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Der Schaftschmerz nach endoprothetischer Versorgung an Knie- und Hüftgelenken mit diaphysär abstützenden Schäften ist eine möglicherweise häufig übersehende und mutmaßlich unterschätzte Komplikation. Ein oft wiederkehrendes klinisches Bild ist das beschwerdefreie Intervall nach der Operation von Wochen bis Monaten mit dann neu auftretender Beschwerdesymptomatik unter gesteigerter Belastung. Der Patient ist häufig auf die erneute Zuhilfenahme von Gehstöcken angewiesen. Der Schaftschmerz ist eine Ausschlussdiagnose. Ist die Klinik eindeutig, projiziert sich der Schmerz auf die Schaftspitze. Differenzialdiagnosen wie eine Lockerung müssen ausgeschlossen werden, um dem Patienten als Option eine „bending plate“ anbieten zu können. Da Knochenzement ein ähnliches Elastizitätsmodul wie die humane Kortikalis aufweist, kann auch ein Verfahrenswechsel auf ein zementiertes Implantat zielführend sein. In der Primärsituation könnte, neben der Anwendung von zementierten „stems“, auch die Verwendung von „split stems“ sinnvoll sein. Nach einer Revisionsoperation, gleich welcher Art, bestätigt die zeitnahe Schmerzfreiheit die Diagnose.

Context: Sublesional osteoporosis is an important sequel after spinal cord injury (SCI) resulting in a high incidence of fractures and impaired osseous healing due to altered bone metabolism. The following study aims to identify demographic characteristics and outcome of patients with SCI with lower extremity fractures.Design: Retrospective observational study.Setting: Level-I cross-regional trauma center.Participants: All patients with SCI suffering from osteoporotic/pathologic fractures during an 11-year-period (01/2003–12/2013) at the Center for Spinal Cord Injuries (Trauma Center Murnau) were analyzed via a chart review.Outcome measures: Demographics, surgical and radiologic outcome as well as complication rate were assessed with a special emphasis on union rates and independent risk factors for non-unions.Results: We identified 132 patients (105 males) who fulfilled the inclusion criteria. Most of them were paraplegic (n=101) and showed motor complete syndromes (n=119). Supracondylar femur fractures were the most prevalent in this study (n=47). We observed a non-union rate of 15.9% (n=21). The development of pseudarthrosis was associated with the time interval since the initial SCI (P < 0.010), delayed in-patient submission (P < 0.038), fracture classification (P < 0.002) and the localization of the fracture (P < 0.0001). The overall complication rate was 16.7%. All dislocated subtrochanteric femur fractures (Garden III and IV) (n=10) developed a non-union, regardless of their management (conservative or surgical). The following independent predictors for non-unions were identified: fracture localization (P < 0.0002), fracture classification (P < 0.056), and fracture management (P < 0.036).Conclusions: Even though modern techniques allow surgical interventions in bones with reduced mineral density, non-unions remain a common complication in patients with SCI. Risk factors for non-unions of lower extremity fractures are identified.

Radiushalsfrakturen bei Kindern besitzen trotz des relativ geringen Wachstumspotenzials der proximalen Fuge ein hohes Spontankorrekturpotential. Gering bis mäßig abgekippte Frakturen haben somit bei jungen Kindern eine gute Prognose. Problematisch sind stark dislozierte Frakturen, welche nicht der spontanen Wachstumskorrektur überlassen werden können. Je nach Frakturdislokation und Versorgungstechnik muss in bis zu 50 % der Fälle mit Komplikationen wie Pseudarthrosenbildungen, Wachstumsstörungen, Kopfnekrosen oder periartikulären Verkalkungen bis hin zur radioulnaren Synostose gerechnet werden. Eine schonende, möglichst geschlossene Reposition und Osteosynthese reduziert dieses Risiko. Despite the relatively low growth potential of the proximal physis, radial neck fractures in children have a high rate of spontaneous growth correction. Therefore, mild to moderately dislocated fractures in young children have a good prognosis. Highly dislocated fractures can not be corrected by spontaneous growth alone and are therefore more problematic. Depending on the degree of dislocation and method of reduction and fixation a complication rate of up to 50 % can be expected, such as non-union, growth arrest, heterotopic ossifications, necrosis of the head or radioulnar synostosis. These risks can be reduced by a gentle and if possible closed reduction and internal fixation.

The aim of this article is to provide a concise review of the basic science of extracorporeal shock wave therapy (ESWT) and to perform a systematic review of the literature for the use of ESWT in the treatment of fractures and delayed unions/nonunions.

Biomechanical study on cadaveric bones using physiological loading conditions to quantify interfragmentary movements in a tibial shaft fracture model fixed by intramedullary nailing.

