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The quality of care of seriously injured persons in Germany is nationally and internationally recognized to be at a high level. However, there are local discrepancies. In 2006 the German Association of Trauma Surgery published the White Paper for the Management of the Seriously Injured. The goal of the paper is a further increase in the quality of care of seriously injured persons. A crucial point of the publication is the call to establish regional trauma networks in Germany. Work on this project has been carried out in eastern Bavaria since spring 2007. The first meeting of the Trauma Network of eastern Bavaria took place in July 2007. On 3rd September 2008 the university hospital of Regensburg was the first clinic audited in Germany. To date nearly 75% of all hospitals in the trauma network of eastern Bavaria have been audited. The establishment of a regional trauma network is a multifactorial event. Essential factors in the development of the trauma network were found to be the communication between the head physicians and the nomination of an appointee of the regional trauma network. For the head physicians the 9 meetings of the trauma network since July 2007 functioned as the communication platform. These exchanges of the head physicians are necessary to animate a trauma network. The appointee of the regional trauma network--most suitably a member of staff of the speaker of the trauma network--is essential to guarantee communication between meetings and to manage prompt responses to questions from the network. This article describes the experiences gained during the implementation of the trauma network in eastern Bavaria.

A 26-year-old female patient with a femoral shaft fracture underwent retrograde femoral nailing. Nail removal was performed 2 years later, after fracture healing. An intraoperative fracture of the medial condyle of the femur occurred. This complication has not been previously described in the literature. Screw osteosynthesis of the fracture was performed and articular congruence reestablished. After 6 weeks of fractional weight bearing, the patient proceeded up to full weight bearing without complication. The case demonstrates that the removal of retrograde femoral nails is not without complications. The decision to undertake implant removal should be made carefully.

The influence of an unreamed femur nail on axial and torque stiffness of nine different external fixator devices was investigated in a biomechanical study. With a newly developed femur bone model simulating segmental transport, 582 biomechanical tests were performed. The additional use of an unreamed femur nail (UFN) increased axial stiffness of the external fixator devices up to 8108% (average 1673.8-2631.8%) and increased torque stiffness up to 86% (average 47%). The best results could be achieved when combining a small-diameter UFN (9 x 360 mm, Synthes Co.) and external fixator devices with high torque and comparatively little axial stiffness. The use of stainless steel half-pins instead of titanium half-pins improved torque stiffness significantly. Concerning the biomechanical demands made on external fixator devices used for femoral segmental transport, the Hexfix fixator with steel bar and steel half-pins combined with an UFN achieved the best results.

Supracondylar femoral fractures still present a challenge to the treating surgeon. The incidence of delayed and non-unions is reduced due to the minimally invasive plating techniques, but establishing a correct axis and good function is still a problem. During the last few years new implants have been developed to allow less difficult operative techniques in minimally invasive surgery. The Less Invasive Stabilization System (LISS) is a percutaneous plating system with monocortical self-drilling screws. The screws are inserted with an aiming guide and form a stable angle with the plate. The distal femoral nail allows placement of a spiral blade in the nail, thereby enhancing the interlocking stability.

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of sub-trochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.

Between 1987 and 1993, 41 grade 3B open tibial shaft fractures were treated with the unreamed tibial nail (URTN n = 22) or an external fixator (FIX n = 19). The method of treatment was left to the choice of the operating surgeon. Three below the knee amputations were performed, three patients died, and three were lost to follow-up. In all, 32 patients were followed up to union or at least for 1 year. There were no significant statistical differences between the two groups (P < 0.2, chi-squared, t-test) with respect to fracture type, fracture location, age, gender or accompanying injuries. The URTN group showed significantly better results regarding time to full weight-bearing (URTN 11 +/- 4 weeks; FIX 20 +/- 11 weeks, P < 0.01 M-W) Mann-Whitney Test, number of reoperations (URTN 1.04; FIX 2.89; P < 0.01 M-W), isolated bone grafting (URTN 3/22; FIX 8/19; P < 0.05 chi-squared), and average Karlström and Olerud score (URTN 30 +/- 4; FIX 26 +/- 5; P < 0.05 M-W). In all, 15/17 URTN patients and only 6/15 FIX patients achieved unlimited walking distance (P < 0.01 M-W). Time to bony union, infection, and nonunion were not significantly different between groups.

