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Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed.Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group.Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required.Level of Evidence: III

Background: Avascular necrosis of the femoral head is a progressive perfusion disorder of the hip joint. Progress in avascular necrosis causes structural damage to the affected joint, often requiring total hip replacement., Aim: This article is intended to give the reader an overview of the current literature on total hip replacement of patients with an avascular necrosis of the femoral head., Results: Before 1990, patients with avascular necrosis of the femoral head had significantly higher revision rates after total hip replacement. Recent studies, however, showed no significant differences in clinical outcomes after total hip replacement in femoral head necrosis and primary osteoarthritis. Despite the young age of the patients, good long-term clinical results can be expected even in patients with an avascular necrosis of the femoral head after total hip replacement.

Background: Cartilage is an avascular, alymphatic and non-innervated tissue with limited intrinsic repair potential. The high prevalence of cartilage defects and their tremendous clinical importance are a challenge for all treating physicians., Aim: This article provides the reader with an overview about current cartilage treatment options and their clinical outcome., Methods: Microfracture is still considered the gold standard in the treatment of small cartilage lesions. Small osteochondral defects can be effectively treated with the autologous osteochondral transplantation system. Larger cartilage defects are successfully treated by autologous membrane-induced chondrogenesis (AMIC) or by membrane-assisted autologous chondrocyte implantation (MACI)., Conclusion: Despite limitations of current cartilage repair strategies, such procedures can result in short- and mid-term clinical improvement of the patients. Further developments and clinical studies are necessary to improve the long-term outcome following cartilage repair.

Background: Cartilage defects around the knee joint frequently occur in the region of the medial femoral condyle and the retropatellar cartilage surface. The distinction between local cartilage defects and large area degenerative cartilage lesions is very important for both prognosis and surgical therapy. The size and position of the lesion, the underlying pathomechanism and the age of the patient are very important factors which should be considered in the therapy algorithm for optimal cartilage defect restoration. Important cofactors such as stability, long leg axis and muscle balance should be taken into account., Aim: Current procedures for cartilage repair of the knee joint and their results are summarized in this article. In addition, the necessity of precise and comprehensive preoperative clinical and radiological diagnostics is displayed to be able to treat co-pathologies in order to enable a successful repair of the cartilage defect., Results and Conclusions: Preoperative planning of cartilage-repair techniques usually includes x‑ray images and a magnetic resonance imaging (MRI) examination. If MRI is not available, an arthro-computed tomography could be an alternative. Modern and routinely used procedures for cartilage repair at the knee joint are microfracture, autologous matrix-induced chondrogenesis, autologous chondrocyte transplantation, matrix-induced autologous chondrocyte implantation and osteochondral transplantation. Successful surgical cartilage-repair surgeries require a correct and individualized indication, addressing of copathologies and a standardized rehabilitation that is adapted to the surgical procedure. Evidence-based criteria for an exact time point for the return to sports according to individually operative cartilage repair techniques currently do not exist.

Scoliosis is a complex, three-dimensional spinal deformity with various causes. Adolescent idiopathic scoliosis (AIS) is the most common form. Surgical treatment is indicated for curves greater than 45-50° meaured using the Cobb method. We can distinguish among posterior, anterior or combined surgical procedures. Today, the posterior, transpedicular approach has revolutionized scoliosis surgery. This review gives an overview of current surgical options in scoliosis treatment.