Background:Intramedullary implants are being used with increasing frequency for tibiotalocalcaneal fusion (TTCF). Clinically, the question arises whether intramedullary (IM) nails should have a compression mode to enhance biomechanical stiffness and fusion-site compression. This biomechanical study compared the primary stability of TTCF constructs using compressed and uncompressed retrograde IM nails and a screw technique in a bone model. Methods:For each technique, three composite bone models were used. The implants were a Biomet nail (static locking mode and compressed mode), a T2™ femoral nail (compressed mode); a prototype IM nail 1 (PT1, compressed mode), a prototype IM nail 2 (PT2, dynamic locking mode and compressed mode), and a three-screw construct. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as percent of the available fusion-site area. Stiffness was tested in dorsiflexion and plantarflexion (D/P), varus and valgus (V/V), and internal rotation and external rotation (I/E) (20 load cycles per loading mode). Results:Mean contact surfaces were 84.0 ± 6.0% for the Biomet nail, 84.0 ± 13.0% for the T2 nail, 70.0 ± 7.2% for the PTI nail, and 83.5 ± 5.5% for the compressed PT2 nail. The greatest primary stiffness in D/P was obtained with the compressed PT2, followed by the compressed Biomet nail. The dynamically locked PT2 produced the least primary stiffness. In V/V, PT1 had the (significantly) greatest primary stiffness, followed by the compressed PT2. The statically locked Biomet nail and the dynamically locked PT2 had the least primary stiffness in V/V. In I/E, the compressed PT2 had the greatest primary stiffness, followed by the PT1 and the T2™ nails, which did not differ significantly from each other. The dynamically locked PT2 produced the least primary stiffness. The screw construct's contact surface and stiffness were intermediate. Conclusions:The IM nails with compression used for TTCF produced good contact surfaces and primary stiffness. They were significantly superior in these respects to the uncompressed nails and the screw construct. The large contact surfaces and great primary stiffness provided by the IM nails in a bone model may translate into improved union rates in patients who have TTCF.

Background: Many techniques of tibiotalar arthrodesis have been described. Screw fixation is widely used. At our center, intramedullary compression nailing has been successfully used for over 10 years. The question to be answered by this study was whether tibiotalar arthrodesis with a compressed intramedullary nail was superior, in terms of primary stiffness and fusion-site compression, to selected other techniques. Methods: Plane fusion surfaces were machined in third-generation synthetic composite tibiae and the bodies of anatomically correct tali; fixation was with a compressed external fixator (cEF), an uncompressed interlocking nail (uIN), a compressed interlocking nail (cIN), and two different three-screw techniques (ST1 and ST2); three specimens per construct were tested. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as a percent of the available fusion-site area. Construct stiffness was tested in dorsiflexion/plantar flexion (D/P), varus/valgus (V/V), and internal rotation/external rotation (I/E), analyzing 20 cycles per loading mode. Results: Compressed surface area: cIN 80% ± 10.7; cEF 60% ± 8.6; ST2 59% ± 4.4; ST1 55% ± 6.1; uIN no discernible compression. The greatest primary stiffness in D/P was obtained with the cIN (p < 0.001), followed by ST1. In V/V, ST1 and the cIN had the greatest primary stiffness; the two techniques did not differ significantly. Stabilization with the cEF was significantly better (p < 0.001) than with ST2. In I/E, the cIN produced the greatest primary stiffness (p < 0.001), followed by the two screw techniques, which did not differ significantly between themselves. The uIN had the least primary stiffness in all directions tested. Conclusions: In this biomechanical study, the cIN and ST1 were superior, in terms of primary stiffness in tibiotalar arthrodesis, to the other techniques tested. In D/P and I/E, the cIN construct was signficantly stiffer than the ST1 construct, whose I/E rigidity might, however, be enhanced by a fourth, horizontal screw. Clinical Relevance: Intramedullary compression nailing offers stable tibiotalar arthrodesis fixation with a large bony contact area and may enhance the likelihood of successful tibiotalar arthrodesis.

Résumé Entre janvier 1996 et décembre 1999, nous avons exécuté 30 ostéotomies fémorales de dérotation avec enclouage en compression chez 29 malades. Dans 18 cas (groupe 1), nous avons utilisé un scie intramédullaire (technique mini invasive) et dans 12 cas (groupe 2), nous avons utilisé une technique ouverte conventionnelle. Le suivi à était fait par estimation clinique, radiologie conventionnelle, et tomodensitométrie. L’angle moyen de dérotation était 28,6°±12,3 dans le groupe 1 et 27,6°±10.7 dans le groupe 2. La déviation rotationnelle moyenne postopératoire entre le côté gauche et le côté droit était 7,9°±6.7 dans le groupe 1 et 6,6°±4.4 dans le groupe 2. Il y avait cinq complications postopératoires: deux retards de consolidation, deux corrections insuffisantes et une infection. Il n’y avait aucune différence significative entre les groupes. Quand on utilise la technique mini invasive nous recommandons de marquer les angles de dérotations avec des vis de Schanz plutôt que des broches de Kirschner car la résistance des parties molles peut les courber.

Zusammenfassung Mit modernen Kompressionsmarknägeln sind die Aneinanderlagerung (Apposition) der Frakturenden sowie die Kompression geeigneter Quer- und Schrägfrakturen im Schaftbereich und von Osteotomien, Pseudarthrosen und Arthrodesen möglich. Die wesentlichen Vorteile bestehen in einer verbesserten biomechanischen Stabilität der Osteosynthese und in der Vermeidung eines klaffenden Frakturspalts bzw. einer Diastase der Fraktur. Mit dem aktuellen T2-Marknagel-System liegt ein vorteilhaftes Implantatsystem für die ante- und retrograde Anwendung an Humerus, Tibia und Femur mit integriertem optionalem Kompressions- bzw. Appositionsmechanismus vor.

