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Background/Objectives : A neck of femur (NOF) fracture is one of the most common fractures, and its treatment in the geriatric population using cemented bipolar hemiarthroplasty (HA) is a standard procedure worldwide. Various surgical approaches have been described for this operation, aiming to reduce complications and improve early mobilization. The present study compares two minimally invasive approaches, the anterolateral minimally invasive approach (ALMIS) and the direct superior approach (DSA), with respect to their intraoperative and early postoperative complications in cemented bipolar HA. Methods : The medical records of all patients undergoing cemented bipolar HA for a NOF fracture between January 2017 and December 2023 were analyzed. The aim of the study was to compare the two surgical approaches. The evaluation focused on intraoperative parameters and early complications. Results : A total of 226 patients were included in the analysis, with 62 undergoing DSA and 164 ALMIS, with an average age of 83.5 years. The two approaches did not differ significantly in terms of stem implantation quality, length of hospital or intensive care unit stay, postoperative mobilization, or the need for transfusions. However, the ALMIS was associated with a significantly shorter operative time (DSA: 89.7 min vs. ALMIS: 77.2 min; p < 0.01). On the other hand, the DSA had a significantly lower complication rate (DSA: 0/61 vs. ALMIS: 11/163; p = 0.04). Conclusions : In a comparison of the two minimally invasive approaches, DSA and ALMIS, for treating a NOF fracture with cemented bipolar HA, the DSA demonstrated a lower complication rate, though it had a slightly longer operating time.

Objective: Diabetes mellitus (DM) is an important risk factor for the development of osteoarthritis (OA), increasing OA progression and OA pain. To gain insight into the underlying mechanisms of how DM exacerbates OA processes and OA pain, this study analyzed histological differences of synovial tissues from non-DM and DM patients with OA and correlated these differences with knee pain severity., Materials and Methods: Synovial tissue was obtained from 12 non-DM and 10 DM patients with advanced knee OA who underwent total knee arthroplasty. Synovial inflammation was assessed using the Synovitis score developed by Krenn. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to assess knee pain intensity and disability in OA patients. The number of mast cells, macrophages, nerve fibers, capillaries, larger vessels and erythrocyte extravasation were analyzed microscopically in histological and immunostained synovial sections from non-DM and DM patients. Association analyses were performed to determine associations between OA knee pain and synovial changes affected by DM., Results: Synovial tissue from OA patients with DM had a higher synovitis score, more erythrocyte extravasation, and contained higher numbers of mast cells and macrophages compared to non-DM patients. The number of capillaries and vessels in the lining/sublining layer of the synovial tissue was reduced in DM patients. OA patients with DM had more severe knee pain compared to non-DM patients. The KOOS pain score was associated with the synovitis score, the number of tissue macrophages, and the number of mast cells in the synovial tissue (adjusted for age, sex, and BMI). In addition, the erythrocyte extravasation score was associated with the KOOS pain score and with the synovitis score., Conclusion: The study suggests that increased OA progression and pain severity in patients with DM result from more pronounced synovitis and synovial vascular leakage and increased infiltration of macrophages and mast cells., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Eitner, Rutte, Marintschev, Hofmann and Schaible.)

Background: Metastatic bone disease (MBD) and its complications have a significant impact on patients' quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system., Case Presentation: Case 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL ® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved. Case 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin's lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred., Conclusions: The cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL ® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility., (© 2024. The Author(s).)

When treating ankle fractures, the question of syndesmosis complex involvement often arises. So far, there is no standardized method to reliably detect syndesmosis injuries in the surgical treatment of ankle fractures. For this reason, an intraoperative syndesmosis-test-tool (STT) was developed and compared to the recommended and established hook-test (HT). Tests were performed on cadaveric lower legs (n = 20) and the diastasis was visualized by 3D camera. Tests were performed at 50, 80, and 100 N in native conditions and four instability levels. Instability was induced from anterior to posterior and the reverse on the opposite side. The impact on diastasis regarding the direction, the force level, the instability level, and the device used was checked using a general linear model for repeated measurement. The direction of the induced instability showed no influence on the diastasis during the stability tests. The diastasis measured with the STT increased from 0.5 to 3.0 mm depending on the instability, while the range was lower with the HT (1.1 to 2.3 mm). The results showed that the differentiation between the instability levels was statistically significantly better for the developed STT. The last level of maximum instability was significantly better differentiable with the STT compared to the HT. An average visualizable diastasis of more than 2 mm could only be achieved at maximum instability. In conclusion, the newly developed STT was superior to the commonly used HT to detect instability., (© 2024. The Author(s).)

Purpose: Dorsal pelvic ring fractures may result from high energy trauma in younger patients or from osteoporosis as fragility fractures in elderly patients. To date, no strong consensus exists on the best surgical technique to treat posterior pelvic ring injuries. The aim of this study was to evaluate the surgical performance of a new implant for angle-stable fixation of the posterior pelvic ring and patient outcome., Methods: In a prospective pilot study, 27 patients (age: 39-87 years) with posterior pelvic ring fractures classified according to the AO classification (n = 5) or to the fragility fractures of the pelvis (FFP) classification (n = 22) were treated using the new implant. During a follow-up period of 1 year, surgical parameters of the implantation technique, complication rate, morbidity, mortality, preservation of patient mobility, and social independence were evaluated., Results: No implant misplacement or failure was observed. Two patients developed symptomatic spinal canal stenosis at L4/L5 following mobilization. MRI diagnosis proved the implant was not responsible for the symptoms. In one case, an additional plate stabilization of a pubic ramus fracture was necessary 6 months later. There was no inpatient mortality. One patient died due to her underlying oncological disease within the first 3 months. The main outcome parameters were pain, mobility, preservation of independent living and employment., Conclusion: Operative instrumentation of dorsal pelvic ring fractures should be stable enough to allow for immediate weight bearing. The new locking nail implant offers percutaneous reduction and fixation options and may decrease the generally observed rate of complications., Trail Registration: German Clinical Trials Register ID: DRKS00023797, date of registration: 07.12.2020., (© 2023. The Author(s).)

SuperPATH is a novel approach to the hip joint that needs to be compared to other known surgical approaches. To conduct a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing short-term outcomes of SuperPATH, direct anterior (DAA), and posterior/ posterolateral approaches (PA) in total hip joint arthroplasty (THA). We performed a systematic review on PubMed, CNKI, Embase, The Cochrane Library, Clinical trials, and Google Scholar up to November 30th, 2021. We assessed treatment effects between SuperPATH, DAA, and PA by performing a frequentist NMA, including a total of 20 RCTs involving 1501 patients. SuperPATH showed a longer operation time (MD = 16.99, 95% CI 4.92 to 29.07), a shorter incision length (MD = -4.71, 95% CI -6.21 to -3.22), a lower intraoperative blood loss (MD = -81.75, 95% CI  -114.78 to -48.72), a higher HHS 3, 6 and 12 months postoperatively (MD = 2.59, 95% CI 0.59-4.6; MD = 2.14, 95% CI 0.5-3.77; MD = 0.6, 95% CI 0.03-1.17, respectively) than PA. DAA showed a higher intraoperative blood loss than PA and SuperPATH (MD = 91.87, 95% CI  27.99-155.74; MD = 173.62, 95% CI 101.71-245.53, respectively). No other relevant differences were found. In conclusion, the overall findings suggested that the short-term outcomes of THA through SuperPATH were statistically superior to PA. DAA and PA as well as SuperPATH and DAA showed indifferent results., (© 2022. The Author(s).)