Scoliosis affects up to 6 % of the population. The resulting spine deformity, the increasing risk of back pain, cosmetic aspects, pulmonary disorders if the Cobb angle is > 80°, and the progress of the deformity to > 50° after the end of growth indicate non-operative or operative therapy. In daily clinical practice, the classifications of scoliosis allow the therapy to be adapted. Classifications consider deformity, topography of the scoliosis, and the age at diagnosis. This publication gives an overview of the relevant and most common classifications in the treatment of adolescent scoliosis. For evaluation, the deformity measurement on the coronary radiographic projection of the total spine (Cobb angle) is relevant to therapy. The classification of topography, form, and the sagittal profile of the deformity of the spine are useful for preoperative planning of the fusion level. Classifications that take into account the age at the time of the diagnosis of scoliosis differentiate among early onset scoliosis (younger than 10 years of age), adolescent scoliosis (up to the end of growth), and adult scoliosis. Early onset scoliosis is subdivided by age and etiology. Therapy is derived from the classification of clinical and radiological findings. Classifications that take into account clinical and radiological parameters are essential components of modern scoliosis therapy.

Background: Scoliosis is a complex three-dimensional deformity of the spine, which usually occurs during childhood and adolescence. Up to now, whole spine X-rays have been the therapeutic gold standard in the diagnosis and follow-up of scoliosis., Aim: This review gives a brief overview of the history, technical background and possible fields of use for video-rasterstereography, Methods: Alternative measurement systems have been developed over the past few years for the treatment of scoliosis, because of the risk of radiation exposure of X-rays. The rasterstereographic system Formetric (Diers International GmbH, Schlagenbad) allows a radiation-free, three-dimensional analysis of the back surface and the spine., Outlook: Even dynamic measurements can now be conducted with this rasterstereographic system, which will help to further understand and analyze the human spine.