Zusammenfassung Mit modernen ausgereiften Marknagelsystemen, wie dem T2-System, kann ein breites Indikationsspektrum abgedeckt werden. Neben Frakturen, Pseudarthrosen und Osteotomien im Schaftbereich können durch endständig angeordnete Verriegelungsoptionen auch metaphysäre Frakturen und Pseudarthrosen stabilisiert werden. Die Materialeigenschaften der Titanlegierung Anodisation Typ II konnten bezüglich niedrigerer Abriebs- und Verschleißraten und eines physiologischeren Elastizitätsmoduls optimiert werden. Die Entwicklung von kurzen Kompressionsschrauben, welche axial in das Nagellumen eingeführt werden können, ermöglicht eine Verblockung der Verriegelungsschrauben im Bereich der Nagelbasis und somit eine angenäherte Winkelstabilität. Durch diese Kompressionsschraube können auch eine feindosierte Aneinanderlagerung der Hauptfragmente und ggf. auch Kompression auf die Fraktur bzw. Osteotomie ausgeübt werden.

Zusammenfassung Die winkelstabile Plattenosteosynthese ist für die Versorgung von Problemfrakturen bzw. Instabilitäten geeignet, da die Vorteile der winkelstabilen Verankerung mit einer minimalinvasiven Implantationstechnik und postoperativer Funktionsstabilität erreicht werden können. Aus diesen Gründen ist die winkelstabile Plattenosteosynthese auch bei Problemversorgungen wie Pseudarthrosen, Infektpseudarthrosen, periprothetischen Frakturen, Korrekturosteotomien und pathologischen Frakturen indiziert. Nachteilig wirken sich die eingeschränkten Korrekturmöglichkeiten zur Applikation der Schrauben, das bei großen Röhrenknochen relativ massive Implantat mit daraus resultierender Einschränkung der Modellierfähigkeit und der eingeschränkte Einsatz bei kritischer Weichteilsituation aus. Die Besonderheiten der Implantateigenschaften erfordern eine kritische Indikationsstellung und einen erfahrenen Operateur.

Case report, literature review, discussion.

: Die Ellengelenksteife ist die unspezifische Antwort auf eine Vielfalt von Schädigungen, d. h. vor Beginn der Therapie ist eine Analyse der möglichen Ursachen erforderlich, wobei sich die Einteilung in intraartikuläre und extraartikuläre Ursachen bewährt hat, da die Behandlungsprognose bei Letzteren günstiger ist. Häufigstes pathologisches Substrat der Ellengelenksteife sind die Gelenkkapselfibrose und/oder heterotope Osssifikationen (hO). Therapieziele sind die Resektion der Gelenkkapsel und der Verknöcherungen. Der Zeitpunkt der Entfernung von hO ist der frühestmögliche, das Rezidiv kann zuverlässig durch eine prä- oder postoperative Bestrahlung verhindert werden. In der Nachbehandlung nach operativer Arthrolyse und bei rein konservativer Therapie hat sich der Einsatz blockierbarer Schienen bewährt. Die Verwendung von Quengelschienen und die alleinige Narkosemobilisation sollten als Therapiekonzept verlassen werden. Die Möglichkeiten der arthroskopischen Chirurgie sind auf die Entfernung freier Körper oder die Lösung intraartikulärer Adhäsionen begrenzt. Die Distraktionsarthrolyse des Ellengelenks ist ein neuer Therapieansatz, dessen Nutzen noch nicht geprüft ist.

Zusammenfassung: Beckenringverletzungen sind schwere Verletzungen, die betroffenen Patienten sind meist polytraumatisiert und vital bedroht. Im Management der Polytraumaversorgung spielt die Fixateur-externe-Anlage eine wichtige Rolle.Die schnelle externe Stabilisierung des Beckenrings verkleinert das Volumen des kleinen Beckens und begrenzt hierdurch den weiteren Gewebeschaden und den Blutverlust. Die externe Stabilisierung kann temporär oder definitiv sein.Primär mit Fixateur externe stabilisierte Verletzungen im Wachstumsalter oder schwere Weichteilschäden sprechen gegen einen sekundären Verfahrenswechsel.

Posttraumatische Fehlstellungen am Oberschenkelschaft treten v.a. nach komplexen Frakturen auf. Die Indikation zur Korrekturosteotomie kann bei klinisch relevanten Beinlängendifferenzen, bei kosmetisch entstellenden und biomechanisch wirksamen Rotations- und Achsfehlern im Sinn einer präarthrotischen Deformität gestellt werden. Bei Umstellung im Femurschaftbereich hat sich der Verriegelungsmarknagel aufgrund der frühen Belastungsfähigkeit und des limitierten Weichteilzugangs als Implantat bewährt. Jeder Korrekturosteotomie sollte eine exakte präoperative Planung mit übersichtsradiographischer und ggf. computertomographischer Analyse vorausgehen. Comminuted femoral shaft fractures are particularly likely to result in posttraumatic deformities. Significant leg-length discrepancy and symptomatic rotational and axis malalignment with prearthrotic deformities are indications for corrective osteotomy. When a corrective osteotomy in the diaphyseal part is indicated intramedullary nailing is the technique of choice for stabilization. Intramedullary nailing in combination with closed osteotomy avoids the potential morbidity of a large wound and allows early weight-bearing. Before a corrective osteotomy is undertaken a careful analysis of the geometry of the lower extremities by clinical investigation, radiography and computed tomography is mandatory.

