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ZusammenfassungEine erfolgreiche Behandlung von offenen Verletzungen von Frakturen hängt von vielen Einflussfaktoren ab (Inflammation, Perfusion, Kompartmetsyndrom). Neben lokalen Besonderheiten der verletzten Körperregion spielen patientenbezogene Grunderkrankungen eine wesentliche Rolle (Stoffwechselerkrankungen, Arteriosklerose). Der therapeutische Erfolg wird häufig nur interdisziplinär erzielt.Die initiale Therapie findet idealerweise schon am Unfallort statt. Luxationsfrakturen müssen zwingend reponiert und geschient werden, offene Frakturen im Anschluss steril abgedeckt. Neben der Stabilisierung der Vitalfunktion muss eine vollumfängliche körperliche Untersuchung und Diagnostik mit Gefäßdarstellung und Fotodokumentation im Schockraum stattfinden. Hier wird auch der Tetanusschutz eruiert und eine kalkulierte antimikrobielle Therapie eingeleitet.Offene Frakturen werden dann nach dem Damage Control Prinzip im OP exploriert, debrediert und transfixiert. Manifeste oder drohende Kompartmentsyndrome müssen gespalten werden, ggf. muss mithilfe der Gefäßchirurgie eine Revaskularisation angestrebt werden. Sollte eine plastisch-chirurgische Expertise vor Ort sein, so ist diese so früh wie möglich einzubinden. Häufig wird das Ausmaß des sekundären Gewebsschadens erst durch weitere Débridements und Gewinnung von Gewebeproben sichtbar. Der geeignete Zeitpunkt für die definitive Osteosynthese hängt vom Gesamtzustand des Patienten ab. Diaphysäre Frakturen werden in der Regel mit einem Verriegelungsmarknagel weichteilschonend operativ versorgt. Gelenk- oder metaphysäre Frakturen werden hingegen durch winkelstabile Plattensysteme stabilisiert. Der vital bedrohte Patient oder Patienten mit einem ausgedehnten Weichteilschaden können von einem Ilizarov-Hybridfixateur profitieren. Limitierend für jede Osteosynthese sind die Weichteilverhältnisse. Sollte die temporäre Weichteildeckung notwendig werden, so wird im eigenen Vorgehen zunächst ein Epigard gewählt mit second look nach 24 Stunden und Wechsel auf einen Vakuumversiegelungssystem (V. A. C. Therapy). Mittels plastisch-chirurgischer Konsultation lässt sich schon frühzeitig die optimale Deckung der posttraumatischen Defekte planen.

ZusammenfassungUnter den seltenen Primärtumoren des Skelettsystems zählen die chondrogenen zu den am häufigsten auftretenden. Innerhalb des chondroiden Grundmusters, zeigt sich eine große Bandbreite an radiomorphologischen und histopathologischen Erscheinungsformen mit variierender tumor-biologischer Aktivität. An der Wirbelsäule treten diese Tumoren deutlich seltener auf und klinisch stehen Schmerzen im Vordergrund. Aufgrund ihrer oft dorsalen Lokalisation sind neurologische Defizite nicht selten. CT und MRT sind maßgeblich für die bildgebende Diagnostik. Für das Management gilt das Prinzip der interdisziplinären Entscheidungsfindung und Therapie nach abgeschlossener Diagnostik, die eine suffiziente Biopsie einschließt. Entsprechend der Enneking Klassifikation der Tumoren sind intraläsionale und aggressive Resektionen in Abhängigkeit der zu Grunde liegenden, oft heterogenen tumor-biologischen Aktivität möglich. Entsprechend different sind Lokalrezidiv- und auch sekundäre Entartungsraten. Aufgrund ihres seltenen Auftretens, der notwendigen Diagnostik und der teils komplexen Therapie wird eine Zuweisung an ein spinal tumor-chirurgisches Referenzzentrum mit angeschlossener Infrastruktur empfohlen. Der folgende Artikel soll die Charakteristika, Diagnostik und Therapie benigner chondrogener Primärtumoren der Wirbelsäule aufzeigen und beschreibt exemplarisch Osteochondrome, Enchondrome, Chondro-myxoidfibrome und Chondroblastome der Wirbelsäule.

Background: The intra-articular graft force (IAGF) in anterior cruciate ligament reconstruction decreases quickly over the first hours after surgery. Nevertheless, little is known about whether the initial extra-articular tensioning force (EATF) and screw diameter affect the graft force after fixation. Purpose: To investigate the effects of different EATFs on the IAGF of a soft tissue graft fixated via a bioabsorbable interference screw over 100 minutes after fixation and to evaluate the effects of different screw diameters within 1 mm of the tunnel width during this process. Study Design: Controlled laboratory study. Methods: In this biomechanical study, a porcine quadruple-strand soft tissue graft was inserted into the tibial anterior cruciate ligament tunnel. On the extra-articular side, 3 loads were applied during retrograde insertion of the bioabsorbable interference screw (6, 7, and 8 mm): 20 N, 80 N, and maximum manual EATF (Nmax). Nine study groups consisting of 10 tibiae each were created to test the effects of different EATFs and screw sizes. The IAGF was measured up to 100 minutes after the EATF was released. Results: An EATF ≥80 N resulted in a larger IAGF for all screw sizes at 100 minutes. There were no significant associations between the IAGF at 100 minutes and different screw diameters. Inserting the tibial screw significantly increased the IAGF in all groups, with the exception of Nmax applied in groups with 7- or 8-mm screws. When compared with the end of screw insertion, after the release of the EATF, the IAGF dropped by 55% to 77 % at 100 minutes. Conclusion: An initial EATF ≥80 N is associated with a significantly larger IAGF at 100 minutes in this cadaveric simulation. The IAGF in soft tissue grafts decreased substantially after the retrograde placement of an interference screw. A recommendation regarding screw diameter with respect to the IAGF cannot be given. Clinical Relevance: To obtain a higher residual graft force after bioabsorbable interference screw fixation, an initial EATF ≥80 N should be applied according to this model. The significant decrease in graft force after the release of the EATF indicates that the reconstructed knee cannot be mechanically stabilized after the surgery.

