Search Results

You are looking at 1 - 5 of 5 items for

  • Author: Hagen Schmal x
Clear All Modify Search
Morten Schultz Larsen Department of Orthopaedics and Traumatology, Odense University Hospital, Denmark

Search for other papers by Morten Schultz Larsen in
Google Scholar
PubMed
Close
and
Hagen Schmal Department of Orthopaedics and Traumatology, Odense University Hospital, Denmark

Search for other papers by Hagen Schmal in
Google Scholar
PubMed
Close

  • Atypical femoral fractures (AFF) are stress or ‘insufficiency’ fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. While these drugs are beneficial for the intact osteoporotic bone, they probably prevent a stress fracture from healing which thus progresses to a complete fracture.

  • Key features of atypical femoral fractures, essential for the diagnosis, are: location in the subtrochanteric region and diaphysis; lack of trauma history and comminution; and a transverse or short oblique configuration.

  • The relative risk of patients developing an atypical femoral fracture when taking bisphosphonates is high; however, the absolute risk of these fractures in patients on bisphosphonates is low, ranging from 3.2 to 50 cases per 100,000 person-years.

  • Treatment strategy in patients with AFF involves: radiograph of the contralateral side (computed tomography and magnetic resonance imaging should also be considered); dietary calcium and vitamin D supplementation should be prescribed following assessment; bisphosphonates or other potent antiresorptive agents should be discontinued; prophylactic surgical treatment of incomplete AFF with cephalomedullary nail, unless pain free; cephalomedullary nailing for surgical fixation of complete fractures; avoidance of gaps in the lateral and anterior cortex; avoidance of varus malreduction.

Cite this article: EFORT Open Rev 2018;3:494-500. DOI: 10.1302/2058-5241.3.170070.

Open access
Andreas Frodl Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Andreas Frodl in
Google Scholar
PubMed
Close
,
Benjamin Erdle Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Benjamin Erdle in
Google Scholar
PubMed
Close
, and
Hagen Schmal Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
University Hospital Odense, Dep. Of Orthopedic Surgery, Sdr. Boulevard 29, 5000 Odense C, Denmark

Search for other papers by Hagen Schmal in
Google Scholar
PubMed
Close

  • Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

  • We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

  • A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

  • Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Open access
Pernille Bovbjerg Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark

Search for other papers by Pernille Bovbjerg in
Google Scholar
PubMed
Close
,
Ditte Høgh Department of Orthopedic Surgery, Hospital of Southern Denmark, Odense, Denmark

Search for other papers by Ditte Høgh in
Google Scholar
PubMed
Close
,
Lonnie Froberg Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark

Search for other papers by Lonnie Froberg in
Google Scholar
PubMed
Close
,
Hagen Schmal Department of Orthopedic Surgery, Odense University Hospital, Odense, Denmark
Clinic of Orthopaedic Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

Search for other papers by Hagen Schmal in
Google Scholar
PubMed
Close
, and
Moustapha Kassem Department of Endocrinology, Odense University Hospital, Odense, Denmark

Search for other papers by Moustapha Kassem in
Google Scholar
PubMed
Close

  • The aging of our society is associated with an increasing number of insufficiency fractures of the pelvis and the current standard of care is pain control and early mobilization. The aim of this study was to explore whether parathyroid hormone (PTH) treatment can support bone healing in these patients.

  • We conducted a systematic review searching the databases PubMed, Embase and Cochrane. Our primary outcome was fracture healing, secondary outcome measures comprised pain, mobility and patient-reported outcome measures (PROMs).

  • Eight articles were included in the qualitative synthesis, of which two were included in a meta-analysis. However, only three studies were comparative including one randomized controlled trial. Fracture healing and reported pain were assessed after eight weeks, and were significantly improved in the group being treated with PTH (p < 0.01) in the meta-analysis. All articles described a positive effect for PTH on fracture healing and pain.

  • Our systematic review indicates that there is a positive effect of PTH treatment on healing and pain in patients with insufficiency fracture in the pelvic ring, but further research is necessary.