Background: Various plate shapes and implant configurations are used for stabilization of acetabulum fractures via anterior approaches. Little is known about the biomechanical stability of a two-dimensionally shaped "conventional" plate ("J-Plate"-JP) in comparison to three-dimensionally shaped plate configurations (3DP). In addition, the augmentary effect of an infra-acetabular lag-screw (IACS) fixation for anterior column and posterior hemi-transverse acetabulum fractures has not been clarified in comparison of JP and 3DP constructs. This study analyzed the difference between the biomechanical stability of JP compared to 3DP and the role of an IACS in a standardized acetabular fracture model in a single-leg stance loading configuration., Methods: In an artificial bone substitute pelvis model (Synbone © Malans, Switzerland), a typical and standardized fracture pattern (anterior column and posterior hemi-transverse) was created with osteotomy jigs. After anatomic reduction the stabilization was performed using JP or 3DP. Eight pelvises per group were axially loaded in a single-leg stance model up to 400 N. After the load cycle, an additional infra-acetabular screw was placed and the measurement repeated. Fragment displacement was recorded by an optical tracking system (Optitrack Prime 13®, Corvallis, USA)., Results: In the pure placement, 3DP provided significantly superior stability when compared to JP. Augmentation of JP by IACS increased the stability significantly, up to the level of 3DP alone, whereas augmentation of the 3DP did not result in further increase of overall stability., Conclusion: The anatomically shaped plate alone provides a superior biomechanical stability in fixation of an anterior column and posterior hemi-transverse fracture model. In a JP fixation the augmentation by IACS provides similar strength as the anatomically shaped 3DP. By use of the anatomically shaped 3DP the need of a clinically risky application of IACS might be avoidable., Level of Evidence: IV, Experimental study., (© 2021. The Author(s).)

Background: Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs) - the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, these three approaches have never been ranked in a network meta-analysis (NMA) before. Therefore, we conducted a systematic review and NMA of randomized controlled trials comparing short-term outcomes of DAA, SuperPATH and CAs in total hip joint arthroplasty (THA), using CAs as common comparator., Methods: A systematic literature search up to February 2021 was performed to identify randomized controlled trials (RCTs) comparing DAA with CAs and SuperPATH with CAs in THA. We measured surgical, functional and radiological outcomes. A NMA, using frequentist methods was performed to assess treatment effects between DAA, SuperPATH and CAs. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator., Results: A total of 24 RCTs involving 2,074 patients met the inclusion criteria, six trials with a level I evidence, 18 trials with level II evidence. SuperPATH reduced operation time (fixed effects model: MD=8.1, 95% CI: 5.7 to 10.4), incision length (fixed effects model: MD=2.7, 95%CI: 2.5 to 2.9; random effects model: MD=4.1, 95%CI: 0.6 to 7.6), intraoperative blood loss (fixed effects model: MD=157, 95%CI: 139.2 to 174.2; random effects model: MD=129, 95%CI: 11.5 to 245.7) and early pain intensity (VAS 1 day postoperatively with a fixed effects model: MD=0.8, 95%CI: 0.4 to 1.2) compared to DAA. The two approaches did not differ in functional outcome and in acetabular cup inclination positioning., Conclusions: Our overall findings suggest that short-term outcomes of THA through SuperPATH were superior to DAA and CAs and that short-term outcomes of THA through DAA were superior to CAs., Level of Evidence: II; systematic review with level I studies and level II studies., (Copyright © 2021 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background: Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA)., Methods: A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator., Results: A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome., Conclusions: Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Background: Incorrect screw placement and penetration in screw fixation of scaphoid fractures are found in 5 to 30 %. Therefore, optimizing of screw placement is desirable, especially because an exact central position of the screw in the proximal fragment leads to a significant higher stability as a more peripheral position., Patients Und Methods: 36 patients with an acute non-displaced scaphoid fracture were included in this randomized prospective study. 18 patients underwent navigated, the other 18 conventional percutaneous screw fixation of an acute non-displaced scaphoid fracture through a dorsal approach. Operation time and x-ray dose were measured. In both groups the position of the screw in the scaphoid was calculated on CT scans and compared with each other. Clinically, 17 patients with navigated and 11 with conventional percutaneous screw fixation with an average age of 52 resp. 43.2 years were available for follow-up examination including Krimmer- and DASH-score., Results: All scaphoids healed within an adequate time. Two cases of navigated screw fixation have been converted to conventional percutaneous screw fixation. The average operation time in the navigated group was 83.2 minutes, in the conventional group 42.1 minutes. X-ray dose measured 106,5 ± 19,9cGy/cm 2 in the navigated group and 45,6 ± 8,0cGy/cm 2 in the conventional group. Screw penetration using an intraosseous compression screw (HSC) was observed in 5 conventionally fixed scaphoids, 4 distally (2,27 ± 1,47 mm), 1 proximally. In the navigated group there were 11 screw penetrations, 4 proximally (2,01 ± 0,81 mm) and distally (1,21 ± 0,64 mm), 3 distally (1,18 ± 0,44 mm), and 4 proximally (1,61 ± 0,57 mm). Axial screw position was more accurate in the conventional group. The 17 navigated patients averaged a Krimmer-Score of 83.6 and a DASH-score of 5,6 points at follow-up. The 11 conventional treated patients averaged a Krimmer-Score of 95 and a DASH-score of 8.0 points at follow-up., Conclusion: In this study navigated screw fixation of acute non-displaced scaphoid fractures was not superior to conventional percutaneous screw fixation, neither for screw position, screw penetration nor with respect to the clinical outcome., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Fractures of the pelvic ring in elderly patients have increased in frequency over time. These injuries are associated with a high morbidity and have a socio-economic impact. The diagnostic procedures and their influence of therapy decisions are still controversial., Methods: In a retrospective study, we investigate the value of additional MRI examination on therapy decision of fragility fractures of the pelvis. The evaluation of all patients with pelvic fractures without adequate trauma and with performed CT and MRI was conducted at three large German hospitals. The imaging procedure took place within a maximum interval of 4 weeks. After evaluation of the imaging, the resulting therapeutic consequences either based on CT alone or on CT and MRI were reviewed by experienced pelvic surgeons., Results: Of 754 patients with pelvic injuries, 67 (age 80 +/- 9.7 years, f: m 54:13) could be included. The detection of vertical fractures in CT (n = 40 unilateral, n = 11 bilateral) could be increased by the additional MRI (n = 44 unilateral, n = 23 bilateral). A horizontal fracture component was identified in CT in 9.0% (n = 6) vs. MRI in 25.4% (n = 17) of the cases. An anterior pelvic ring injury was detected in 71.6% (n = 44; 4x bilateral) in CT, in 80.6% in MRI (n = 50, 4 bilateral). Additive MRI imaging increased the decision rate for surgical therapy from 20.9% (n = 14) to 31.3% (n = 21)., Conclusions: The results of this study further support the value of bone marrow edema detection by MRI diagnostics (or dual source CT which showed promising initial results) for the detection of pelvic ring fractures. For the first time, the study identifies an additional therapeutic consequence by an increased rate of surgical procedures., Competing Interests: The authors have declared that no competing interests exist.

Different multiplanar reformation (MPR-512 and -256) algorithms of intraoperative acquired 3-D-fluoroscopy data exist without recommendations for use in the literature. To compare algorithms, 3-D-fluoroscopic data sets of 46 radius fractures were blinded and processed using MPR-256 and -512 (Ziehm, Vision-Vario 3D). Each reformatted data set was analysed to evaluate image quality, fracture reduction quality and screw misplacements. Overall image quality was higher rated in the MPR-512 compared with the MPR-256 (3.2 vs. 2.2 points, scale 1-5 points), accompanied by a reduced number of scans that could not be analysed (10 vs. 19%). Interobserver evaluation of fracture reduction quality was fair to moderate (independent of the algorithm). In contrast, for screw misplacements MPR-depended ratings were found (MPR-256: fair to moderate; MPR-512: moderate to substantial). Optimization of post-processing algorithms, rather than modifications of image acquisition, may increase the image quality for assessing implant positioning, but limitations in evaluating fracture reduction quality still exist.

Purpose: Secondary hip osteoarthritis after acetabular fractures requiring total arthroplasty (THA) poses a huge burden on the affected patients as well as health systems. The present study aimed to assess risk factors associated with THA after acetabular fractures based on the data from the German Pelvic Trauma Registry., Methods: Retrospective analysis of 678 acetabular fracture cases without concomitant pelvic ring fracture treated and followed-up between January 2004 and May 2015 at six large trauma centres. Multivariate Cox regression analysis was performed assessing the association of patient/treatment characteristics with THA likelihood at an average follow-up of 2.7 years (range 0.4-9.5 years; SD 1.8 years)., Results: Overall, the rate of secondary osteoarthritis was 19.8%. The likelihood for THA increased with 6% per age year (95% CI 1.04-1.09) and with 21% per millimetre subluxation (95%CI 1.09-1.33). This likelihood was 3.54 (95% CI 1.77-7.08) and 3.68 times (95% CI 1.87-7.47) higher if the posterior wall was involved and a contusion and/or impaction of the femoral head was present. Other covariates (sex, ISS, trauma type, AO/OTA and Letournel classification, initial displacement, surgical approach, intra-articular fragments, contusion and/or impaction to the acetabulum, reduction, intervention type, duration of surgery, soft tissue damage, residual fracture step/gap, and prevention of heterotopic ossifications) were not significantly associated (p > 0.15)., Conclusions: Twenty percent of patients with acetabular fractures require THA. The associated risk factors are patient age, femoral head lesion/subluxation, and involvement of the posterior wall. The identified risk factors support previous research and should be minded when treatment of acetabular fractures is planned.