Die minimal-invasive Osteosynthese der distalen Fibula mit intramedullarem Nagel dient als biomechanisch stabiles und weichteilschonendes Verfahren bei instabiler Fraktur, schlechter Knochenqualitat und/oder kritischen Weichteilverhaltnissen zur Wiederherstellung der Lange, Achse und Rotation der distalen Fibula mit Stabilisierung der Malleolengabel. Ziel der Operation ist die rasche und weichteilschonende Reposition und Stabilisierung der distalen Fibulafraktur bei Verletzungen des oberen Sprunggelenks. Frakturen der distalen Fibula; Kombinationsverletzung des distalen Unterschenkels mit versorgungspflichtiger Fibulafraktur; osteoporotische Fibulafrakturen; kritische Weichteilverhaltnisse am oberen Sprunggelenk. Ablehnung der Operation durch den Patienten, vitale Bedrohung durch begleitende Verletzungen oder schwere Begleiterkrankungen, sehr enger Markraum der Fibula (implantatabhangig, in der Regel

Die Transfixierung des oberen Sprunggelenks dient bei hochgradig instabiler Fraktur und/oder kritischen Weichteilverhaltnissen zur meist temporaren Retention der Reposition mit Wiederherstellung der Lange und Achsen sowie Stabilisierung der Malleolengabel, um eine Redislokation zu vermeiden und Konsolidierung der Weichteile – meist bis zu einer definitiven internen Osteosynthese – zu erzielen. In speziellen Fallen kann der Fixateur als zusatzliche Stabilisierung auch nach abgeschlossener Osteosynthese dienen oder die Fraktur auch im Fixateur externe ausbehandelt werden. Ziel der Operation ist die rasche und weichteilschonende Stabilisierung des oberen Sprunggelenks sowie angrenzender Strukturen. a) Frakturen des Pilon tibiale; b) sehr distale, extraartikulare Unterschenkelfrakturen (ohne Option der Pinplatzierung im distalen Fragment); c) Luxationsfrakturen und instabile Malleolarfrakturen mit Subluxationstendenz; d) kritische Weichteilverhaltnisse am oberen Sprunggelenk; e) Luxationsfrakturen von Talus, Chopart- und Lisfranc-Gelenk (ggf. mit zusatzlicher transartikularer Transfixierung). Ablehnung der Operation durch den bewusstseinsklaren Patienten, vitale Bedrohung durch vorrangig zu versorgende Verletzungen. Perkutane Platzierung von Schanz-Schrauben des entsprechenden Kalibers in den sog. „safe zones“ der Tibia, Metatarsus und ggf. Kalkaneus. Zusatzliche Transfixierung auf Hohe der Chopart- und Lisfranc-Gelenke mit Kirschner-Drahten, soweit erforderlich. Montage der Verbindungstrager mit dem Fus in Neutralstellung. Essenziell sind neben der Beachtung biomechanischer Grundlagen auch die vorausschauende Platzierung des Fixateur externe unter Berucksichtigung zukunftiger Operationszugange sowie anatomischer Strukturen mit maximaler Stabilitat und Weichteilprotektion. Nach initialer Transfixation sind zunachst die weichteilprotektive Lagerung mit milder lokaler Kuhlung sowie Bettruhe indiziert. Bei manifestem Kompartmentsyndrom sowie offenen Frakturen mit temporarer Weichteildeckung ist ein Second-look-Eingriff nach 24–72 h obligat. Zur exakten Frakturanalyse und optimalen Planung der definitiven Versorgungsstrategie ist die Indikation zur CT(Computertomographie)-Diagnostik groszugig zu stellen. Der Zeitpunkt der definitiven Versorgung richtet sich dann nach dem lokalen Weichteilbefund sowie dem Allgemeinzustand des Patienten. Das Vorliegen einer Luxation zum Unfallzeitpunkt stellt einen negativen prognostischen Faktor bei Sprunggelenkfrakturen dar. Hohere posttraumatische Arthroseraten finden sich auch bei Trimalleolarfrakturen, insbesondere mit Frakturen der Tibiahinterkante, direkten Knorpelschaden und Syndesmosenrupturen. Bei anatomischer Wiederherstellung der Knochelgabel und der Gelenkkongruenz lassen sich in 75–89 % gute bis sehr gute Ergebnisse erzielen.

Tumours of the foot and ankle constitute about 4–5% of all musculoskeletal tumours with the majority of them being benign. Diagnosis of malignant soft tissue or bone tumours is frequently delayed because of the relatively low prevalence and uncommon presentation at the foot and ankle. Suspicious lesions or lumps should be subjected to CT, MRI and biopsy. Subfascial location, lump size more than 5 cm, increase in size, painful and recurrent tumours should raise the suspicion of malignancy and lead to patient referral to a designated tumour centre. Neoadjuvant and adjuvant systemic chemotherapy and/or radiation therapy, isolated limb perfusion (ILP) and hyperthermia for malignant tumours have to be discussed in a multidisciplinary tumour board. With the advances in local and free tissue transfer, limb-sparing techniques have increasingly replaced primary amputations thus preserving lower limb function as much as possible without compromising on the principles of oncologic resection.

