate distance. There was a significant loss of reduction in group C- (2.56 ± 2.65 mm) compared to C+ (0.77 ± 1.44 mm; p = 0.01).</p> <p>Conclusions</p> <p>The placement of calcar screws in the angular stable plate fixation of proximal humeral fractures is associated with less secondary loss of reduction by providing inferomedial support. An increased risk for complications could not be shown.</p

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

BACKGROUND: Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques. METHODS: The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options. RESULTS: THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy. CONCLUSIONS: THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectanc

Gastrocnemius muscle herniation as a rare differential diagnosis of ankle sprain: case report and review of the literature

BACKGROUND: Muscle herniation of the leg is a rare clinical entity. Yet, knowing this condition is necessary to avoid misdiagnosis and delayed treatment. In the extremities, muscle herniation most commonly occurs as a result of an acquired fascial defect, often due to trauma. Different treatment options for symptomatic extremity muscle herniation in the extremities, including conservative treatment, fasciotomy and mesh repair have been described. CASE PRESENTATION: We present the case of a patient who presented with prolonged symptoms after an ankle sprain. The clinical picture showed a fascial insufficiency with muscle bulging under tension. Ultrasound and MRI imaging confirmed the diagnosis of muscle hernia of the medial gastrocnemius on the right leg. Conservative treatment did not lead to success. Therefore, the fascial defect was treated surgically by repairing the muscle herniation using a synthetic vicryl propylene patch. CONCLUSIONS: Muscle hernias should be taken into consideration as a rare differential diagnosis whenever patients present with persisting pain or soft tissue swelling after ankle sprain. Diagnosis is mainly based on clinical aspect and physical examination, but can be confirmed by radiologic imaging techniques, including (dynamic) ultrasound and MRI. If conservative treatment fails, we recommend the closure with mesh patches for large fascial defects

Is the Internal Rotation Lag Sign a Sensitive Test for Detecting Hip Abductor Tendon Ruptures after Total Hip Arthroplasty?

INTRODUCTION: Total hip arthroplasty (THA) is one of the most frequently performed procedures in orthopaedics and weakness of external rotators is often recognized thereafter. However, the etiology of lateral hip pain is multifaceted. For the diagnosis of abductor tendon rupture, magnetic resonance imaging (MRI) is the gold standard. As not every patient can be subjected to MRI, a clinical diagnostic test for easy detection of lesions of the abductor tendon is missing. Here, we present the internal rotation lack sign indicating abductor tendon pathology. METHODS: The patient is placed in lateral position on a stretcher with hips and knees in neutral position. The knee is flexed to 45° and the hip passively abducted and elevated by the investigator. With the foot passively abducted, the patient is then asked to bring his knee in direction to the examination table. This motion is also tested passively. The test is regarded positive, if no internal rotation is possible and/or if this is painful. If groin pain is elicited during either of the exercises, the test is also rated positive. RESULTS: We evaluated this test in 20 patients clinically and by magnetic resonance imaging (MRI). All patients demonstrated a positive internal rotation lag sign. Twelve of them lag of internal rotation and evidence of anterior abductor tendon rupture on MRI, 8 with lag of internal rotation and no evidence of abductor tendon rupture. CONCLUSION: The new clinical diagnostic sign presented here may improve the diagnosis of abductor tendon rupture in the future.Level of Evidence: Diagnostic study, level I

Mediale Abstützung mit kortikalem intramedullärem Interponat bei winkelstabiler Plattenosteosynthese der proximalen Humerusfraktur: Fallbericht und Literaturübersicht

Zusammenfassung: Die Versorgung der osteoporotischen, dislozierten proximalen Humerusfraktur stellt - auch nach Entwicklung neuer Implantate - weiterhin eine technische und chirurgische Herausforderung dar. Die winkelstabile Plattenosteosynthese hat sich dabei als ein Standardverfahren durchgesetzt. Dennoch sind die Komplikationsraten unbefriedigend, insbesondere hinsichtlich Varusdislokation und Penetration der proximalen Schrauben durch die Kopfkalotte. In der aktuellen Literatur wird die Wiederherstellung der medialen Abstützung als wichtigstes Ziel der operativen Versorgung genannt. Der vorliegende Artikel demonstriert anhand eines Fallbeispiels die Alternative einer intramedullären Augmentation und erläutert das Konzept der medialen Abstützung bei der winkelstabilen Plattenosteosynthese proximaler Humerusfrakturen. Es werden diesbezüglich Möglichkeiten, Ergebnisse und Empfehlungenunterschiedlicher Verfahren vorgestellt. Diskutiert werden die Bedeutung einer korrekten Reposition der medialen Kortizes, die Verwendung von Kalkarschrauben, die Doppelplattenosteosynthese sowie das vorgestellte Verfahren der intramedullären Augmentatio