Die richtige Beurteilung des Weichteilschadens beim Unterschenkelschaftbruch ist unabdingbare Voraussetzung für deren erfolgreiche Behandlung. Eine konservatives Vorgehen ist selten möglich. Je höhergradiger der Weichteilschaden ist, umso weniger invasiv sollte die operative Stabilisierung sein. Ob die Ziele der Behandlung, nämlich Heilung der Fraktur und des Weichteilmantels, erreicht werden könne, ist aber von der erzielten Stabilität der Osteosynthese und der Weichteilrekonstruktion abhängig. Knochen und Weichteile werden folglich immer gemeinsam behandelt. Beim besonders schweren Weichteilschaden ist der Einsatz plastisch-chirurgischer Verfahren unabdingbar. After a lower leg fracture, adequate assessment of soft tissue damage is absolutely essential if treatment is to be successful. Nonoperative treatment is rarely possible. The more severe soft tissue injury is, the less invasive the techniques that can be used for surgical stabilization. Whether or not it is possible to achieve the objectives of treatment, namely healing of the fracture and of the soft tissue damage, depends on the stability of the bone fixation and the soft tissue reconstruction. Bone and soft tissue are treated simultaneously throughout. When soft tissue injury is particularly severe and extensive, trauma surgeon and plastic reconstructive surgeon should work closely together on the case.

Traumatische Läsionen mit Dehnung, Quetschung, Durchtrennung oder Zerreißung der Nerven resultieren häufiger aus stumpfen, gedeckten Gewalteinwirkungen, seltener aus scharfen Verletzungen von außen. Klassische Konstellationen stellen die Luxationen großer Gelenke und die Kombinationsverletzungen der Gefäß-Nerven-Bahnen dar. ¶Lediglich milde Überdehnungsverletzungen als Neuropraxie heilen unter konservativer Behandlung unter völliger Funktionswiederkehr aus. Komplette Durchtrennungen als Neurotmesis sollten möglichst rasch durch mikrochirurgisch gestützte Konstruktionen wiederhergestellt werden. Die Rehabilitation nach peripheren Nervenläsionen bedarf ¶einer intensiven physiotherapeutischen ¶Betreuung.

Zusammenfassung Es werden die vorläufigen Ergebnisse von ¶3 Patienten mit allogenen vaskularisierten Femurdiaphysen- und 4 Kniegelenktransplantationen vorgestellt. Alle Transplantate wurden von Multiorganspendern gewonnen und frisch transplantiert. Zur Osteosynthese dienten Marknägel. Die Gefäßpedikel der Transplantate wurden in End-zu-Seit-Technik beim Empfänger anastomosiert. Zur Immunsuppression dienten im wesentlichen Cyclosporin A und Azathioprin. Eine gute Durchblutung der Transplantate zeigten DSA und Duplexsonographie. Der Knochenstoffwechsel wurde durch die SPECT-Szintigraphie kontrolliert. Eine knöcherne Konsolidierung der Osteotomien im konventionellen Röntgenbild zeigte sich 5 Monate nach der Transplantation. Biopsien aus den transplantierten Knochen ergaben intakte Osteozyten, und arthroskopisch zeigten sich intakte Synovial-, Knorpel- und Bandstrukturen. Technisch erscheint eine solche Transplantation machbar. Das Hauptproblem liegt im Bereich der Immunologie. Alle Transplantationen wurden unter Berücksichtigung der entsprechenden AB0-Kompatibilität, jedoch unter HLA-Mismatch, durchgeführt. Deshalb muss mit akuten und chronischen Abstoßungsreaktionen gerechnet werden, die entsprechende Schäden an den Transplantaten hinterlassen können. Deshalb erscheint eine andauernde Immunsuppression der Transplantatempfänger unvermeidbar. Abstract This paper presents preliminary results achieved with allogeneic vascularized transplantations of three femoral diaphyses and four total human knee joints. Grafts were harvested from multi-organ donors and transplanted immediately. Osteosyntheses were performed employing intramedullary nails. The vascular pedicles of the grafts were attached by constructing end-to-side anastomoses. Cyclosporine and azathioprine were the main preparations used for immunosuppression. DSA and Duplex ultrasonography were performed to check that the grafts were perfused, and by SPECT scintigraphy to check the bone metabolism. Five months after transplantation consolidation of the osteotomies was demonstrated by conventional X-rays. Biopsies of the grafted bone revealed intact osteocytes, and arthroscopy demonstrated intact synovial, chondral and ligamentous structures. From the technical aspect vascularized transplantation of the femoral diaphyses and total knee joints is feasible. The main problems are immunologic in nature. Transplantations were performed respecting the ABO compatibility, but with a pronounced HLA mismatch. Acute and chronic rejection crises may damage the grafts. At least in synovial joints, lifelong immunosuppression of the recipients seems to be unavoidable.