Even minor residual fragment malpositioning after internal fixation of ankle fractures is associated with a worse prognosis. Frequent causes for non-anatomical reduction are fibular shortening due to comminuted fractures or poor bone quality, translational or rotational malpositioning of the distal fibula within the tibial incisura with unstable syndesmosis injuries, and inadequately addressed bony avulsions of the tibiofibular syndesmosis. After operative treatment of fracture dislocations with syndesmotic fixation, in case of complex fracture pathoanatomy, and with suspected non-anatomic reduction in postoperative radiographs, computed tomography imaging of both ankles should be performed. Correction of relevant malreductions should be performed as early as possible in order to speed up rehabilitation and to avoid late sequelae due to a load shift or instability in a weight-bearing joint.Bereits geringe residuale Fehlstellungen nach Osteosynthese von Sprunggelenkfrakturen gehen mit einer verschlechterten Prognose einher. Häufige Ursachen für nicht anatomische Repositionen sind Fibulaverkürzungen bei Trümmerfrakturen oder schlechter Knochenqualität, Fehlstellungen und Malrotationen der distalen Fibula in der Tibiainzisur bei instabilen Syndesmosenverletzungen sowie nicht adressierte knöcherne Ausrisse der vorderen oder hinteren Syndesmose. Nach operativer Versorgung von Frakturen mit notwendiger Syndesmosenstabilisierung, komplexer Frakturmorphologie sowie bei jedem Verdacht auf eine ungenügende Reposition im postoperativen Röntgenbild sollte eine CT-Kontrolle unter Einbeziehung der unverletzten Seite erfolgen. Die Korrektur relevanter Fehlstellungen sollte so früh wie möglich erfolgen, um die Rehabilitation zu beschleunigen und Dauerschäden durch die Druckumverteilung bzw. Instabilität in einem lasttragenden Gelenk zu vermeiden.

Periprothetische Infektionen nach Versorgung mittels Tumorspezialendoprothese treten in etwa 10 % aller Falle auf. Ebenso wie in der Primarendoprothetik definieren die Kriterien der „Musculoskeletal Infection Society“ (MSIS) das Vorliegen einer periprothetischen Infektion. Die Managementstrategien bei einer periprothetischen Infektion nach Tumorspezialendoprothese richten sich nach der Dauer der Infektion und dementsprechend dem Alter des Biofilms. Eine implantaterhaltende Therapie mit Wechsel der mobilen Teile ist bei Vorhandensein unreifer Biofilme moglich. Das Vorliegen eines reifen Biofilms erfordert einen ein- oder zweizeitigen Implantatwechsel. Sofern moglich, ist hier ein vollstandiger Austausch aller Endoprothesenkomponenten anzustreben, da eine partielle Retention von Fremdmaterialien zu verminderten Erfolgsraten fuhrt. Die hochsten Erfolgsraten werden durch ein zweizeitiges Vorgehen erzielt. Mehrere Risikofaktoren wie z. B. Hautnekrosen, postoperative Hamatombildung, eine prolongierte Wundsekretion sowie eine Operationsdauer ≥2,5 h konnten als Risikofaktoren fur die Entstehung einer periprothetischen Infektion identifiziert werden. Die Kenntnis daruber erlaubt eine Identifikation und ein fruhzeitiges Management der besonders gefahrdeten Patienten.

Tumorose Destruktionen der periazetabularen Region und des proximalen Femurs konnen durch primare Knochentumoren oder infolge metastatischer Destruktion verursacht sein. Unter allen Skelettabschnitten weist diese Region die hochste Rate pathologischer Frakturen auf. Darstellung der haufigsten Komplikationen nach Tumorresektion und Defektrekonstruktion mittels Tumorendoprothesen am Huftgelenk sowie Beschreibung des Managements mit Therapieempfehlungen und Komplikationsvermeidung. Darstellung der typischen Komplikationen und Empfehlungen zum therapeutischen Komplikationsmanagement auf der Basis ausgedehnter Literaturrecherchen und eigener Erfahrungen im Management tumorendoprothetischer Komplikationen am Huftgelenk. Vergleichend mit der elektiven Huftendoprothetik haben Tumorspezialendoprothesen eine erhohte Rate von Infekten, septischen/aseptischen Lockerungen, Luxationen, periprothetischen und pathologischen Frakturen und tiefen Becken‑/Beinvenenthrombosen. Die erhohte intra- und postoperative Mortalitat sowie das lokale Tumorrezidiv und die tiefe Infektion sind die schwerwiegendsten Komplikationen. Das Komplikationsrisiko ist bei Tumorendoprothesen vielfaltig und im Vergleich zur Primarendoprothetik deutlich erhoht. Detaillierte Planung und Vorbereitung der Resektion in enger Abstimmung mit allen an der Tumorbehandlung beteiligten Fachdisziplinen (interdisziplinares Board) kann die Komplikationsrate minimieren und gewisse Komplikationen auch direkt vermeiden. Die Durchfuhrung ausgedehnter kurativer und palliativer Resektionen sollte muskuloskelettalen Tumorzentren mit ausgewiesener Expertise in osteosynthetischen und endoprothetischen Rekonstruktionsverfahren von Becken und Femur vorbehalten sein.