Cite this article: EFORT Open Rev 2021;6:9-14. DOI: 10.1302/2058-5241.6.200029

Open access
Andreas Frodl Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Andreas Frodl in
Google Scholar
PubMed
Close
,
Johannes Hauss Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Johannes Hauss in
Google Scholar
PubMed
Close
,
Andreas Fuchs Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Andreas Fuchs in
Google Scholar
PubMed
Close
,
Markus Siegel Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Markus Siegel in
Google Scholar
PubMed
Close
,
Hagen Schmal Department of Orthopedic Surgery, University Hospital Odense, Odense, Denmark

Search for other papers by Hagen Schmal in
Google Scholar
PubMed
Close
, and
Jan Kühle Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

Search for other papers by Jan Kühle in
Google Scholar
PubMed
Close

Purpose

  • The fixation method of distal, extra-articular femur fractures is a controversially discussed. To ensure better stability itself, earlier mobilization and to prevent blood loss – all these are justifications for addressing the femur via reamed intramedullary nailing (RIMN). Anatomical reposition of multifragmentary fractures followed by increased risks of non-union are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of non-union and wound infection, as well as blood loss and time of surgery.

Methods

  • According to the PRISMA guidelines we conducted this systematic review by searching the Cochrane, PubMed, Ovid, MedLine, and Embase databases. Inclusion criteria were the modified Coleman methodology score (mCMS) >60, age >18 years, and extra-articular fractures of the distal femur. Biomechanical and animal studies were excluded. By referring to title and abstract relevant articles were reviewed independently. In the consecutive meta-analysis, we compared 9 studies and 639 patients.

Results

  • There is no statistically significant difference comparing superficial wound infections when RIMN was performed (OR = 0.50; 95% CI: 0.18 – 1.42; P = 0.19) as well as in deep wound infections (OR = 0.74; 95% CI: 0.19–2.81; P = 0.62). However, these results were not significant. We also calculated for potential differences in the rate of non-unions depending on the surgical treatment applied. Data of 556 patients revealed an overall number of 43 non-unions. There was no significant difference in rate of non-unions between both groups (OR = 0.97; 95% CI: 0.51–1.85; P = 0.92).

Conclusion

  • No statistical difference was found in our study among RIMN and plate fixation in the treatment of distal femoral fractures with regard to the incidence of non-union and wound infections. Therefore, the indication for RIMN or plating should be made individually and based on the surgeon’s experience.

Open access
Hagen Schmal Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.
Department of Orthopaedics and Traumatology, Freiburg University Hospital, Freiburg, Germany.

Search for other papers by Hagen Schmal in
Google Scholar
PubMed
Close
,
Michael Brix Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.

Search for other papers by Michael Brix in
Google Scholar
PubMed
Close
,
Mats Bue Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark

Search for other papers by Mats Bue in
Google Scholar
PubMed
Close
,
Anna Ekman Orthopaedic Department, Södersjukhuset, Stockholm, Sweden

Search for other papers by Anna Ekman in
Google Scholar
PubMed
Close
,
Nando Ferreira Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa

Search for other papers by Nando Ferreira in
Google Scholar
PubMed
Close
,
Hans Gottlieb Department of Orthopaedic Surgery, Herlev Hospital, Herlev, Denmark

Search for other papers by Hans Gottlieb in
Google Scholar
PubMed
Close
,
Søren Kold Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg University, Aalborg, Denmark

Search for other papers by Søren Kold in
Google Scholar
PubMed
Close
,
Andrew Taylor Department of Orthopaedic Surgery, Nottingham University Hospitals, UK

Search for other papers by Andrew Taylor in
Google Scholar
PubMed
Close
,
Peter Toft Tengberg Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

Search for other papers by Peter Toft Tengberg in
Google Scholar
PubMed
Close
,
Ilija Ban Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

Search for other papers by Ilija Ban in
Google Scholar
PubMed
Close
, and
Danish Orthopaedic Trauma Society Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

Search for other papers by Danish Orthopaedic Trauma Society in
Google Scholar
PubMed
Close

  • Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

  • Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

  • The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

  • The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

  • Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

  • The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

Open access