Zusammenfassung Es werden die vorläufigen Ergebnisse von ¶3 Patienten mit allogenen vaskularisierten Femurdiaphysen- und 4 Kniegelenktransplantationen vorgestellt. Alle Transplantate wurden von Multiorganspendern gewonnen und frisch transplantiert. Zur Osteosynthese dienten Marknägel. Die Gefäßpedikel der Transplantate wurden in End-zu-Seit-Technik beim Empfänger anastomosiert. Zur Immunsuppression dienten im wesentlichen Cyclosporin A und Azathioprin. Eine gute Durchblutung der Transplantate zeigten DSA und Duplexsonographie. Der Knochenstoffwechsel wurde durch die SPECT-Szintigraphie kontrolliert. Eine knöcherne Konsolidierung der Osteotomien im konventionellen Röntgenbild zeigte sich 5 Monate nach der Transplantation. Biopsien aus den transplantierten Knochen ergaben intakte Osteozyten, und arthroskopisch zeigten sich intakte Synovial-, Knorpel- und Bandstrukturen. Technisch erscheint eine solche Transplantation machbar. Das Hauptproblem liegt im Bereich der Immunologie. Alle Transplantationen wurden unter Berücksichtigung der entsprechenden AB0-Kompatibilität, jedoch unter HLA-Mismatch, durchgeführt. Deshalb muss mit akuten und chronischen Abstoßungsreaktionen gerechnet werden, die entsprechende Schäden an den Transplantaten hinterlassen können. Deshalb erscheint eine andauernde Immunsuppression der Transplantatempfänger unvermeidbar. This paper presents preliminary results achieved with allogeneic vascularized transplantations of three femoral diaphyses and four total human knee joints. Grafts were harvested from multi-organ donors and transplanted immediately. Osteosyntheses were performed employing intramedullary nails. The vascular pedicles of the grafts were attached by constructing end-to-side anastomoses. Cyclosporine and azathioprine were the main preparations used for immunosuppression. DSA and Duplex ultrasonography were performed to check that the grafts were perfused, and by SPECT scintigraphy to check the bone metabolism. Five months after transplantation consolidation of the osteotomies was demonstrated by conventional X-rays. Biopsies of the grafted bone revealed intact osteocytes, and arthroscopy demonstrated intact synovial, chondral and ligamentous structures. From the technical aspect vascularized transplantation of the femoral diaphyses and total knee joints is feasible. The main problems are immunologic in nature. Transplantations were performed respecting the ABO compatibility, but with a pronounced HLA mismatch. Acute and chronic rejection crises may damage the grafts. At least in synovial joints, lifelong immunosuppression of the recipients seems to be unavoidable.

Abstract Background: In the past few years, endoscopic operations on the spinal column have developed from representing exceptional interventions to becoming standard procedures in spinal surgery. Operating techniques and instruments have been standardized and unified, making it possible now to perform safe endoscopic surgery, as the results of more than 350 operative treatments in a 5-year period show. History: This development was aided by the scarcely satisfactory results of purely dorsal treatment concepts, which intensified the demand for reconstruction of the anterior load-bearing spinal column. It was the high access morbidity of the conventional open procedure which stood in the way of a broader use of open ventral operations in spinal surgery and which limited the indication for open interventions to a few cases showing marked destruction or malformation in the anterior section of the spine. For this constellation, the endoscopic procedures could provide a solution based on the reduced access morbidity typical for endoscopic procedures without the need to accept diminished surgical effectiveness. Indications: The possibilities of endoscopic spinal surgery have been developed continuously during the past few years, so that today nearly all operations in spinal traumatology can be performed endoscopically. Endoscopic splitting of the diaphragm also made it possible to open up the upper sections of the lumbar spine, so that the area between the third thoracic vertebra and the third lumbar vertebra is now accessible to endoscopic surgery. The potential indications include repositioning, the incision and resection of ligaments and intervertebral disks, the removal of fragmented sections of vertebrae including anterior decompression of the spinal canal, the replacement of vertebral bodies with biological or alloplastic materials and, last but not least, the minimally invasive insertion of an implant for ventral stabilization.

Zusammenfassung: Die Kompressionsmarknagelung kombiniert das Prinzip der intramedullären Osteosynthese mit der Möglichkeit, durch interfragmentäre Kompression eine erhöhte Primärstabilität zu erzielen. Durch die daraus zusätzlich resultierende Schmerzreduktion können eine sehr rasche Vollbelastung angeschlossen und eine verkürzte Knochenbruchheilung erzielt werden. Idealer Frakturtyp ist der Quer- oder kurze Schrägbruch. Des Weiteren kann das Kompressionsprinzip zur gesicherten Fragmentadaption auch bei instabileren Frakturen zur Anwendung kommen. Auf diese Weise kann eine Fragmentdehiszenz sicher vermieden werden. Ideales Einsatzgebiet für die Kompressionsmarknagelung ist die rekonstruktive Chirurgie (Pseudarthrosenbehandlung, Korrekturosteotomie, Arthrodese). Mit biomechanischen Methoden kann der Stabilitätsgewinn nachgewiesen werden, wobei interfragmentär Kräfte bis zu 4000 N auftreten. Die hier vorgestellten Implantate können sowohl antegrad als auch retrograd mit demselben Instrumentarium eingebracht werden.