(1) Can iliosacral osseous corridor diameters in sacral dysmorphism be enlarged by in-out-in screw placement at the posterior iliosacral recessus? (2) Are lumbosacral transitional vertebra (LSTV) the anatomical cause for sacral dysmorphism? (3) Are there sex-specific differences in sacral dysmorphism? 594 multislice CT scans were screened for sacral dysmorphism and 55 data-sets selected. Each pelvis was segmented manually and cylindrical iliosacral corridors (on the level of S1 and S2 vertebra) were semi-automatically determined. Corridor trajectories, -diameters and -lengths were measured. LSTV (Castellvi-type IIIb and IV) were found in 3 of 55 pelves and these lumbosacral variations are therefore not the anatomical basis for sacral dysmorphism. The prevalence of transsacral osseous corridors with diameters of <7.5 mm in axial CT images correlates with qualitative and quantitative criteria of sacral dysmorphism. Enlarging the osseous corridor diameters by penetration of the posterior iliosacral recessus increase the safe corridor diameters (females versus males) by 26% versus 15% at the level of S1- and 50% versus 48% at the level of S2-vertebra. Sex-specific differences for both corridors (osseous and in-out-in) were only found for the osseous corridor diameters at the level of S1 vertebra, being smaller in females (females versus males: 13.3 ± 3.6 mm versus 15.5 ± 3.8 mm, p = 0.04). Dysmorphic sacra can be reliably detected on standard axial CT slice images. Modified in-out-in corridors on the level of S1-vertebra allow screw placement in all patients, but is still demanding compared to non-dysmorphic sacra, due to the oblique corridor axis. Recommendations for intraoperative orientation for oblique screw placement are defined. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res., (© 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

The major burden of knee joint osteoarthritis (OA) is pain. Since in elder patients diabetes mellitus is an important comorbidity of OA, we explored whether the presence of diabetes mellitus has a significant influence on pain intensity at the end stage of knee OA, and we aimed to identify factors possibly related to changes of pain intensity in diabetic patients. In 23 diabetic and 47 nondiabetic patients with OA undergoing total knee arthroplasty, we assessed the pain intensity before the operation using the "Knee Injury and Osteoarthritis Outcome Score". Furthermore, synovial tissue, synovial fluid (SF), cartilage, and blood were obtained. We determined the synovitis score, the concentrations of prostaglandin E2 and interleukin-6 (IL-6) in the SF and serum, and of C-reactive protein and HbA1c and other metabolic parameters in the serum. We performed multivariate regression analyses to study the association of pain with several parameters. Diabetic patients had on average a higher Knee Injury and Osteoarthritis Outcome Score pain score than nondiabetic patients (P < 0.001). Knee joints from diabetic patients exhibited on average higher synovitis scores (P = 0.024) and higher concentrations of IL-6 in the SF (P = 0.003) than knee joints from nondiabetic patients. Multivariate regression analysis showed that patients with higher synovitis scores had more intense pain independent of all investigated confounders, and that the positive association between pain intensities and IL-6 levels was dependent on diabetes mellitus and/or synovitis. These data suggest that diabetes mellitus significantly increases pain intensity of knee OA, and that in diabetic patients higher pain intensities were determined by stronger synovitis.

Objectives: Anatomical acetabular plates the anterior intrapelvic approach (AIP) were recently introduced to fix acetabular fractures through the intrapelvic approach. Therefore, we asked the following: (1) Does the preshaped 3-dimensional suprapectineal plate interfere with or even impair the fracture reduction quality? (2) How often does the AIP approach need to be extended by the first (lateral) window of the ilioinguinal approach?, Design: Observational case series., Setting: Two Level 1 trauma centers., Patients/participants: Patients with unstable acetabular fractures in 2014., Intervention: Fracture fixation with anatomical-preshaped, 3-dimensional suprapectineal plates through the AIP approach ± the first window of the ilioinguinal approach., Outcome Measurements: Fracture reduction results were measured in computed tomography scans and graded according to the Matta quality of reduction. Intraoperative parameters and perioperative complications were recorded. Radiological results (according to Matta) and functional outcome (modified Merle d'Aubigné score) were evaluated at 1-year follow-up., Results: Thirty patients (9 women + 21 men; mean age ± SE: 64 ± 8 years) were included. The intrapelvic approach was solely used in 19 cases, and in 11 cases, an additional extension with the first window of the ilioinguinal approach (preferential for 2-column fractures) was performed. The mean operating time was 202 ± 59 minutes; the fluoroscopic time was 66 ± 48 seconds. Fracture gaps and steps in preoperative versus postoperative computed tomography scans were 12.4 ± 9.8 versus 2.0 ± 1.5 and 6.0 ± 5.5 versus 1.3 ± 1.7 mm, respectively. At 13.4 ± 2.9 months follow-up, the Matta grading was excellent in 50%, good in 25%, fair in 11%, and poor in 14% of cases. The modified Merle d'Aubigné score was excellent in 17%, good in 37%, fair in 33%, and poor in 13% of cases., Conclusion: The AIP approach using approach-specific instruments and an anatomical-preshaped, 3-dimensional suprapectineal plate became the standard procedure in our departments. Radiological and functional early results justify joint preserving surgery in most cases., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Percutaneous iliosacral screw placement is the standard procedure for fixation of posterior pelvic ring lesions, although a transsacral screw path is being used more frequently in recent years owing to increased fracture-fixation strength and better ability to fix central and bilateral sacral fractures. However, biomorphometric data for the osseous corridors are limited. Because placement of these screws in a safe and effective manner is crucial to using transsacral screws, we sought to address precise sacral anatomy in more detail to look for anatomic variation in the general population., Questions/purposes: We asked: (1) What proportion of healthy pelvis specimens have no transsacral corridor at the level of the S1 vertebra owing to sacral dysmorphism? (2) If there is no safe diameter for screw placement in the transsacral S1 corridor, is an increased and thus safe diameter of the transsacral S2 corridor expected? (3) Are there sex-specific differences in sacral anatomy and are these correlated with known anthropometric parameters?, Methods: CT scans of pelves of 280 healthy patients acquired exclusively for medical indications such as polytrauma (20%), CT angiography (70%), and other reasons (10%), were segmented manually. Using an advanced CT-based image analysis system, the mean shape of all segmented pelves was generated and functioned as a template. On this template, the cylindric transsacral osseous corridor at the level of the S1 and S2 vertebrae was determined manually. Each pelvis then was registered to the template using a free-form registration algorithm to measure the maximum screw corridor diameters on each specimen semiautomatically., Results: Thirty of 280 pelves (11%) had no transsacral S1 corridor owing to sacral dysmorphism. The average of maximum cylindrical diameters of the S1 corridor for the remaining 250 pelves was 12.8 mm (95% CI, 12.1-13.5 mm). A transverse corridor for S2 was found in 279 of 280 pelves, with an average of maximum cylindrical diameter of 11.6 mm (95% CI, 11.3-11.9 mm). Decreasing transsacral S1 corridor diameters are correlated with increasing transsacral S2 corridor diameters (R value for females, -0.260, p < 0.01; for males, -0.311, p < 0.001). Female specimens were more likely to have sacral dysmorphism (defined as a pelvis without a transsacral osseous corridor at the level of the S1 vertebra) than were male specimens (females, 16%; males, 7%; p < 0.003). Furthermore female pelves had smaller-corridor diameters than did male pelves (females versus males for S1: 11.7 mm [95% CI, 10.6-12.8 mm] versus 13.5 mm [95% CI, 12.6-14.4 mm], p < 0.01; and for S2: 10.6 mm [95% CI, 10.1-11.1 mm] versus 12.2 mm [95% CI, 11.8-12.6 mm ], p < 0.0001)., Conclusions: Narrow corridors and highly individual, sex-dependent variance of morphologic features of the sacrum make transsacral implant placement technically demanding. Individual preoperative axial-slice CT scan analyses and orthogonal coronal and sagittal reformations are recommended to determine the prevalence of sufficient-sized osseous corridors on both levels for safe screw placements, especially in female patients, owing to their smaller corridor diameters and higher rate of sacral dysmorphism.