Spinale Tumoren bilden eine kontinuierlich anwachsende Pathologiegruppe unter den Wirbelsaulenerkrankungen. Aufgrund der haufig schwierigen Umstande resultiert eine deutlich erhohte Vulnerabilitat fur das Erleiden einer grosen Bandbreite an interventionsbedingten Komplikationen, die zu verschiedenen Zeitpunkten im Krankheitsverlauf auftreten konnen und die in die Abwagung bei der Indikationsstellung zwingend einbezogen werden mussen. Ziel der Arbeit ist die Darstellung des breiten Komplikationsspektrums im Rahmen der chirurgischen Behandlung spinaler Tumoren sowie deren Therapie und Prophylaxe durch ein optimales Therapiemanagement. Der Artikel fasst die aktuelle Literatur zusammen. In der Literatur werden Komplikationsraten von 10–67 % nach Metastasenchirurgie an der Wirbelsaule beschrieben. Die haufigsten Komplikationen sind Infektionen und internistische, insbesondere pulmonale Komplikationen. Des Weiteren relevant sind Komplikationen durch Lagerung, den chirurgischen Zugang, Instrumentation und mechanisches Versagen sowie anasthesiologische, neurologische, vaskulare und onkologische Komplikationen. Die soziookonomischen Kosten durch Patienten mit gegenuber solchen ohne Komplikationen betragen das Zweifache. Eine besondere Risikolage besteht bei radikalen spinalen Tumorresektionen. Als negative Pradiktoren gelten Voroperationen, vorherige Bestrahlung und Lokalrezidive. Durch ein fruhzeitiges, interdisziplinar strukturiertes Konzept lassen sich Komplikationen deutlich reduzieren. Aufgrund der Planungsintensivitat, chirurgischer Expertise und umfassender struktureller Voraussetzungen, ist die Behandlung in einem interdisziplinaren Tumorzentrum notwendig.

Purpose Questionnaire survey among the members of the German Spine Society (Deutsche Wirbelsaulen-Gesellschaft, DWG) to objectify oncological infrastructure and current standard of care in spinal tumor treatment in Germany. Methods All DWG-members were contacted via the society's e-mail and asked to respond in anonymized form to a related questionnaire. Questions were asked regarding surgical specialty, type of institution involved, numbers of spinal procedures, as well as questions on treatment for primary tumors, whether the respondent belonged to a tumor center, decision-making procedures for surgery, and the type of procedure. Results 84 centers providing surgical treatment for spinal tumors in their departments were identified. 52.6% were carrying out more than 500 spinal procedures per year. There was a significant association (P ≤ 0.05) between the numbers of spinal surgeries, the number of treated tumor patients per year, the organisation in a tumor center and the treatment of primary tumors. 76% are part of a local tumor center for interdisciplinary decision making (i.e.surgical treatment and adjuvant therapy). 74% of the institutions stated that conventional postoperative radiotherapy is standardly administered in the case of secondary lesions, with 24% of them referring patients to external services for radiotherapy. Conclusion In spite of often large numbers of spinal operations, the centers perform relatively small numbers of tumor operations, particularly for primary tumors. A nearly three-quarter majority of the departments are integrated into interdisciplinary tumor care. However, there is a marked number that do not belong to an interdisciplinary organisation. Further advances in multidisciplinarity and oncology training are a continuous issue to increase treatment quality in spinal tumor patients.

Tumorendoprothesen sind als modulare Systeme verfugbar, womit Knochendefekte partiell, zumeist gelenknah, oder als totaler Ersatz langer Rohrenknochen rekonstruiert werden konnen. Infolge kontinuierlich verbesserter Uberlebenszeiten werden diese bei Knochentumoren, Skelettmetastasen und zunehmend mehr in der Revisionsendoprothetik verwendet. Darstellung der haufigsten Komplikationen bei Tumorendoprothesen und Beschreibung deren Managements mitsamt Therapieempfehlungen. Nach selektiver Literaturrecherche erfolgte die Darstellung eigener Erfahrungen im Management tumorendoprothetischer Komplikationen. Die Anzahl tumorendoprothetischer Verfahren ist begrenzt, sodass limitierte Studien und Klassifikationen vorliegen. Tiefe periprothetische Infektionen mit Beteiligung der Weichteile stellen nach perioperativem Versterben und lokalem Tumorrezidiv die schwerwiegendsten Komplikationen dar. Der zweizeitige Wechsel ist beim periprothetischen Infekt weiterhin der Goldstandard, auch wenn in selektiven Indikationen der einzeitige Wechsel vertretbar ist. Sekundare Amputationen sind bei periprothetischer Infektion und Lokalrezidiv mitunter als Ultima Ratio notwendig. Mechanische Komplikationen sind in der Regel Extremitat erhaltend therapierbar. Spezifische Pfannensysteme beim proximalen Femurersatz und Anbindungsschlauche ermoglichen eine adaquate Weichteilrekonstruktion, die Wiederherstellung der Gelenkfunktion und minimieren das Luxationsrisiko. Das Komplikationsrisiko ist bei Tumorendoprothesen vielfaltig und im Vergleich zur Primarendoprothetik erhoht, durch Revisionsoperationen aber grundsatzlich beherrschbar.