An aiming technique for an unreamed tibial nail was developed, which uses the relatively constant distance between the first transverse distal nail hole and the anterior aspect of the tibia. This aiming device is set at a distance of 12.3 mm from the anterior cortex, and fine tuning is finally resolved by use of a "working channel" with a 10 mm diameter from the medial side. The aiming system was tested in 20 cases in a video-documented prospective study using the unreamed tibial nail (UTN, Synthes) between July 1993 and March 1995. In all cases (100%) distal locking could be performed without image intensification. With a high percentage (55%) of open fractures (3 O3B fractures) the total operation time was 108 min (median, range 60-180 min). The time for distal locking (always 3 bolts) was 15.5 min (median, range 8.0-39.0 min), while the time for proximal locking (average 1.6 +/- 0.7 bolts) was 4.5 min (median, range 3.0-15.0 min). There were no major intra- or postoperative complications related to the aiming system. The major advantages are that it is not necessary to have image intensification for distal locking, there is a reduction in radiation exposure for the surgeon, and the drill holes are very precise.

While working to develop a distal locking device, we analyzed distal nail position with reference to nail deformation and a radiographic-morphometric investigation. The amount and the direction of implant deformation in unslotted stainless steel unreamed tibial nails (Synthes) were analyzed. Measurement of implant deformation (3 translations, 3 angles) in the center of the distal transverse locking hole was performed with a 3D magnetic motion tracker system before and after nail insertion. Unreamed tibial nails (diameter 8 mm, n = 10; diameter 9 mm, n = 10) were inserted in paired human cadaver tibiae. The results showed lateral translations of -4.5 +/- 3.5 mm (mean and standard deviation, range 14.3 mm) and dorsal translations of -7.8 +/- 5.8 mm (mean and standard deviation, range 19.2 mm). Rotational deformations around the longitudinal axis of the nail were 0.3 +/- 0.7 degree (mean and standard deviation, range 2.4 degrees). The results showed, that a simple aiming arm, mounted on the proximal nail end, alone or even in combination with a large working channel (e.g. 10 mm in diameter), was not adequate to the aiming process. A radiographic-morphometric analysis was subsequently performed in 40 tibiae after experimental (n = 20) or clinical (n = 20) implantation of nails 8 mm and 9 mm in diameter. These measurements showed a relatively constant distance between the upper distal transverse hole and the anterior aspect of the tibia (average 12.3 mm and only a narrow range (7.6 mm). These data were the basis for the development of an aiming technique that exploits the relatively constant distance between the distal nail hole and the anterior aspect of the tibia. This aiming device is set at a distance of 12.3 mm from the anterior cortex, and the fine tuning is finally resolved by the use of a "working channel' 10 mm in diameter.

The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by high-energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. This small but important group with severe injuries needs a detailed treatment algorithm, because despite the treating surgeon's skill, enthusiasm and wishful thinking, these injuries frequently lead to unsatisfactory results. The combination of distal femoral fractures and proximal tibial fractures was defined as complex knee injury type 1; the combination of distal femoral fractures or proximal tibial fractures with second or third degree open or closed soft-tissue injury was defined as complex knee injury type 2; knee dislocations were defined as complex knee injury type 3. A decision-making scheme is presented specifically addressing timing and treatment modalities. Out of 116 type 1 and 2 complex knee injuries, 8 had a deep infection, in 6 cases an amputation was carried out and in 4 cases a knee arthrodesis was performed. In 81 isolated distal femoral fractures, only 4 had a deep infection, none needed amputation, and in only 1 case did a knee arthrodesis have to be performed. The average Neer Score in 90 followed-up complex knee injuries, types 1 and 2, was 76.5 +/- 13.5 compared with 82.8 +/- 10 (out of 54 isolated distal femoral fractures). Out of 37 cases with knee dislocation, 22 (60%) had an poor result according to the Lysholm Score (average Lysholm Score 60.7 +/- 28).