Zusammenfassung: Bei der Korrektur von posttraumatischen Fehlheilungen langer Röhrenknochen mit Rotations-, Varus-, Valgus-, Ante- und Rekurvationsfehlstellungen sowie Längendifferenzen hat sich die Verwendung von Kompressionsmarknägeln bewährt. Dabei kommt das biomechanische Prinzip der Kompressionsmarknagelung mit sofortiger axialer Stabilität und hoher Rotationsstabilität mit Pressung der Knochenabschnitte in den Osteotomiespalt zur Anwendung. Durch eine minimalinvasiv durchgeführte Osteotomie, beispielsweise über Markrauminnensäge, können die Weichteile geschont werden.

Abstract Material and Method: Bioresorbable and biostable interference screws in operative reconstruction of anterior cruciate ligament (ACL) ruptures were compared concerning safety and efficacy. The randomized prospective clinical study consisted of 2 groups with 15 patients each, admitted at our center with acute (&lt; 8 weeks) traumatic loss of ACL-stability. The ACL-reconstruction was performed in open technique using a bone-patellar tendon-bone autograft and fixation with bioresorbable (study group) or titanium (control group) interference screws. Results: Employing a special questionnaire patients' satisfaction was recorded. Functional results were scored using clinical examination and the Lachman test under sonographic control. Foreign-body reactions against the implants were assessed by clinical examinations and on radiographs. The follow-up of all patients was at least for 2 years. Ligament stability of the knee joint, operative and postoperative complication rate did not significantly differ between the two groups. 14 patients of the study group and 13 patients of the control group were completely satisfied. One patient of the study group was dissatisfied because of developing an infection. Conclusion: The results using bioresorbable interference screws in ACL-reconstruction are identic to those employing standard titanium implants. Differences in rates of operative and postoperative complications were not statistically significant. The advantages of the bioresorbable implants include the absence of urgent implant removal in case of secondary ACL-reconstruction procedures and undisturbed MRI and CT scans postoperatively.

Zusammenfassung: Die erweiterte Indikation der Kompressionsmarknagelung zur Herstellung einer Arthrodese des oberen Sprunggelenks wird anhand der Indikation, Technik und Ergebnisse von 147 Patienten in einem 7-Jahres-Zeitraum vorgestellt. Nach offener Gelenkflächenresektion über eine Außenknöchelosteotomie erfolgt die interne Osteosynthese mit dem Kompressionsmarknagel. Durch den speziellen Mechanismus kann eine aktive Kompression hergestellt werden, die eine gipsfreie Weiterbehandlung ermöglicht. Die sehr weit distal platzierten Verriegelungsmöglichkeiten bieten eine sichere Verankerung im Talus. Die Marknagelarthrodese stellt bei korrekter Ausführung ein sicheres Verfahren zur Erstellung von Arthrodesen des oberen Sprunggelenks dar.

Zusammenfassung: Die Kompressionsmarknagelung ist ein hervorragendes Osteosyntheseverfahren zur Versorgung von axial stabilen Frakturen ¶(AO-Typ A2 und A3) der langen Röhrenknochen. An Humerus, Femur und Tibia kann sowohl antero- als auch retrograd vorgegangen werden. Sollte intraoperativ bei Schräg- oder Spiralfrakturen ein Teleskoping auftreten, kann bei dem verwendeten Implantat jederzeit statisch verriegelt werden. Für die Anwendung beim Polytrauma und bei Weichteildefekten gelten die gleichen Prinzipien wie beim Verriegelungsmarknagel. Der Vorteil der Kompressionsmarknagelung besteht in der Kompression der Fraktur auch bei Entlastung der betroffenen Extremität. Nachteile wegen des Aufreamens der Markhöhle wurden von uns nicht beobachtet.

Summary: Objectives: Using a thoracoscopic approach reduction of vertebral body fractures and interbody fusion of the involved segment after implantation of an autogenous bone graft and plate fixation. Indications: Unstable fractures of the vertebral column from T4 to L3 inclusive of Types A1.2 and A1.3 of the AO classification. Fractures of types A2, A3, B and C. Discoligamentous instability. Posttraumatic deformity. Contraindications: Cardiopulmonary insufficiency. Acute posttraumatic respiratory failure. Coagulopathies.Surgical Technique: Endoscopic approach with 4 portals for fibre optic and instruments. Notching of diaphragm when treating thoracolumbar or lumbar fractures. Insertion of 2 screws under image intensification into the segment to be fused: they are placed parallel to the posterior wall of the body. Removal of all disc material and of fragments from the vertebra (partial corporectomy). If decompression of spinal canal is indicated, the posterior rim of the body is resected. Insertion into the defect of a tricortical bone graft removed from the iliac crest. A titanium plate is inserted over the screws. With the help of nuts and additional screws a stable fixation of the plate is achieved. Suture of the diaphragm. Chest tubes. For Type B and C fractures an additional posterior instrumentation is mandatory. Results: Between May 1996 and May 1998 100 patients with 103 unstable thoracic or lumbar fractures were operated. Depending on the fracture type 66 patients had a combined anterior and posterior approach and stabilization. Spinal decompression in 19 patients. Of 61 spinal fusions followed at least for 6 months 54 had a bony consolidation. Advantages: Decreased morbidity associated with the approach, early mobilization, decreased use of analgesics, cosmetic advantages. Complications: Haemorrhage, transient peripheral nerve irritation, infection at site of harvesting, pleural effusion, loss of correction secondary to loosening of screws or displacement of graft.