Background: Tibial-sided graft fixation is thought to be critical for the success of anterior cruciate ligament (ACL) reconstruction. Nevertheless, little is known about the graft force after fixation during the first 24 hours after surgery or the influence of screw diameter and length during this time. Purpose: To investigate the force, over the course of 24 hours, in soft tissue grafts secured with a tibial interference screw and to evaluate the effect of different screw diameters (7, 8, and 9 mm) and lengths (25 and 30 mm) on the force in these grafts. Study Design: Controlled laboratory study. Methods: Quadruple-strand flexor tendon grafts were fixed with bioabsorbable interference screws in 60 porcine tibiae. Grafts were pretensioned at 80 N over 10 minutes, and screws were inserted outside-in while a preload force of 80 N was applied. Different screw lengths (25 and 30 mm) and diameters (7, 8, and 9 mm), resulting in 6 groups with 10 specimens each, were tested. After release of the preload, graft force was recorded over 24 hours. Results: A significant decrease in graft force progressed in all groups over the 24-hour period. In total, a median loss of 75 N (IQR, 68-79 N) compared with the initial loading force was observed. Compared with the loading force of 80 N, this corresponded to a median loss of 91%. No significant differences in the remaining graft force could be found among the 6 different screw length and diameter groups after 10 minutes, 100 minutes, or 24 hours. Conclusion: Graft force in soft tissue grafts secured with a tibial interference screw decreased substantially over the first 24 hours after fixation. Neither the screw diameter nor the screw length affected the decrease in graft force. This raises substantial questions regarding the remaining fixation strength in vivo. Clinical Relevance: It should not be expected that ACL reconstruction can mechanically restabilize an injured knee as would an intact ACL. Reconstructed knees should be protected from mechanical overload in the early postoperative period.

Aims Periprosthetic fracture is a significant complication of total hip and knee arthroplasty. This study aimed to describe the survival of patients sustaining periprosthetic femoral fractures and compare this with that of the general population, as well as to identify the factors that influence survival. Patients and Methods A total of 151 patients (women: men 116:35, mean age 74.6 years, standard deviation 11.5) that sustained a periprosthetic fracture between January 2005 and October 2012 were retrospectively analysed. Epidemiological data, comorbidities, type of surgical management, type of implant, and mortality data were studied. Results The mean survival time was 77 months (95% confidence interval 71 to 84; numbers at risk: 73) and was lower than that of the general population. The risk analyses showed that previous cardiac disease, particularly ischaemic heart disease, cardiac arrhythmias, and heart failure, age over 75 years and American Society of Anesthesiologists (ASA) scores above 3 were associated with a significantly higher mortality. Conclusions Periprosthetic fractures carry a high risk of post-operative mortality. Our data demonstrate that advanced age (> 75 years) and previous cardiac disease are associated with a significantly higher risk of mortality. The ASA score is an appropriate instrument for risk stratification. Pre-operative cardiac status should be optimised before surgery. Cite this article: Bone Joint J 2017;99-B:921–6.

Background Benign bone lesions are much more common than malignant lesions. Some benign bone tumors have a characteristic and typical radiographic appearance, while others are more challenging. Therapy of benign bone tumors differs greatly. While the majority of benign bone tumors do not require surgical therapy, other specific lesions, e. g. aneurysmal bone cysts or giant cell tumors (GCT) of the bone require surgery due to their locally aggressive behavior. Diagnostics The major challenge for the radiologist and/or pathologist is the differentiation between a benign and low-grade malignant lesion (e. g. enchondroma versus low-grade chondrosarcoma) for which all available clinical and radiographic information is mandatory. Therefore, surgical therapy is rather more often performed than necessary due to uncertainty in many cases. Therapy Novel systemic therapies are available for fibrous dysplasia and GCT of the bone: Fibrous dysplasia can be treated with bisphosphonates, and GCT responds to denosumab. In fact, denosumab has been approved for the treatment of irresectable GCT. Osteoid osteoma is fairly easy to recognize and also to treat given the characteristic clinical presentation and rapid and effective response to local therapy (possible as percutaneous thermo-/laser ablation). In summary, several therapeutic options exist for benign bone tumors, and the choice depends upon the tendency/risk of local recurrence, the rate of surgical complications, options for defect reconstruction, postoperative functional deficits, and specific patient characteristics.

Korrektur von Fehlstellungen des Ellenbogengelenks, die meist sekundar durch direktes oder indirektes Trauma auf den betroffenen Arm bzw. Ellenbogen und anschliesender Fehlverheilung mit Achs- und/oder Rotationsmalalignment entstehen und mit kosmetischem oder funktionellem Leidensdruck des Patienten verbunden sind. Relevante Fehlstellung der Armachse mit entsprechendem kosmetischem oder funktionellem Leidensdruck des Patienten. Vorbestehende degenerative oder chronisch-entzundliche Veranderungen. Im Allgemeinen kommen zweidimensionale suprakondylare Open- oder Closed-Wedge-Osteotomien zur Anwendung. Bei Vorliegen einer dreidimensionalen Fehlstellungskomponente (Rotation) sind zusatzliche derotierende Umstellungen vorzunehmen. Extrakapsulare Fehlstellungen konnen im Falle von Extensionsfrakturen bevorzugt mit einer Open-Wedge-Osteotomie, extrakapsulare Flexionsfrakturen dagegen mit einer Closed-Wedge-Osteotomie korrigiert werden. Bei Vorliegen einer Valgusfehlstellung sollte eine Korrektur ebenfalls mittels Closed-Wedge-Osteotomie erfolgen; bei Varusfehlstellungen kann vornehmlich uber einen dorsalen oder alternativ uber einen radialen Zugang eine Closed-Wedge-Osteotomie vorgenommen werden. Ruhigstellung des Arms fur 2–3 Wochen postoperativ in der Oberarm-Cast-Longuette mit taglicher passiver Beubung des Ellenbogens ab dem 7. postoperativen Tag. Im Allgemeinen sind gute bis sehr gute Ergebnisse nach einer dreidimensionalen Korrektur des distalen Humerus zu erwarten. Nur in seltenen Fallen (ca. 2,5 %) tritt eine Nervenirritation (vor allem des N. ulnaris) auf, die jedoch meist nur transient besteht.