Techniques for operative treatment of supra- and intercondylar fractures have changed in recent years. Some of these changes have come about in reduction techniques and implant selection. Operative approach concepts, which had remained unchanged for several decades, have been critically evaluated and modified, leading to a minimally invasive osteosynthesis (MIO) with transarticular joint reconstruction, closed plate positioning techniques or retrograde intramedullary nailing. These techniques result in better operative visualization and management of intraarticular comminution, safer fracture healing and better functional outcome. New strategies and techniques for the avoidance of axial malalignment, rotational deformities and leg length discrepancies are described.

The biomechanical properties of human Achilles tendon are described with a computer-controlled material-testing machine. With an optimized fixation device for the muscle-tendon-calcaneus system the rupture was intratendineal. The tendons were compared for different rupture speed (1000 mm/min vs 100 mm/min), sex and age ( < 35 years vs > 35 years). The tendons ruptured at 1000 mm/min had better results in terms of maximum rupture force, stiffness and tensile stress, while the results for elongation and energy were less good. None of these differences were statistically significant. Significant differences were found between the sexes: male tendons had higher maximum rupture force and stiffness and a larger cross-sectional area. In the younger tendons significantly higher tensile rupture stress and lower stiffness were found.

Various different interlocking intramedullary nail designs are now available for the tibia the designs resulting from a different approaches to achieving stability for fracture fixation. During recent years small-diameter unreamed interlocking nails have been developed. So far there are no data on stiffness of different nail designs that can justify the use of certain nail types. We compared different nail types in the bone-implant complex (BIC) with reference to stiffness under axial load, bending and torsion of the BIC. We simulated comminuted mid-shaft fractures by a 2-cm defect osteotomy in paired human cadaver tibiae. We fixed each tibia with one of nine different interlocking nails (AO Unreamed Tibial Nail 9 mm [UTN9], AO Unreamed Tibial Nail 8 mm [UTN8], Russell & Taylor Delta Tibial Nail 9 mm [RTD], Russell & Taylor Reconstruction Tibial Nail 11 mm [RTR], Brooker & Wills Nail 11 mm [B-W], Grosse & Kempf Tibial Nail 11 mm [G-K], AO Universal Tibial Nail 11 mm [AOU], Klemm & Schellmann Tibial Nail 11 mm [K-S], Börner & Mattheck Tibial Nail 11 mm [B-M]) according to the manufacturers' recommendations. Each BIC was tested mechanically using a Zwick universal testing machine. Torque testing was performed with a maximum moment of 5 Nm in both directions. Maximum axial load was 1100 N. Four-point bending was done up to a moment of 66 Nm. For each implant bending and torque stiffness of the nail were calculated and compared with the test results obtained in the cadaver study. A P-value less than 0.05 (least significance difference test, ANOVA) was considered significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Nailing technique has changed in recent years in some important aspects which are not limited to the omitted reaming procedure. These changes concern patient positioning, reduction technique, the use of temporary stabilizers such as the 'Pinless', and determination of implant length and diameter. Approach and exposure techniques have been modified to new, less invasive procedures, in order to fulfill technical, functional and aesthetic requirements. Techniques and tricks have been developed for avoidance of fragment diastasis and axial and torsional malalignment. Finally, simple algorithms are described for the management of large bone defects, bilateral tibia shaft or ipsilateral femoral shaft fractures, number and location of locking bolts, the 'when and how' of patient mobilization and load bearing, and primary and secondary dynamization. These algorithms, techniques and procedures were developed in a series of 152 tibia shafts, which were stabilized with the AO unreamed tibia nail (UTN) in a prospective study between March 1989 and June 1994. Of these, 75 cases with a mean follow-up of 19.4 +/- 6.3 (range 11-37) months after trauma were reviewed. Fractures were classified according to Müller (1990): 14 type A, 37 type B and 24 type C. Closed soft tissue damage was categorized according to our classification: C0/1, n = 5; C2, n = 12; C3, n = 9 (Tscherne 1982). Among 49 open fractures 8 were OI, 18 OII, 10 OIIIA and 13 OIIIB (Gustilo 1976). The main minor intraoperative complication was drill bit breakage (n = 10), most frequently at the proximal locking holes. The main postoperative complication was breakage of locking bolts (n = 16), mainly between weeks 6 and 20. Minor secondary reinterventions were, in most cases, secondary dynamization under local anaesthesia. Major reintervention were: soft tissue reconstructions (n = 5), isolated cancellous bone graft (n = 6), and change of treatment (n = 12). There were nine changes to a reamed nail, two changes, in very proximal fractures, to plate osteosyntheses. There were three deep infections. Mean time to union was 23.9 weeks (range 10-48 weeks, n = 73); in two cases non-union was observed. The overall result was judged with the Karlström-Olerud score, which was applicable in 66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n = 24; fair, n = 9; poor, n = 9. In the remaining nine cases no scoring was attempted because of severe injuries around the knee or ankle.