Although there is ample evidence that intra-articular injuries are associated with the up-regulation of pro-inflammatory cytokines, the success of anti-inflammatory, disease-modifying treatments to prevent posttraumatic osteoarthritis (PTOA) remain uncertain. To summarize the current status of anti-inflammatory therapy for PTOA, we conducted a systematic review. 9 clinical studies in humans were identified applying anti-inflammatory agents to prevent or treat PTOA. A total of 347 patients aged an average 41 ± 14 years were included in this review. 5 studies had comparable designs with randomized allocation. Those studies of course had a statistically significant higher Coleman Methodology Score (65 ± 6) than the case-control studies (39 ± 13, p = 0.013). The most frequently reported main outcome parameter was pain assessed by different scales (n = 7), the most examined joint the knee (n = 7). The majority of the analyses (n = 6) focused on the intra-articular (IA) application of hyaluronic acid (HA) reporting mainly positive effects. One study stated positive results following IA administration of Interleukin 1 receptor antagonist in -patients presenting rupture of the anterior cruciate ligament. Platelet-rich plasma was also used to relieve symptoms following acute injury, but the study quality was too low to conclude any effects. Although the initial data, especially regarding IA HA injection, are encouraging, study designs differ substantially. Therefore, current data does not allow us to conclude that anti-inflammatory therapy following acute injuries has beneficial effects on short- or long-term outcomes.

Background: Volar locking plate fixation has become the gold standard in the treatment of unstable distal radius fractures. Juxta-articular screws should be placed as close as possible to the subchondral zone, in an optimized length to buttress the articular surface and address the contralateral cortical bone. On the other hand, intra-articular screw misplacements will promote osteoarthritis, while the penetration of the contralateral bone surface may result in tendon irritations and ruptures. The intraoperative control of fracture reduction and implant positioning is limited in the common postero-anterior and true lateral two-dimensional (2D)-fluoroscopic views. Therefore, additional 2D-fluoroscopic views in different projections and intraoperative three-dimensional (3D) fluoroscopy were recently reported. Nevertheless, their utility has issued controversies., Objectives: The following questions should be answered in this study; 1) Are the additional tangential view and the intraoperative 3D fluoroscopy useful in the clinical routine to detect persistent fracture dislocations and screw misplacements, to prevent revision surgery? 2) Which is the most dangerous plate hole for screw misplacement?, Patients and Methods: A total of 48 patients (36 females and 13 males) with 49 unstable distal radius fractures (22 x 23 A; 2 x 23 B, and 25 x 23 C) were treated with a 2.4 mm variable angle LCP Two-Column volar distal radius plate (Synthes GmbH, Oberdorf, Switzerland) during a 10-month period. After final fixation, according to the manufactures' technique guide and control of implant placement in the two common perpendicular 2D-fluoroscopic images (postero-anterior and true lateral), an additional tangential view and intraoperative 3D fluoroscopic scan were performed to control the anatomic fracture reduction and screw placements. Intraoperative revision rates due to screw misplacements (intra-articular or overlength) were evaluated. Additionally, the number of surgeons, time and radiation-exposure, for each step of the operating procedure, were recorded., Results: In the standard 2D-fluoroscopic views (postero-anterior and true lateral projection), 22 screw misplacements of 232 inserted screws were not detected. Based on the additional tangential view, 12 screws were exchanged, followed by further 10 screws after performing the 3D fluoroscopic scan. The most lateral screw position had the highest risk for screw misplacement (accounting for 45.5% of all exchanged screws). The mean number of images for the tangential view was 3 ± 2.5 images. The mean surgical time was extended by 10.02 ± 3.82 minutes for the 3D fluoroscopic scan. An additional radiation exposure of 4.4 ± 4.5seconds, with a dose area product of 39.2 ± 14.5 cGy/cm(2) were necessary for the tangential view and 54.4 ± 20.9 seconds with a dose area product of 2.1 ± 2.2 cGy/cm(2), for the 3D fluoroscopic scan., Conclusions: We recommend the additional 2D-fluoroscopic tangential view for detection of screw misplacements caused by overlength, with penetration on the dorsal cortical surface of the distal radius, predominantly observed for the most lateral screw position. The use of intraoperative 3D fluoroscopy did not become accepted in our clinical routine, due to the technical demanding and time consuming procedure, with a limited image quality so far.

It is hypothesized that ilio-sacro-iliacal corridors for a new envisioned pelvic ring implant (trans-sacral nail with two iliacal bolts = ISI-nail: ilio-sacro-iliacal nail) exists on the level of S1- or S2-vertebra in each patient. The corridors of 84 healthy human pelves (42x ♂; 42x ♀, 18-85 years) were measured in high resolution CT scans using the Merlin Diagnostic Workcenter Software. Trans-sacral corridors (≥ 9 mm diameter) on the level of S1 and S2 were found in 62% and 54% of pelves with a mean length [mm ± SD] of 164 ± 12.9 and 142 ± 10.2. Corresponding iliac corridors were present in all specimens in caudally tilted axial planes of 37.8 ± 0.67° and 53.7 ± 0.94° in relation to the operating table plane and divergent angulations of 69.0 ± 0.49° and 70.1 ± 0.32° in relation to the sagittal midline plane. Sacral dysmorphism, with compensatory larger S2 corridors were prevalent in 24% of pelves; ilio-sacro-iliacal osseous corridors for the envisioned implant were found in 88% of pelves on the level of S1 or S2. In the remaining 12% with too narrow corridors for any trans-sacral implant (screws, bars, ISI nail) alternative fixation methods have to be considered. Expected advantages of the envisioned ISI nail compared to available fixation devices are discussed., (© 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: An infraacetabular screw path facilitates the closure of a periacetabular fixation frame to increase the plate fixation strength in acetabular fractures up to 50%. Knowledge of the variance in corridor sizes and axes has substantial surgical relevance for safe screw placement., Questions/purposes: (1) What proportion of healthy pelvis specimens have an infraacetabular corridor that is 5 mm or larger in diameter? (2) Does a universal corridor axis and specific screw entry point exist? (3) Are there sex-specific differences in the infraacetabular corridor size or axis and are these correlated with anthropometric parameters like age, body weight and height, or the acetabular diameter?, Methods: A template pelvis with a mean shape from 523 segmented pelvis specimens was generated using a CT-based advanced image analyzing system. Each individual pelvis was registered to the template using a free-form registration algorithm. Feasible surface regions for the entry and exit points of the infraacetabular corridor were marked on the template and automatically mapped to the individual samples to perform a measurement of the maximum sizes and axes of the infraacetabular corridor on each specimen. A minimum corridor diameter of at least 5 mm was defined as a cutoff for placing a 3.5-mm cortical screw in clinical settings., Results: In 484 of 523 pelves (93%), an infraacetabular corridor with a diameter of at least 5 mm was found. Using the mean axis angulations (54.8° [95% confidence interval {CI}, 0.6] from anterocranial to posterocaudal in relation to the anterior pelvic plane and 1.5° [95% CI, 0.4] from anteromedial to posterolateral in relation to the sagittal midline plane), a sufficient osseous corridor was present in 64% of pelves. Allowing adjustment of the three-dimensional axis by another 5° included an additional 25% of pelves. All corridor parameters were different between females and males (corridor diameter, 6.9 [95% CI, 0.2] versus 7.7 [95% CI, 0.2] mm; p<0.001; corridor length, 96.2 [95% CI, 0.7] versus 106.4 [95% CI, 0.6] mm; p<0.001; anterior pelvic plane angle, 54.0° [95% CI, 0.9] versus 55.3° [95% CI, 0.8]; p<0.01; sagittal midline plane angle, 4.3° [95% CI, 0.6] versus -0.3° [95% CI, 0.5]; p<0.001)., Conclusion: This study provided reference values for placement of a 3.5-mm cortical screw in the infraacetabular osseous corridor in 90% of female and 94% of male pelves. Based on the sex-related differences in corridor axes, the mean screw trajectory is approximately parallel to the sagittal midline plane in males but has to be tilted from medial to lateral in females. Considering the narrow corridor diameters, we suggest an individual preoperative CT scan analysis for fine adjustments in each patient.