Study design Survey study. Objectives Spinal cord injury (SCI)-associated pneumonia (SCI-AP) is associated with poor functional recovery and a major cause of death after SCI. Better tackling SCI-AP requires a common understanding on how SCI-AP is defined. This survey examines clinical algorithms relevant for diagnosis and treatment of SCI-AP. Setting All departments for SCI-care in Germany. Methods The clinical decision-making on SCI-AP and the utility of the Centers for Disease Control and Prevention (CDC) criteria for diagnosis of ‘clinically defined pneumonia’ were assessed by means of a standardized questionnaire including eight case vignettes of suspected SCI-AP. The diagnostic decisions based on the case information were analysed using classification and regression trees (CART). Results The majority of responding departments were aware of the CDC-criteria (88%). In the clinical vignettes, 38–81% of the departments diagnosed SCI-AP in accordance with the CDC-criteria and 7–41% diagnosed SCI-AP in deviation from the CDC-criteria. The diagnostic agreement was not associated with the availability of standard operating procedures for SCI-AP management in the departments. CART analysis identified radiological findings, fever, and worsened gas exchange as most important for the decision on SCI-AP. Frequently requested supplementary diagnostics were microbiological analyses, C-reactive protein, and procalcitonin. For empirical antibiotic therapy, the departments used (acyl-)aminopenicillins/β-lactamase inhibitors, cephalosporins, or combinations of (acyl-)aminopenicillins/β-lactamase inhibitors with fluoroquinolones or carbapenems. Conclusions This survey reveals a diagnostic ambiguity regarding SCI-AP despite the awareness of CDC-criteria and established SOPs. Heterogeneous clinical practice is encouraging the development of disease-specific guidelines for diagnosis and management of SCI-AP.

Background A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. Methods Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. Results An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. Conclusion On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Selection of boundary constraints may influence amount and distribution of loads. The purpose of this study is to analyze the potential of inertia relief and follower load to maintain the effects of musculoskeletal loads even under large deflections in patient specific finite element models of intact or fractured bone compared to empiric boundary constraints which have been shown to lead to physiological displacements and surface strains. The goal is to elucidate the use of boundary conditions in strain analyses of bones. Finite element models of the intact femur and a model of clinically relevant fracture stabilization by locking plate fixation were analyzed with normal walking loading conditions for different boundary conditions, specifically re-balanced loading, inertia relief and follower load. Peak principal cortex surface strains for different boundary conditions are consistent (maximum deviation 13.7%) except for inertia relief without force balancing (maximum deviation 108.4%). Influence of follower load on displacements increases with higher deflection in fracture model (from 3% to 7% for force balanced model). For load balanced models, follower load had only minor influence, though the effect increases strongly with higher deflection. Conventional constraints of fixed nodes in space should be carefully reconsidered because their type and position are challenging to justify and for their potential to introduce relevant non-physiological reaction forces. Inertia relief provides an alternative method which yields physiological strain results.

Wiederherstellung eines stabilen Pfannenlagers fur Verankerung einer Wechselkomponente durch Stabilisierung des dorsalen Pfeilers. Dislozierte/nichtdislozierte periprothetische Azetabulumfrakturen mit Beteiligung des hinteren Pfeilers. Instabilitat der Pfannenkomponente bei ausreichender Knochenqualitat. Periprothetische Azetabulumfrakturen mit unzureichender Knochenqualitat. Ausgedehnte periazetabulare Defekte ohne Verankerungsmoglichkeit. Isolierte periprothetische Frakturen des vorderen Pfeilers. Septische Lockerung. Dorsaler Zugang zur Hufte. Luxation der Huftprothese und Explantation der Pfanne. Reposition des hinteren Pfeilers uber Doppelplattenosteosynthese. Verankern der Revisionspfanne in rekonstruiertes Azetabulum, Reposition der Huftprothese. Fruhzeitige Mobilisation, Teilbelastung der Extremitat fur 12 Wochen. Thrombembolieprophylaxe. Klinische und radiologische Kontrolle. 17 Patienten mit periprothetischer Azetabulumfraktur, 9 nach Primar-, 8 nach Revisionseingriff, davon 1 Patientin mit Hemiendoprothese; 12 mit traumatischer Genese, 5 spontan; 7 vordere Pfeiler-, 5 Quer-, 4 hintere Pfeiler- und 1 Zwei-Pfeiler-Fraktur nach Hemiendoprothese; 5 Typ-1- und 12 Typ-2-Frakturen. Eingesetzt wurden bei 10/17 Patienten 3 Abstutzringe, 2 Sockel-, 1 Wechselpfanne, 1 Cup-Cage-Konstrukt, 1 ventrale Plattenosteosynthese, 1 dorsale Doppelplattenosteosynthesen, davon 1-mal mit simultanem Pfannenwechsel (Harris-Hip-Score: 78 Punkte nach 10 Monaten). Radiologische Kontrolle bei 10 Patienten: je eine Konsolidierung der Fraktur ohne Dislokation und eine fest verankerte Pfannenkomponente. Kein Revisionseingriff im Beobachtungszeitraum, 2-mal Prothesenluxation, 1-mal transiente Fusheberschwache.