The aim of the study was to investigate the time course of neutrophil activation after skeletal muscle ischemia in humans and to assess the effect of xanthine oxidase inhibitor allopurinol or cyclooxygenase inhibitor indomethacin. In patients undergoing tourniquet ischemia of the upper limb, polymorphonuclear neutrophils (PMN) were simultaneously isolated from antecubital vein blood of both the contralateral control arm and the tourniquet arm. PMN-superoxide production (PMN-SOP) was determined by a cytochrome C reduction assay, PMN-myeloperoxidase activity (PMN-MPO) by guaiacol oxidation and serum PMN-elastase concentration by an enzyme immunoassay. At 60 min after release of the tourniquet, significant increases of PMN-SOP, PMN-MPO, and serum elastase concentrations were observed in tourniquet arms as compared with control arms (p< .05). Allopurinol (300 mg orally, 12 and 2 h before ischemia) significantly inhibited the increase of PMN-SOP, PMN-MPO, and serum elastase (p< .05). Indomethacin (50 mg orally, 2 h before ischemia) prevented increased PMN-MPO and serum elastase, but prevented increased PMN-SOP only when neutrophils were incubated in the presence of their autologous plasma. These findings suggest that ischemia/reperfusion of human skeletal muscle involves both xanthine oxidase-dependent oxygen free radicals and cyclooxygenase metabolites. These pathways could activate circulating neutrophils which potentially inflict local and remote endothelial injury.

AbstractTrauma surgery lack, substitute, for the reconstruction of large defects of the long bones. Encouraged by the promising results of bone allotransplantation in animal models, we successfully performed vascularized bone transplantation in humans. Vascularized femoral diaphyses were allogenically transplanted into three patients suffering from chondrosarcoma or post‐traumatic osteomyelitis with postoperative immunosuppression. The bone segments were harvested from multi‐organ donors and perfused with UW solution. After back‐table preparation, the grafts were transplanted into the defect zone. Interlocking devices were used in these operations. Vascular anastomoses were performed in end‐to‐side technique. The early clinical course of the patients was not free of anatomical, technical, or immunological complications. However, all patients are currently free of malignancy and infection. They are also free of pain and full weight bearing. We conclude that allogenic grafting of vascularized bone segments has the potential to become an alternative for the replacement of large bone defects.

Abstract. Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral and tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient’s superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110� flexion.:

Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral and tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient's superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110° flexion.

Abstract: Trauma surgery lack, substitute, for the reconstruction of large defects of the long bones. Encouraged by the promising results of bone allotransplantation in animal models, we successfully performed vascularized bone transplantation in humans. Vascularized femoral diaphyses were allogenically transplanted into three patients suffering from chondrosarcoma or post-traumatic osteomyelitis with postoperative immunosuppression. The bone segments were harvested from multi-organ donors and perfused with UW solution. After back-table preparation, the grafts were transplanted into the defect zone. Interlocking devices were used in these operations. Vascular anastomoses were performed in end-to-side technique. The early clinical course of the patients was not free of anatomical, technical, or immunological complications. However, all patients are currently free of malignancy and infection. They are also free of pain and full weight bearing. We conclude that allogenic grafting of vascularized bone segments has the potential to become an alternative for the replacement of large bone defects.

Integrity of the hepatic microcirculation and maintenance of endothelial cell viability are critical components in preventing primary non-function after liver transplantation. Therefore, hepatic microcirculation and leucocyte-endothelial interaction were studied in rat livers stored for 1 h in Euro-Collins (EC), University of Wisconsin (UW), and histidine-tryptophan-ketoglutarate (HTK) solutions and subsequently transplanted. One hour after transplantation surgery, the livers were exposed under an intravital fluorescence microscope. After injection of the leucocyte marker acridine orange (1 µmol/kg), six pericentral fields were observed for 30 s and experiments were recorded continuously. The percentage of perfused sinusoids was reduced in the livers in the EC group (82.9%) in contrast to the UW (93.2%) and HTK groups (91.0%). Livers in the EC group showed a reduction in the diameters of pericentral sinusoids (7.3±0.2 µm; mean±SEM) compared with the UW group (9.5±0.2 µm; P<0.05) and HTK group (10.2±0.8 µm; P<0.05), indicating substantial cell swelling in livers stored in EC solution. Permanent adherence of leucocytes was most frequently observed in the EC group (33.5±1%), while this phenomenon was less pronounced in the UW group (14.5+1.1%; P<0.05) and HTK group (16.3±0.7%; P<0.05). Conversely, temporary adherence of leucocytes was reduced in the EC group (19.7+1.3%) compared with the UW group (30.5+2.1%) and the HTK group (34.4+0.8%). Microcirculatory failure and cell swelling in the EC group might be due to the lack of osmotic substances or oxygen radical scavengers included in UW (allopurinol, glutathione) and HTK (mannitol) solutions. In conclusion, cold storage of livers in UW and HTK solutions results in better preservation of the microcirculation and prevention of adhesion of leucocytes after transplantation compared with the EC solution.