Background: Non-destructive techniques for the detection and classification of pathological changes of cartilage in the early stages of osteoarthritis are required for arthroscopic and open surgery of joints. Biochemical and histological changes in cartilage with different degrees of destruction were analysed and correlated to changes in the spectroscopic characteristics of cartilage., Patients, Material and Methods: 24 patients (n = 25 knees) with severely destructed knee joints received total knee replacement. The cartilage of the resected joints was classified according to the ICRS system. Defined cartilage specimens were investigated spectroscopically employing NIRS (near-infrared spectroscopy). In the following the cartilage specimens were harvested to determine the content of proteoglycan (GAG) and hydroxyproline (HP) as an essential part of collagen. Histological evaluation of the Mankin score and Otte score was performed using haematoxylin/eosin and safranin-O staining. Spearman's rank correlation coefficient was used to characterise links between the parameters investigated., Results: We found significant correlations between spectroscopic, histological and biochemical characteristics. NIRS corresponded to the content of GAG (ρ = 0.58) and HP (ρ = 0.59), as well as to the Mankin (ρ = 0.55) and Otte (ρ = 0.5) scores. Furthermore, the ICRS classification correlated with histological evaluation (Mankin score ρ = 0.725 and Otte score ρ = 0.736), as to be expected., Conclusion: Characteristic cartilage changes in different degrees of osteoarthritis can be detected and evaluated by the spectroscopic method NIRS as a non-destructive technique. However, the quality of this technical evaluation cannot compete with biochemical and histological analysis., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function., Methods: A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay., Results: The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01)., Conclusions: In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

To determine bone morphogenetic protein (BMP)-2 protein and Aggrecan in osteoarthritic and healthy cartilage with special regard to localization and degree of cartilage damage 95 samples representing osteoarthritic cartilage and 17 samples out of normal cartilage were graded histological by Mankin Score and were studied by immunohistochemistry for the expression of BMP-2 and Aggrecan. BMP-2 protein was detected intracellular in normal and in osteoarthritic cartilage. Extracellular BMP-2 was detected exclusively in osteoarthritic cartilage and exhibits characteristic extracellular patterns: samples with BMP-2 in the extracellular matrix show BMP-2 negative coronae around BMP-2 positive cells. There is a statistically significant increase in the prevalence of extracellular BMP-2 with increasing ICRS grade/Mankin grade. Aggrecan was detected in the extracellular matrix und exhibited coronas throughout all layers. A decline of extracellular Aggrecan with increasing ICRS grade could be observed. Normal cartilage shows no intracellular Aggrecan whereas an increase in the prevalence of intracellular Aggrecan could be detected in osteoarthritic cartilage. The appearance of intracellular Aggrecan is often associated with extracellular BMP-2. The detection of BMP-2 protein in normal as well as in osteoarthritic cartilage highlights the importance of BMP-2 in tissue homeostasis and point to a putative role for maintaining tissue integrity during the development of osteoarthritis. The co-appearance of extracellular BMP-2 and intracellular Aggrecan indicates a functional relationship. The most interesting result is the characteristic distribution of extracellular BMP-2. These coronas seem to have an impact during progression of osteoarthritis and need to be further investigated.

The aim of this study was to detect characteristic structural changes in the cartilage composition of osteoarthritis (OA), hereby improving the arthroscopic identification of cartilage pathology by the use of a non-destructive technique - NIRS (Near-Infrared Spectroscopy). 682 cartilage samples out of 25 knees with OA were classified visually, using the ICRS system, biophotonically, histologically (n = 66), using the Score of Mankin and the Score of Otte, and biochemically (n = 616), determining the content of glycosaminoglycan (GAG) and hydroxyproline (HP). Significant correlations were found between biophotonical, histological, biochemical and visual characteristics of cartilage lesions. NIRS values corresponded to the content of GAG, HP and to the Score of Mankin and Otte. The data show that changes in the composition and structure of articular cartilage influence the optical properties and can be measured objectively by NIRS. The ease of use during arthroscopy, the quick response and the non-destructive nature of NIRS make it a promising addition to the assessment of disease intervention in OA.

Background: Open or percutaneous arthroscopic-based procedures are reported to fix unstable or displaced intra-articular glenoid fractures. Approach related morbidity has to be considered for open procedures, and arthroscopic-based procedures are demanding. Therefore an alternative percutaneous navigated approach is described., Technical Procedure: In an experimental setting an operative workflow was simulated to evaluate the best position of the patient on the operation table, the operating room set up and the fixation technique for the dynamic reference base of the navigation system. Based on two clinical cases, screw fixation of glenoid fractures via a posterior percutaneous approach is described, using a 2D-fluoroscopic based navigation system. Compared to the common approaches, the advantages and disadvantages of this procedure are discussed., Conclusion: The described technique of percutaneous navigated screw fixation of glenoid fractures is an alternative minimal invasive procedure. A reduction of approach related morbidity and more rapid return to function could be expected. The intraoperative results and postoperative functional outcome of both cases are promising.

Background: Intramedullary nailing is a standard surgical procedure for fixation of proximal femoral fractures, but is associated with considerable radiation exposure for controlling the implant placement, due to the percutaneous insertion technique.The aim of this study was the evaluation of potential benefits of 2D-fluoroscopic based navigation focused on the reduction of radiation exposure, a decrease of procedure time, as well as an increase of accuracy for Gamma3 nail insertions., Methods: Twenty randomized Gamma3 nail insertions were performed in non-fractured synthetic femora according to the manufactures operation guidelines (group I) or with use of a 2D-fluoroscopic based navigation system (group II). Time of different steps of the procedure and the radiation exposure were measured, as well as the accuracy evaluated in postoperative CT scans., Results and Discussion: All Gamma3 nails were placed without any technical problems. Independent of the used procedure, the overall operating time (group I: 584 ± 99.2 sec; group II: 662 ± 64.9 sec; p=0.06) and accuracy of the final nail-positions were equivalent, but the radiation exposure was significantly reduced (92% reduction in fluoroscopic images and 91% reduction in fluoroscopic time, p< 0.01), using the 2D fluoroscopic based navigation procedure., Conclusions: 2D-fluoroscopic based navigation for Gamma3 nail insertion facilitates a relevant reduction of radiation exposure with equivalent accuracy of the final implant position and no prolonged operating time. This promising procedure modification is independent of different cephalomedullary implant manufacturers and specific implant designs, but needs to be evaluated in further clinical settings.

Intramedullary nail removal can be demanding, especially in cases of implant breakage or bony overgrowth at the end-cap, if the exact insertion depth of the nail is neglected in the index surgery. In the presented case, two challenging nail removals were necessary. The first was performed in a re-nailing procedure due to a pseudarthrosis with implant breakage, and the second was performed during hardware removal after fracture healing in a situation where there was deep intramedullary placement of the exchange nail. For the second implant removal a minimally invasive approach based on instrument placements over a navigated guide-wire was used to reduce the iatrogenic morbidity associated with an extensive open approach to the nail and to decrease the radiation exposure for the patient and the operating team.

Objectives: Screw navigation techniques with different image guidance [2-dimensional (2D) vs. 3-dimensional (3D) fluoroscopy] were evaluated for acetabular fracture surgery., Methods: Two-dimensional and 3D navigation images were analyzed for visualization of different osseous corridors: supra-acetabular, anterior column, posterior column, and infra-acetabular. Forty guide wires per group were placed in synthetic pelvis with a prefabricated soft tissue envelope (10 per group) using a 2D or 3D fluoroscopic navigation procedure. Duration of the single steps for each procedure and of cumulative fluoroscopy time was measured. The accuracy of guide wire placement was evaluated visually and in 3D cone-beam scans., Results: The overall procedure time per pelvis was significantly reduced in the 3D group compared with the 2D group [mean ± standard error (SE) (minutes): 50.11 ± 1.38 vs. 63.42 ± 2.32; P < 0.0001]. A trend to reduction in image acquisition time [mean ± SE (minutes): 12.37 ± 1.34 vs. 15.43 ± 1.03; P = not significant] and significant increase in the cumulative fluoroscopy time [mean ± SE (seconds): 64 ± 9 vs. 13 ± 1.3; P < 0.0001) was measured in the 3D compared with the 2D group, caused by the 3D scan. Intra-articular misplacements were not observed in both the groups, but an increased accuracy could be achieved using the 3D image-based navigation procedure (perfect placement: 37 vs. 29; secure placement: 2 vs. 7; misplacement: 1 vs. 4)., Conclusions: Both navigation procedures securely prevent an intra-articular penetration during drilling, but the 3D image-based navigation procedure increases the overall accuracy compared with the 2D image-based navigation technique (misplacement rates of 2.5% vs. 10%). Especially, in very narrow corridors (as the infra-acetabular screw path), the use of 3D navigation should be preferred.