Extent and orientation of interfragmentary movement (IFM) are crucially affecting course and quality of fracture healing. The effect of different configurations for implant fixation on successful fracture healing remain unclear. We hypothesize that screw type and configuration of locking plate fixation profoundly influences stiffness and IFM for a given load in a distal femur fracture model.Simple analytical models are presented to elucidate the influence of fixation configuration on construct stiffness. Models were refined with a consistent single-patient-data-set to create finite-element femur models. Locking plate fixation of a distal femoral 10mm-osteotomy (comminution model) was fitted with rigid locking screws (rLS) or semi-rigid locking screws (sLS). Systematic variations of screw placements in the proximal fragment were tested. IFM was quantitatively assessed and compared for different screw placements and screw types.Different screw allocations significantly affect IFM in a locking plate construct. LS placement of the first screw proximal to the fracture (plate working length, PWL) has a significant effect on axial IFM (p0.001). Replacing rLS with sLS caused an increase (p0.001) of IFM under the plate (cis-cortex) between +8.4% and +28.1% for the tested configurations but remained constant medially (1.1%, trans-cortex). Resultant shear movements markedly increased at fracture level (p0.001) to the extent that plate working length increased. The ratio of shear/axial IFM was found to enhance for longer PWL. sLS versus rLS lead to significantly smaller ratios of shear/axial IFM at the cis-cortex for PWL of ≥ 62 mm (p ≤ 0.003).Mechanical frame conditions can be significantly influenced by type and placement of the screws in locking plate osteosynthesis of the distal femur. By varying plate working length stiffness and IFM are modulated. Moderate axial and concomitantly low shear IFM could not be achieved through changes in screw placement alone. In the present transverse osteotomy model, ratio of shear/axial IFM with simultaneous moderate axial IFM is optimized by the use of appropriate plate working length of about 42-62 mm. Fixation with sLS demonstrated significantly more axial IFM underneath the plate and may further contribute to compensation of asymmetric straining.

The purpose of this retrospective analyses was to evaluate the bone viability in the ventral column of the spine following large segmental defect reconstructions. Osseous integration of implants following spinal fusion procedures is an essential precondition to provide adequate mechanical strength to any applied forces and subsequently satisfying patient outcomes. Although CT scan is the non-invasive gold standard for fusion assessment, it lacks the ability to visualize bone viability and, therefore, discrepancy remains about sensitivity and specificity of CT as evaluation tool of spinal fusion.A novel modality, (18)F Fluoride PET/CT, specifically allows quantitative in vivo evaluation of metabolic activity of the osseous integration. Bone viability following large segmental reconstructions in patients after mono- and multi-level en bloc spondylectomies (EBS) was analyzed. Spinal fusion was assessed on plain radiographs and CT scans according to the FDA fusion criteria as well as (18)F PET/CT.A total of eight patients underwent (18)F PET/CT were included (one 4-level-, one 3-level, two 2-level and four 1-level EBS). The average follow-up between EBS and radiographic studies was 24.8 months. On plain radiographs and CT scans, successful fusion was confirmed in all patients. However, (18)F PET/CT showed non-union in all cases. The metabolic bone activity within the cage was fourfold decreased compared to the reference vertebra, whereas the metabolic activity of the adjacent endplates was 1.6-fold increased compared to the reference vertebra.This study suggests a discrepancy between fusion rates assessed by plain radiographs and CT scan compared to (18)F PET/CT.

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.Cite this article: Bone Joint J 2015;97-B:1271-8.

Hintergrund Periimplantare Infektionen (PII) zahlen zu den haufigsten postoperativen Komplikationen und erfordern in der Regel ein kombiniertes chirurgisches und antibiotisches Vorgehen. In diesem Ubersichtsartikel stellen wir die aktuellen Kenntnisse bezuglich der Pathogenese, Klassifikation, Diagnose und Therapie osteosyntheseassoziierter Infektionen vor. Ziel der Arbeit ist es, die rationalen Hintergrunde und die Evidenz der einzelnen chirurgischen Masnahmen zu erlautern und konkrete Therapieempfehlungen auszuarbeiten.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA).A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically.A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%.There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively.A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.Cite this article: Bone Joint J 2015;97-B:950–6.

The tibia shaft is the most often fractured long bone of human beings. Among others traffic accidents (37.5 %), falls (17.8 %), sport accidents (30.9 %) and assaults (4.5 %) are typical mechanisms. A brief clinical examination including the correct classification of the fracture pattern and even more important the degree of the soft tissue damage are the most crucial factors for the following therapeutic cascade. This follows a defined algorithm based on the degree of soft tissue damage. As biplanar X-ray diagnostics are obligatory, CT scans are subject to complex fracture patterns and accompanying intraarticular pathologies.The treatment of tibial shaft fractures is the preserve of operative stabilization, which should be done primarily depending on the degree of the soft tissue injury. Here intramedullary methods - especially intramedullary nailing - are the golden standard.The most serious complication of these fractures is the development of a compartment syndrome. This requires rapid diagnosis and an adequate surgical management in order to avoid extensive muscle necrosis with ischaemic contractures and irreversible neurovascular deficits. Apart from postoperative infections, which are the predominant complication especially in open injuries, non union provide typical and late complications which are partly difficult to treat. These should, depending on their type, follow a dedicated treatment algorithm.