The unique arrangement of large numbers of fixed tissue macrophages, endothelial, and pa-renchymal cells along hepatic sinusoids as well as their key role in the acute phase response makes the liver a primary target organ in endotoxemia. Pathogenesis of hepatic failure in endotoxemia is incompletely understood, but microcirculatory failure as well as leukocyte-endothelial interaction in response to inflammatory mediators may relate to it. Using intravital fluorescence microscopy, sinusoidal widths, leukocyte flow velocity, and sublobular leukocyte (white blood cell (WBC)) adhesion characteristics 1 h after randomized intravenous application of 0, 0.1 1, or 5 mg/kg b.w. Escherichia coli endotoxin O 111 B4 (ETX) were evaluated in female Sprague-Dawley rats (n = 6–8/group). Whereas the bolus injection of ETX caused only minor concurrent macrohemodynamic effects, a significant increase of permanent WBC adhesion especially in periportal areas (0 mg, 2.1 ± 0.7; 0.1mg, 16.2–3.6; 1 mg, 15.5 ± 1.0; 5 mg, 13.2 ± 2.3 (p< .01, p< .05, compared to vehicle)) was found in all groups 60 min after ETX challenge. In contrast, an increase of WBC margination in midzonal and pericentral regions was only seen with the higher doses of 1 or 5 mg/kg ETX, respectively. The sublobular pattern of WBC margination is consistent with the concept of regulation of WBC adhesion by inflammatory mediators released by lipopolysaccharide-stimulated Kupffer cells in vivo. We propose that overwhelming the detoxifying capacity of predominantly periportally located Kupffer cells with large amounts of ETX may lead to activation of pericentral-located resting macrophages paralleled by a rise of adhering leukocytes.

Zusammenfassung Die abdominelle posttraumatische Infektion liegt in der Häufigkeitsskala der posttraumatischen Infektionen an 5. Stelle. Hinsichtlich der Sterblichkeit der Verletzten steht sie mit 25% aber schon an Platz 2 nach der posttraumatischen Pneumonie (29%).Die posttraumatische abdominelle Sepsis hat sogar eine Letalität von bis zu 50%. Diese Sterblichkeit kann nur reduziert werden,wenn die zugrunde liegende Verletzung oder Komplikation frühzeitig erkannt werden.Die verspätete Laparotomie verschlechtert die Prognose abdominell verletzter Patienten im Vergleich zu rechtzeitig laparotomierten Verletzten eklatant (Letalität 46% vs. 11).Parallel hierzu liegt die Sterblichkeit der frischen lokalen Peritonitis bei 14%, die der älteren diffusen Peritonitis bei 42%. Abstract Abdominal infection has the fifth highest incidence of all posttraumatic infections but has the second highest mortality rate with 25%,pneumonia,with 29%, being the only posttraumatic infection that is more frequently lethal.Posttraumatic abdominal sepsis, on the other hand, has a mortality rate of almost 50%.This rate cannot be reduced except by prompt identification of the correct diagnosis of the underlying injury or complication.This means that delayed laparotomy is strikingly detrimental in these patients, with 46% mortality as opposed to 11% in patients who undergo laparotomy promptly. In parallel with this, the mortality of fresh-onset and localized peritonitis is 14%,whereas that of diffuse purulent peritonitis is up to a devastating 42%.

Zusammenfassung: Das Vorhandensein von angeborenen Fehlbildungen und erworbenen Deformitäten bei Frakturen der Halswirbelsäule erfordert spezielle Kenntnisse der Biomechanik und der entsprechenden operativen Versorgung. Der Fall einer Densfraktur bei Blockwirbel HWK 2/3 wird dargestellt.

Introduction Traumatic cervical spinal cord injury affects the individual in a multi-faceted way. Early decompression of the spinal canal is recommended. The optimal time point for this intervention has been under debate for decades. This study compares a variety of neurologic, radiologic and functional outcome parameters between patients after early (<8 hour) versus delayed decompression.Materials and Methods We performed a retrospective analysis at the Center for Spinal Cord Injuries (Trauma Center Murnau, Germany), an over-regional level-I trauma center. Follow-up data was collected prospectively for one year after injury, according to institutional and international consensus criteria. We included data acquired over a 10-year period (2004 – 2014). We only analyzed patients over 18 years with traumatic cervical spinal cord injury without concomitant extremity injury, traumatic brain injury or central cord injuries.Results We identified 70 patients (59 males), who met in- and exclusion criteria. Out of this population, 35 patients were decompressed within the first 8 hour (average: 4.36 hour after the insult) (= early group). After one year, patients from the early group showed a significantly higher gain in total motor score (TMS) points and upper extremity motor score (UEMS) points. Additionally, this patient cohort showed significantly better grades on the American Spinal Injury Association Impairment Scale (AIS) and a significantly higher AIS conversion rate. Furthermore, they were more likely to experience a significant greater difference in the Spinal Cord Independence Measure (SCIM) within the follow-up period.Conclusion This study shows that an early surgical decompression not only leads to higher AIS conversion rates, but – most importantly – also to a better functional outcome (as indicated by the SCIM score).