Background: In this paper we present our first experience in the application of a new, fixed-angle plate fixation: the locking attachment plate (LAP, Synthes, Oberdorf, Switzerland). We examined whether the LAP is a useful addition to the existing technical palette for periprosthetic fractures. The LAP is used for periprosthetic fractures with stable prostheses or intramedullary implants. The plate can be installed, e.g., on a 4.5 mm locking compression plate (LCP). Locking screws or cortical screws can be placed through its 4 diagonal fixed-angle arms, bicortical around the prosthesis stem into the bone. The LAP is designed to prevent lateral screw pull-out, to stabilise the prosthesis stem and thus to allow early postoperative mobilisation of patients., Patients and Methods: We implanted the LAP by operative fracture-treatment in the ORIF technique in 17 patients with periprosthetic fractures of the femur, tibia and humerus. The follow-up was at least 13 months., Results: There were two losses to follow-up: the patients died a few weeks postoperatively. There was a total of two of 17 cases with infection events (11.8 %). We could examine 15 patients for follow-up. Eleven of these 15 patients regained their original range of motion (ROM) and nine of 15 patients their pretraumatic mobility. In all cases with periprosthetic humeral fractures we detected muscular deficits. In five out of 15 cases (33.3 %) no radiological fracture healing could be observed. Nevertheless in 14 of 15 cases the implant was stable without signs of implant or prosthetic loosening. There was no case of material failure., Conclusion: Periprosthetic fractures are an increasingly common complication in old, often multi-morbid patients. A contemporary therapeutic intervention and early postoperative mobilisation contribute substantially to the success of treatment. The first results in the use of the LAP as a new implant option for periprosthetic fractures of the femur, tibia and humerus are promising. Further studies are necessary to show whether our overall good results are reproducible in larger groups of patients and whether the LAP can be given a firm position in the technical repertoire for treatment of periprosthetic fractures., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The standard for operative treatment of acetabular fractures is open reduction and plate fixation. Recently, screw fixation-only methods through less invasive approaches are reported, but biomechanical data are missing. Questions posed in this study are (1) is the static fixation strength of different screw types equivalent to the standard plate fixation for anterior column fractures of the acetabulum? and (2) does the placement of an additional screw in the infra-acetabular corridor increase the fixation strength independent of the used implant?, Methods: Three groups of different screws (group II, titanium; group III, stainless steel; and group IV, biodegradable Poly-L-Lactid) were compared with the standard plate fixation (group I) in Synbone pelves with custom-made anterior column fractures. Six pelvises per group were axial loaded with six cycles of 800 N, twice with and without an additional placed infra-acetabular screw., Results: The fixation strength of titanium screws was equivalent to the standard plate fixation. The stainless steel and Poly-L-Lactid screw fixation strengths were equivalent to each other but inferior to the aforementioned. The additional placement of an infra-acetabular screw significantly increased the fracture fixation strength, independent of the used implant., Conclusion: Screw fixation is a promising alternative approach for the stabilization of noncomminuted acetabular fractures of the anterior column with equivalent fixation strength to the standard plate fixation. The additional placement of an infra-acetabular screw significantly increases the fracture fixation independent of the used implant and should be considered for acetabular fractures with separation of both columns., Level of Evidence: Therapeutic study, level IV., (Copyright © 2012 by Lippincott Williams & Wilkins.)

Introduction: The aim of this study was the direct comparison of the static fixation strength of two common plate systems: MPS (Matta Pelvic System) and LPPS (Low Profile Plate System). Furthermore the role of a modified screw placement with addressing the infra-acetabular corridor and the use of locking screws were evaluated., Materials and Methods: Custom made anterior column fractures in artificial SYNBONE pelves were fixed with different acetabular plates (group I: MPS, group II: LPPS none locking and group III: LPPS locking). Each pelvis was tested twice, with the additionally placed infra-acetabular lag screw [+] first, followed by a repeated measurement without the infra-acetabular screw [-]. Six pelves per group were tested under static loading with six cycles up to 800N, each. The fracture displacement was measured in the weight bearing dome using an ultrasound based Zebris-3D-Motion Analyzer., Results: The MPS-plate had a less fixation strength compared to the LPPS-plate (mean±SD of maximum fracture displacement [mm] in group I vs. group II=0.63±0.02 vs. 0.37±0.02, p<0.05). The locking feature did not increase the fracture fixation strength (mean±SD of maximum fracture displacement [mm] in group II vs. group III: 0.37±0.02 vs. 0.37±0.03; ns). The infra-acetabular screw significantly reduces the maximum fracture displacement in all groups, independent of the plate systems ([Delta%] in group I=50; group II=63 and group III=40; p<0.05 each)., Conclusion: The LPPS-plate performed superior fixation strength for anterior column fractures compared to the MPS-plate. The locking plate modality did not reduce the maximum fracture displacement, whereas the additional infra-acetabular screw placement actually doubles the fracture fixation strength independent of the used plate system., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Introduction: This study evaluates the use of a navigation system (BrainLAB, Feldkirchen, Germany) to intra-operatively check for correct length, axis and rotation in intramedullary nailing of femoral-shaft fractures in an experimental setting and in clinical routine., Materials and Methods: We tested the navigation system in two experimental settings before introducing it into clinical routine. In the first experiment, 10 osteotomised model femora were fixed with intramedullary nails by using a navigation system. The goal was a locking fixation in predefined values for length and rotation. In the second experiment, eight examiners assessed values for rotation and length of one femur 10 times to examine the accuracy and reproducibility of that determination. Following this, we navigated 40 femoral nailing procedures in our department. Preoperatively, we assessed values of femur geometry on the contralateral side in a computed tomography (CT) scan and reproduced these values intra-operatively on the fractured side, guided by the navigation system. During the intervention, we recorded the length of the procedure steps and the fluoroscopy time. We verified the intra-operative values achieved with the navigation system in a postoperative CT scan and documented differences in rotation and length. After the assessment, we analysed the data for different findings on femur geometry, fluoroscopy time and procedure duration., Results: The experimental evaluation showed a range of ±5° for anteversion differences and ±2.3 mm for length differences. We estimated this accuracy as sufficient to use the system in clinical routine. The navigation system was used for 40 fracture fixations. All our criteria for restoring femoral geometry could be achieved by navigation guidance in these procedures. Setting up the system took on average 33±11.5 min. An additional fluoroscopy time of 36±22 s was needed to acquire the reference X-rays and to verify pin placement. The differences between anteversion values assessed in intra-operative planning steps on the navigation system and values assessed with a postoperative CT were on average 5.4±3.5°, whilst femur length differed on average by 4±4 mm., Discussion: Many authors judge intra-operative control of anteversion in femoral-shaft fracture fixation as problematic. Neither our experimental navigation assessment nor our clinical navigated evaluation showed relevant anteversion differences to a postoperative CT assessment of femur geometry. After initial training, guidance by a navigation system achieves consistent results in a clinical situation., Conclusions: The use of a navigation system to align axis, length and rotation led to a secure way of avoiding any relevant malalignment in complex femur-shaft fractures whilst exposing patients to an acceptable amount of additional procedure sequences. Malalignment can be avoided by using a navigation system in the operative treatment of femoral-shaft fractures and may be integrated into clinical routine in specialised centres., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Study Objective: To determine longitudinal trends in mortality, and the contribution of specific injury characteristics and treatment modalities to the risk of a fatal outcome after severe and complex pelvic trauma., Methods: We studied 5048 patients with pelvic ring fractures enrolled in the German Pelvic Trauma Registry Initiative between 1991 and 1993, 1998 and 2000, and 2004 and 2006. Complete datasets were available for 5014 cases, including 508 complex injuries, defined as unstable fractures with severe peri-pelvic soft tissue and organ laceration. Multivariable mixed-effects logistic regression analysis was employed to evaluate the impact of demographic, injury- and treatment-associated variables on all-cause in-hospital mortality., Results: All-cause in-hospital mortality declined from 8% (39/466) in 1991 to 5% (33/638) in 2006. Controlling for age, Injury Severity Score, pelvic vessel injury, the need for emergency laparotomy, and application of a pelvic clamp, the odds ratio (OR) per annum was 0.94 (95% confidence interval [CI] 0.91-0.96). However, the risk of death did not decrease significantly in patients with complex injuries (OR 0.98, 95% CI 0.93-1.03). Raw mortality associated with this type of injury was 18% (95% CI 9-32%) in 2006., Conclusion: In contrast to an overall decline in trauma mortality, complex pelvic ring injuries remain associated with a significant risk of death. Awareness of this potentially life-threatening condition should be increased amongst trauma care professionals, and early management protocols need to be implemented to improve the survival prognosis., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Isolated depression fractures of the femoral condyle are rare, but severe injuries due the destroyed congruency of the articular surface in the weight-bearing region of the joint. In most cases, an arthrotomy with fragment reduction and internal fixation by screws buttress or plates is performed. Disadvantages of this procedure are the approach-related complications. Furthermore, an implant removal is necessary, if a secondary osteoarthrosis develops. We present a female patient with a hyperflexion trauma of her right knee, resulting in an isolated depression fracture of the medial femoral condyle. To avoid arthrotomy-related morbidity, the impressed fragment was retrograde addressed using navigated guidance and reduced indirectly under arthroscopic control. Via the retrograde intraosseous tunnel a biodegradable screw was used as a buttress against the fragment to prevent a re-dislocation. The fracture healed without any complications and the patient re-administered her sports activities at 10 weeks follow-up. This procedure enables an accurate reduction and stable fixation of joint depression fragments via a minimal invasive approach.