Introduction: The aim of multidisciplinary rehabilitation after total knee replacement (TKA) is to reduce postoperative complications and costs and enable faster convalescence. The goals of fast-track rehabilitation, as a multidisciplinary concept, are to reduce the length of hospital stay and achieve early functional improvements by optimizing the perioperative setting., Method: A literature review was carried out for the years 1960-2013. The search terms were: "rehabilitation", "training", "physiotherapy", "physical therapy", "recovery", "exercise program", "knee surgery", "TKA", "total knee replacement", "arthroplasty", "intensive", "multidisciplinary", "accelerated", "rapid" or "fast track". Only randomized controlled trials and metaanalyses were included. A survey was also performed to assess care as actually offered in orthopaedic rehabilitation clinics in North Rhine-Westphalia., Results: A total of 729 articles were identified of which 11 studies were included. Fast-track rehabilitation can significantly reduce both the duration of hospital stay and costs after TKA. Current studies showed that a better short-/middle-term clinical outcome might be achieved with multidisciplinary rehabilitation. However, a difference in the long-term outcome could not be observed. Our survey shows that most patients are admitted to a rehabilitation clinic in a state of poor general condition as well as decreased mobility and knee range of motion., Conclusions: Fast-track rehabilitation facilitates a shortened hospital stay as well as cost saving. It probably can be used to optimize the condition of the patient before admission to a rehabilitation facility., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: People who have become victims of violence have manifold problems. Besides medical diagnostics and therapy, it is necessary to recognise the situation in which these patients have become such victims, to document the consequences of this violence for use in court and to offer further assistance. Victims of violence often contact primarily a trauma ambulance. The optimisation of the medical treatment of the victims is a relevant traumatological topic, which so far has received only very scant attention. Therefore the aim of this study was to evaluate the necessity for an interdisciplinary combination of treatments for the targeted treatment of these victims., Material and Methods: Using a standardised data card a retrospective data analysis of all out-patients and all in-patients of a trauma centre with regard to the existence of a violent context was carried out for the year 2004. All such cases were included and the data were evaluated descriptively according to age, gender, information about the act of violence, consequences thereof, type and scope of the diagnostic findings, as well as inducements for further measures. In this context we differentiated between "domestic violence" and "public violence"., Results: The data of 7132 patients were evaluated. Altogether 347 victims of violence were identified (among them 109 victims of "public violence", 59 victims of domestic violence, and 179 cases that could not be allocated clearly). This results in a quota of 4.9% of all patients treated. The average age of the victims was 30.6 years. It was striking that in many cases the anamnesis and documentation were rather fragmentary., Conclusion: A very high percentage of victims of violence could be found among the patients needing traumatological treatment. With regard to the fragmentary care there is an enormous need for medical training and interdisciplinary treatment of victims of violence., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: With a prevalence from 11.8 to 18% no fracture is as often associated with nerve damage as the humeral shaft fracture. Whether the radial nerve should be surgically explored in association with a palsy in humeral shaft fractures in order to exclude an interposition or discontinuity is being discussed controversially. The aim of this study was to assess the strategies for primary care of radial nerve palsies associated with humeral shaft fractures in Germany., Material and Methods: In a standardised survey 495 traumatological and 134 neurosurgical clinics were interviewed regarding the treatment of primary radial nerve palsies after humeral shaft fractures. The distribution of the survey included all level-one trauma centres. Statistics were based on the supply strategies, the number of observed contusions, discontinuities and inter-position of the N. radialis in the fracture gap. Moreover, the results were recorded after primary neurorrhaphy., Results: The evaluable response rate to the questionnaire was 56% (university hospitals 77%, level-one trauma centres 63%, level-two trauma centres 70%, level-three trauma centres 44%). 6097 humeral shaft fractures have been treated per year, the incidence of primary radial nerve palsy was 8.6%. Regarding the management strategies, 59% of the hospitals advocated exploration of the nerve, while 25% reported that the decision depends on the individual case. 16% reject the exploration in case of a primary nerve palsy. In the case of an exploration, contusions (74%) of the nerve were largely seen, followed by nerve interpositions in the fracture gap (19%) and discontinuity (7%). In the case of neurorrhaphy, a partial or complete remission was found in 87% of cases., Discussion: Although a primary expectant procedure is recommended in the literature due to the high spontaneous remission rate of 90%, an early exploration of the nerve is often preferred in clinical practice. In these cases, the use of an interlocking intramedullary nail as a minimally invasive treatment option does not appear useful due to the direct exposure of the fracture zone and the radial nerve. Interestingly, the feared discontinuity occurs rarely. The impact of nerve interposition in the fracture gap without surgical exploration remains unclear due to the lack of visibility., Conclusion: There is no consensus concerning the treatment of radial nerve palsies after humeral shaft fractures in Germany. Discontinuities are rare, the rate of spontaneous recoveries is high. Whether and when an exploration of the radial nerve is obligatory in primary radial palsy remains unclear and should be clarified by prospective randomised trials., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Scaphoid fractures represent the most common carpal bone fractures. These fractures may be overlooked due to insufficient diagnostics and lead to non-union and disability. A standardized diagnostic procedure with X-ray examinations, CT scans and/or MRI is recommended. We report on a case where a scaphoid fracture was overlooked, probably because of an incorrect technique of the computed tomography., Case Report: A 42-year-old man was admitted to our emergency room after a fall on the out-stretched wrist. X-rays showed no evidence of a bony lesion. In the follow-up examination on the next day, a scaphoid fracture was still suspected clinically. Because of that a CT scan in thin slice technique with axial layers and multiplanar reconstruction was performed but showed no sign of a fracture. Six weeks after the trauma the patient presented with persistent wrist pain. X-rays and a CT scan of the wrist now demonstrated an old waist fracture of the scaphoid. -Operative treatment with iliac crest bone grafting and screw fixation was performed., Discussion: Early diagnosis and a correct description of the fracture pattern are of high value in the treatment of scaphoid fractures. X-rays combined with a CT scan or an MRI scan of the affected wrist are considered as the diagnostic standard. The reported case demonstrates that even with a thin thickness layer CT scan in axial planes, a scaphoid fracture can be overlooked. Therefore we recommend after primarily inconspicuous X-rays a CT scan with primary -oblique-sagittal layers in the longitudinal axis of the scaphoid. If this shows no fracture and the clinical suspicion persists, an MRI scan should be performed., (Georg Thieme Verlag KG Stuttgart, New York.)