Cement-augmented dorsal instrumentation of the spine as a safe adjunct to the multimodal management of metastatic pheochromocytoma: a case report

Malignant pheochromocytoma is a neuroendocrine tumor that originates from chromaffin tissue. Although osseous metastases are common, metastatic dissemination to the spine rarely occurs

Mechanical testing of a device for subcutaneous internal anterior pelvic ring fixation versus external pelvic ring fixation

BACKGROUND: Although useful in the emergency treatment of pelvic ring injuries, external fixation is associated with pin tract infections, the patient’s limited mobility and a restricted surgical accessibility to the lower abdomen. In this study, the mechanical stability of a subcutaneous internal anterior fixation (SIAF) system is investigated. METHODS: A standard external fixation and a SIAF system were tested on pairs of Polyoxymethylene testing cylinders using a universal testing machine. Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz with sinusoidal lateral compression/distraction (+/−50 N) and torque (+/− 0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700 and 900 cycles. RESULTS: There was no significant difference in translational stiffness between the SIAF and the standard external fixation when compared at 500 (p = .089), 700 (p = .081), and 900 (p = .266) cycles. Rotational stiffness observed for the SIAF was about 50 percent higher than the standard external fixation at 300 (p = .005), 500 (p = .020), and 900 (p = .005) cycles. No loosening or failure of the rod-pin/rod-screw interfaces was seen. CONCLUSIONS: In comparison with the standard external fixation system, the tested device for subcutaneous internal anterior fixation (SIAF) in vitro has similar translational and superior rotational stiffness

Biomechanical comparison of different external fixation configurations for posttraumatic pelvic ring instability

Background. External fixation is useful in the primary treatment of pelvic ring injuries. The present study compared the biomechanical stability of five different configurations of an external pelvic ring fixation system. Methods. Five configurations of an anterior external pelvic ring fixation system were tested using a universal testing machine. One single connecting rod was used in group “SINGLE,” two parallel connecting rods in group “DOUBLE,” two and four rods, respectively, in a tent-like configuration in groups “SINGLE TENT” and “DOUBLE TENT,” and a rhomboid-like configuration in group “RHOMBOID.” Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz lateral compression/distraction (±50 N) and torque (±0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700, and 900 cycles. Results. The “SINGLE TENT” and “RHOMBOID” configurations already failed with a preloading of 50 N compression force. The “DOUBLE” configuration had around twice the translational stability compared with the “SINGLE” and “DOUBLE TENT” configurations. Rotational stiffness observed for the “DOUBLE” and “DOUBLE TENT” configurations was about 50% higher compared to the SINGLE configuration. Conclusion. Using two parallel connecting rods provides the highest translational and rotational stability

Cross-Talk between TLR4 and FcγReceptorIII (CD16) Pathways

Pathogen-pattern-recognition by Toll-like receptors (TLRs) and pathogen clearance after immune complex formation via engagement with Fc receptors (FcRs) represent central mechanisms that trigger the immune and inflammatory responses. In the present study, a linkage between TLR4 and FcγR was evaluated in vitro and in vivo. Most strikingly, in vitro activation of phagocytes by IgG immune complexes (IgGIC) resulted in an association of TLR4 with FcγRIII (CD16) based on co-immunoprecipitation analyses. Neutrophils and macrophages from TLR4 mutant (mut) mice were unresponsive to either lipopolysaccharide (LPS) or IgGIC in vitro, as determined by cytokine production. This phenomenon was accompanied by the inability to phosphorylate tyrosine residues within immunoreceptor tyrosine-based activation motifs (ITAMs) of the FcRγ-subunit. To transfer these findings in vivo, two different models of acute lung injury (ALI) induced by intratracheal administration of either LPS or IgGIC were employed. As expected, LPS-induced ALI was abolished in TLR4 mut and TLR4−/− mice. Unexpectedly, TLR4 mut and TLR4−/− mice were also resistant to development of ALI following IgGIC deposition in the lungs. In conclusion, our findings suggest that TLR4 and FcγRIII pathways are structurally and functionally connected at the receptor level and that TLR4 is indispensable for FcγRIII signaling via FcRγ-subunit activation

Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report

Atlantoaxial rotatory subluxation is rarely caused by trauma in adults. Usually, the treatment of choice is traction using Halo/Gardner-Wells fixation devices for up to six weeks. CASE PRESENTATION: We present the case of a 19-year-old Caucasian woman with traumatic atlantoaxial subluxation. Early reduction three hours after trauma and immobilization using only a soft collar were performed and yielded very good clinical results. CONCLUSION: In the adult population, atlantoaxial subluxation is a rare condition but is severe if untreated. Early treatment implies a non-surgical approach and a good outcome. Conservative treatment is the recommended first step for this condition