Purpose: Retrograde drilling of osteochondral lesions (OCLs) is a recommended, but demanding operative approach for revascularization of lesions in stage 1-3 according to Berndt and Harty after failed conservative treatment. The gold standard of intraoperative driller guidance is fluoroscopic control. Limitations are a 2D visualization of a 3D procedure and sometimes limited view of the OCL in fluoroscopy, leading to increased radiation exposure. A new image-free navigation procedure was evaluated for practicability and precision in first clinical applications., Methods: In a period of 7 months, retrograde drillings were performed in eight patients (3x femoral condyle, 5x talus) using the new Fluoro-Free navigation procedure without rigidly fixed reference bases., Results: In total, 29 retrograde drillings were performed without any technical problem. The overall mean operating time was 82.1 ± 29.3 min (34.6 ± 6.4 min for the standard arthroscopy and 11.2 ± 1.2 min per drill). Twenty-seven of 29 drillings hit the target with a 100% first-pass accuracy. Two complications during drilling (one navigation specific and one navigation independent) were observed., Conclusion: The paper describes the promising first clinical applications of a new Fluoro-Free navigation procedure for the retrograde drilling of OCLs determined by arthroscopy. The benefit of that navigated drillings with a high rate of first-pass accuracy and no need for radiation exposure in contrast to standard techniques is highlighted.

Fractures of the capitulum of the humerus are rare and difficult to recognize. At present conservative therapy is only indicated in a few cases with no dislocation of the fracture. Otherwise an anatomical reduction and internal fixation should be done as early as possible. This article reports the case of a 51-year-old female patient with bilateral fractures of the capitulum of the humerus which were diagnosed 6 weeks after trauma. In spite of the extra risk of fragment necrosis, a reduction and internal fixation were performed. After rehabilitation, the patient was free of complaints except for a minimal limited range of motion.

Different navigation procedures (based on 2D-, 3D-fluoroscopy or CT modalities) with their respective limitations are established in orthopedic surgery. The hypothesis is that intraoperative matching of different modalities (fluoro and CT) increases the precision of navigated screw placement and reduces the fluoroscopy time. Vertical unstable pelvic ring fractures of 12 patients were treated with vertebro-pelvic fixations (6 in the standard technique and 6 using the fluoro-CT navigation). An optimal osseous corridor could be determined by the navigation procedure increasing the overall precision of screw placement (no misplacement in the second group as compared to one misplaced pedicle screw in the standard group). The achieved screw lengths were [(mean ± SE) 78 ± 5 vs. 53 ± 4 mm, p < 0.001). Less invasive open approaches and a reduction of fluoroscopy time (time per screw in seconds: 121 vs. 62 s) were observed. CT-fluoro-matched navigation improves the intraoperative visualization of osseous structures and increases the precision of screw placement with less radiation exposure.

Periprosthetic fractures are severe complications of total hip arthroplasty with increasing incidence. Most fractures are localized around the femoral component of prosthesis, whereas periacetabular fractures are rare and their management is difficult. In most cases, an operative procedure with revision and exchange of the acetabular cup is necessary. The approaches are demanding and an increased risk of complications is reported. We present the case of a female patient with a cementless total hip arthroplasty due to severe arthritis, suffering of an infratectal transverse periprosthetic fracture. After an initial conservative treatment attempt, we performed a minimally invasive screw fixation using navigated 2-dimensional fluoroscopic guidance. In this report, the literature for treatment recommendations is reviewed and the chosen navigation technique discussed., (Copyright © 2010. Published by Elsevier Inc.)

Background: Retrograde drilling of symptomatic osteochondral lesions (OCL) is usually controlled by fluoroscopy. Due to the limited visualization of the OCLs in the acquired images and the narrow access to the talar dome, this approach can be demanding. Several navigation procedures have been reported (2D- or 3D- fluoroscopy or intraoperative CT-based) to increase the accuracy and reduce the radiation exposure. We developed a new arthroscopic-controlled navigation procedure which is free of radiation exposure and free of a reference base rigidly fixed to the bone. We hypothesized that this procedure (Fluoro-Free) is at least as precise as the standard 2D-Fluoro navigation (2D-Fluoro). Furthermore, our first clinical experiences are described and discussed., Material and Methods: Sixteen drillings per group (standard 2D-Fluoro vs. Fluoro-Free) were performed in artificial sawbones. Times for the different steps of each drilling procedure were recorded and the precision evaluated by measuring the deviation and depth of drilling., Results: The accuracy of the Fluoro-Free navigation was as precise as the standard 2D-Fluoro based navigation (axis deviation of drill tip to the target point: 1.07 ± 0.11 versus 1.14 ± 0.15 mm). Due to the simplified workflow without radiation exposure and fixation of a reference base, the Fluoro-Free procedure was significantly faster (mean procedure time per drilling: 23.7 ± 11.6 versus 165 ± 9 seconds) and easy to use. Its clinical usefulness was demonstrated during three retrograde drillings of a talar OCL in a 16-year-old patient., Conclusion: The Fluoro-Free navigation procedure is a simplified approach for retrograde drilling of OCL in the talus under arthroscopic control without radiation exposure and without the need for fixation of a dynamic reference base to the bone.