Nailing technique has changed in recent years in some important aspects which are not limited to the omitted reaming procedure. These changes concern patient positioning, reduction technique and determination of implant length and diameter. Approach and exposure techniques have been modified to new, less invasive procedures, in order to fulfill technical, functional and aesthetic requirements. Techniques and tricks have been developed for avoidance of fragment diastasis, axial and torsional malalignment and leg length differences. Finally, simple algorithms have been elaborated for the management of bilateral femoral shaft or ipsilateral tibial shaft fractures and the number and location of locking bolts. These algorithms, techniques and procedures were developed in a series of 108 femoral shafts, which were stabilized wit the AO unreamed femoral nail (UFN) in a prospective study between 1991 and 1994. Of these, 39 cases with a mean follow-up of 19.3 (range 8-40) months after trauma were reviewed. Fractures were classified according to Müller (1990): 6 type A, 21 type B and 12 type C. Closed soft tissue damage was classified according to our classification: C0/I, n = 14; CII, n = 15 (Tscherne 1982). Among 10 open fractures 4 were OI, 4OII, 1OIIIA and 1OIIIB (Gustilo 1976). The major complications were breakage of locking bolts (n = 2), one nail breakage after 9 weeks and one case of osteitis.

In a prospective study, since March 1989, 55 tibial shaft fractures have been treated with a new, unreamed solid tibial nail (UTN). This nail was initially designed as a temporary implant. The first 33 cases with second or third degree soft tissue damage were reviewed 6 months or more after the operation. Fractures were classified according to Müller: 6 type A (18.2%), 15 type B (45.5%), and 12 type C (36.7%). In 9 cases (27.3%), there was GII (n = 4) or GIII (n = 5) closed soft tissue damage according to Tscherne's classification. The 24 open fractures (72.7%) comprised 11 OII, 3 OIIIA and 10 OIIIB fractures (Gustilo classification). 24 patients (72.7%) were polytraumatized, the mean PTS (Hannover Polytrauma Score) was 18 points (range: 8-65 points). All fractures were stabilized without reaming. The implant diameter was 8mm (n = 14) or 9 mm (n = 19). Static locking was performed in 31 cases. Dermatofasciotomy was necessary because of compartment syndrome in 14 cases. In 1 grade IIIB open fracture soft tissue coverage was performed with a latissimus dorsi myocutaneous free flap 4 days after nailing. In 32 of the 33 cases the use of an additional cast or brace was not necessary during the follow-up treatment; 1 patient had a cast for 8 weeks for the treatment of accompanying injuries. Full weight-bearing was achieved in 5 cases within 3 weeks, in 16 cases within 12 weeks, and in 30 cases within 26 weeks. In 16 cases (48.5%) the interlocking screws were removed after 5-26 weeks (mean: 10 weeks).(ABSTRACT TRUNCATED AT 250 WORDS)