Epidemiological, clinical and radiological data of 1266 patients with a unilateral acetabular fracture of up to 29 hospitals was reviewed. Three time periods, 1991-1993 (Registry I; n=359), 1998-2000 (Registry II; n=503), and 2005-2006 (Registry III; n=404) were compared with regard to injury pattern and severity, fracture type, and chosen nonoperative vs. operative treatment to elucidate changes over time in the treatment of acetabular fractures. In the operatively treated group, time to operation, surgical approach, fracture fixation implants and fracture reduction quality were examined. 641 (50.6%) patients with isolated acetabular fractures, 410 (32.4%) multiple injured and 215 (17.0%) polytrauma patients with 642 (50.7%) simple and 624 (49.3%) associated acetabular fractures were evaluated. In the time period from 1991 to 2006, the rate of operative treatments increased nationwide to 77% (rho<0.001). The distribution of fracture types involving the anterior and posterior wall changed with age (rho<0.001). Across all registries, 583 (68.0%) operations were performed within 7 days, 212 (24.7%) operations between 7 and 14 days and 54 (6.3%) operations were performed later than 14 days after injury. An anatomical reduction (0-1mm displacement) was achieved in 551 (64%) acetabular fractures. The obtained reduction quality did not correlate with time to operation, was lower in associated than in simple fracture types, and also lower in patients with isolated acetabular fractures than in polytrauma patients. Most importantly, the fracture reduction quality did not improve over time despite a higher frequency of surgical interventions. The Kocher-Langenbeck approach was preferred in the nineties in nearly three quarters of all operative procedures. Currently, the Kocher-Langenbeck and the ilioinguinal approaches are used equally often. The fracture fixation did not change over time and is achieved in 51% with plates in combination with single screws. This multisurgeon series illustrates a nationwide performance in acetabular fracture management. Despite changes in the chosen approaches and an increased surgical frequency, the operative treatment of acetabular fractures of the last 15 years did not lead to an increased reduction quality. Therefore, the rarity and complexity of acetabular fractures demands further specific teaching by experienced acetabular surgeons, scientific research and clinical outcome evaluation., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Screw fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system., Methods: Between August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 +/- 1.2 month., Results: 56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 +/- 4 minutes, mean fluoroscopy time per screw 123 +/- 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure., Conclusion: 2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.

Aim: Precise placement of the sustentaculum tali screw is essential for fixation of calcaneus fractures to achieve the best fixation strength. In the clinical practice, this procedure is demanding due to the complex anatomic configuration of the calcaneus and the limited visualisation in the intraoperative fluoroscopic images. The aim of this study was an evaluation of the accuracy for the sustentaculum tali screw placement by using different navigation procedures compared to the standard procedure. The different navigation specific workflows were evaluated and the feasibility of each procedure proven in clinical applications., Method: Eight sustentaculum screws per group were placed in an artifical Synbone model. Different navigation procedures were evaluated: 2D-fluoroscopy (group I), 3D-fluoroscopy (group II), fluoro-free (group III) and compared to the conventional screw placement without navigation (group IV). For each screw the time of fluoroscopy and the duration of the procedure were measured. The accuracy was evaluated postoperatively by computed tomography using axial slices and coronary as well as sagittal reformations. Furthermore, the workflow of each navigation procedure was analysed and proven in clinical applications., Results: In the experimental setup, no radiation exposure was mandatory for the conventional and fluoro-free procedures, whereas mean fluoroscopy times of 17 +/- 1.03 und 66.8 +/- 0.9 were measured for 2D- and 3D-navigation procedures. In line with this, the overall mean procedure times for the screw placement were 1.26 +/- 0.05 (group IV), 3.49 +/- 0.26 (group III), 13.32 +/- 0.49 (group I) und 19.04 +/- 1.41 minutes (group II). No significant differences were observed for the accuracy of screw placement. In the clinical practice a better orientation was achieved by use of a navigation system. The fluoro-free procedure can be easily integrated into the common operation workflow, whereas the workflow of both image-based navigation procedures is technically demanding., Conclusion: Navigation procedures seem to be helpful for the precise placement of sustentaculum tali screws in cases of operative calcaneus fracture fixation. The kind of application to be used depends on the infrastructure of the department and the navigation-experience of the operating room team. Whereas the fluoro-free procedure is intuitive in use, the 2D-navigation does not justify the extra efforts. The 3D-procedure is the recommended application for surgeons familiar with navigation, providing the best orientation due to the slice image visualisation in all three dimensions., (Georg Thieme Verlag KG Stuttgart, New York.)

Background: Characteristic changes in cartilage of human knee joints with different degrees of osteoarthritis (OA) have been investigated by visual, biophotonical and biomechanical examination. Knowledge about the cartilage composition and changes during the development of OA is important for diagnostic decisions and understanding the pathogenesis of OA., Methods: Thirty two patients with severe knee OA received endoprosthetic replacement. During surgical intervention cartilage specimen were harvested from defined surface areas of the joints. The degree of cartilage defects was classified visually (ICRS Grade: International Cartilage Repair Society), biophotonically (NIRS: near infrared spectroscopy) and biomechanically (Young's Modulus). To characterise links between the investigated parameters the Spearman's rank correlation coefficient was used., Findings: Significant negative correlations were found between visual macroscopic degree of degeneration (ICRS Grade) and biophotonic characteristics (NIRS) (rho=-0.467) or cartilage stiffness (Young's Modulus) (rho=-0.501). Between NIRS and Young's Modulus significant positive correlation of rho=0.535 was detected., Interpretation: Visual, biophotonic and biomechanical properties of cartilage reveal strong correlations in all degrees of cartilage defects in patients with severe OA. According to these results, we indicate that an objective, non-invasive and non-destructive measurement of cartilage properties during open and arthroscopic knee surgery is possible by NIRS and provide a novel tool to evaluate disease intervention and treatment., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Objective: A novel, radiation- and reference base-free procedure for placement of navigated instruments and implants was developed and its practicability and precision in retrograde drillings evaluated in an experimental setting., Materials and Methods: Two different guidance techniques were used: One experimental group was operated on using the radiation- and reference base-free navigation technique (Fluoro Free), and the control group was operated on using standard fluoroscopy for guidance. For each group, 12 core decompressions were simulated by retrograde drillings in different artificial femurs following arthroscopic determination of the osteochondral lesions. The final guide-wire position was evaluated by postoperative CT analysis using vector calculation., Results: High precision was achieved in both groups, but operating time was significantly reduced in the navigated group as compared to the control group. This was due to a 100% first-pass accuracy of drilling in the navigated group; in the control group a mean of 2.5 correction maneuvers per drilling were necessary. Additionally, the procedure was free of radiation in the navigated group, whereas 17.2 seconds of radiation exposure time were measured in the fluoroscopy-guided group., Conclusion: The developed Fluoro Free procedure is a promising and simplified approach to navigating different instruments as well as implants in relation to visually or tactilely placed pointers or objects without the need for radiation exposure or invasive fixation of a dynamic reference base in the bone.

Aim: The aim of the study was to evaluate the application of a navigation system (Brainlab) to control length and torsion intraoperatively while nailing a femoral shaft fracture., Method: At first the system was tested with 10 fractured synthetic bones. The postoperatively reached length and torsion were measured and the difference to the envisioned values statistically evaluated. Clinically we used the navigation system for patients with complex femoral shaft fractures. We always performed a preoperative computed tomography of the opposite leg to analyse the axis and fixed the fractured leg on these parameters using the navigation system. We noticed as improvement opportunities, the duration of the operative steps and the radiation exposure. The operative result was radiologically controlled and the torsion and length differences to the intraoperative measurement evaluated. Furthermore, we analysed the duration of the operation steps including the additional radiation exposure., Results: There were no technical problems during operations on the synthetic bones. The accuracy was with +/- 5 degrees or +/- 2 mm good enough to use the already approved system clinically. The navigation system was used for 17 operations. All navigation-assisted operations were completed successfully. It took an average time of 32 min to install the navigation system and required an additional X-ray time of 44 sec. The average postoperative rotational deviation was 5.5 degrees . The average difference in length was 2 mm., Conclusion: The application of a navigation system for repositioning of femoral shaft axes and controlling the length and torsion while nailing complex femoral shaft fractures is associated with some additional work. Nevertheless, in our study a relevant rotational deviation can be avoided by using the navigation system. To prove the advantage of the navigation system over the conventional technique, clinical studies with larger number of cases are necessary.

Introduction: The current gold standard for operatively treated acetabular fractures is open reduction and internal fixation. In this study we report the early results of percutaneous screw osteosynthesis of acetabular fractures in 14 cases, using a computer navigation system to reduce screw misplacement, approach associated risks and radiation exposure., Results: All 36 acetabular screws were placed correctly without any perioperative complication. The mean operation time per screw was 54 min, the mean fluoroscopic time per screw was 87 s. In the follow-up examinations (current rate: 71 %, mean follow-up: 13.1 +/- 1.8 months) no fixation failure or development of post-traumatic osteoarthritis was seen. One wound infection occured., Conclusion: Our first experience with this novel approach is promising and serious advances of fluoroscopic navigated percutaneous screw osteosynthesis of well selected acetabular fractures can be expected.