Background: Articular reconstruction and stable fixation of tibial plateau fractures and its various subtypes continue to represent a surgical challenge. Only few trials have studied results following angular stable plate fixation. The present study aimed to investigate the clinical, radiological, functional and quality of life results following tibial plateau fractures using angular stable plate fixation. Materials and Methods: 101 patients were retrospectively studied using functional (ROM; KSS; VAS), radiographic (osteoarthritis score, loss of reduction) and quality of life (WOMAC; Lysholm) scores. There were 46 males and 55 females. The average of patients was 51 years (range 22-77 years). Study groups were assigned according to the AO fracture classification. Results: Mean followup was 57 ± 30 months. Fracture type distribution revealed a significantly (P < 0.001) increased number of type B- (62.4%) compared to C-fractures. Functional assessment showed a significantly better total KSS (84.1 ± 15.6 vs. 74.7 ± 18.0; P = 0.01) as well as ROM (active: 124°±17° vs. 116°±15°, P = 0.014; passive: 126°±18° vs. 118 ± 14°, P = 0.017) in the B-fracture group. VAS was found to be markedly higher (P = 0.0039) following type C-fractures. Rating osteoarthritis secondary to a tibial plateau fracture as a function of injury severity (r = 0.485; P < 0.001) and relating the loss of reduction to the grade of evolving osteoarthritis (r = 0.643;P < 0.001) a positive correlation was found. Quality of life showed significantly improved results for Lysholm score (P = 0.004) following B-fractures with low overall values for the WOMAC score. Conclusion: Presented data provide sufficient evidence that anatomic restoration of tibial plateau fractures with angular stable plate fixation result in decreased loss of reduction and declined incidence of posttraumatic osteoarthritis, thereby providing acceptable mid to long term outcome.

OBJECTIVE Anatomic reduction and articular restoration after acetabular fractures occur (Ac-Fxs) are accepted predictors for good function and slow progression of posttraumatic osteoarthritis of the hip. The aim of this study was to retrospectively analyze Ac-Fxs, which were treated with closed reduction and percutaneous (three-dimensional) fluoroscopy-based navigated screw fixation. DESIGN Level 4, retrospective clinical and radiographic assessment. SETTING Level 1 trauma center. PATIENTS Twelve patients (male/female: 9/3; mean age: 60 years; range: 16-80 years) with moderately displaced Ac-Fxs were included. INTERVENTION In enrolled patients, the treatment involved percutaneous three-dimensional fluoroscopy-based navigated lag screw positioning. Closed reduction was achieved by lag screws, or reduction was aided by the insertion of percutaneous Schanz pins. MAIN OUTCOME MEASUREMENTS The quality of the reduction and screw positions were assessed using intraoperative and postoperative computed tomography scans. Functional outcome was assessed using the Harris hip score, the visual analog scale for pain, and the Tegener activity scale. RESULTS A total of 22 periacetabular screws were placed (mean: 1.8 ± 1.1 screws/patient, range: 1-5). The mean follow-up was done for 30 (16-72) months. The postoperative reduction was anatomical in all patients, and the mean fracture displacement was significantly reduced (gap: 4.1 ± 1.8 mm to 0.4 ± 0.7 mm/step: 1.4 ± 0.6 mm to 0.2 ± 0.4 mm). No secondary dislocations or malunions/nonunions were found. All screws correctly addressed the fracture morphology and corresponded to preoperative planning. The Harris hip score, the visual analog scale (motion), and Tegener activity scale showed excellent to very good results (92.4 ± 6.8, 1.9 ± 1.3, and 3.8 ± 1.6, respectively). CONCLUSIONS The navigated, percutaneous screw fixation of selected Ac-Fxs is a promising method that allows for closed reduction and fixation while obtaining a very good radiographic and functional outcome. LEVEL OF EVIDENCE Therapeutic level 4.

Knochenzysten sind gutartige tumorahnliche Knochenlasionen, welche einen flussigkeits- und z. T. zellgefullten Hohlraum im Knochen darstellen. Sie konnen solitar, in seltenen Fallen auch multipel im Skelettsystem vorkommen. In diesem Beitrag werden die Diagnostik, das radiologische Erscheinungsbild und die Therapie der wichtigsten benignen zystischen Knochenlasionen, wie solitare Knochenzysten, aneurysmatische Knochenzysten, intraossare Ganglien, Epidermiszysten und subchondrale Zysten vorgestellt und deren Differenzialdiagnostik zu zystoiden Formationen und Tumoren mit zystischen Anteilen erortert. Es erfolgte eine selektive Literaturrecherche unter Berucksichtigung eigener Erfahrungen. Solche „tumor-like lesions“ konnen radiologisch wie Knochentumoren imponieren, zeigen jedoch kein autonomes reizunabhangiges Wachstum und konnen sich auch spontan vollstandig zuruckbilden. Zumeist ist eine offene Biopsie zur Diagnosesicherung notwendig. Bedarf es in manchen Fallen keiner chirurgischen Intervention („Do-not-touch-“ oder „Leave-me-alone“-Lasionen), stehen in vielen Fallen die Pravention und die Behandlung pathologischer Frakturen sowie die Rezidivprophylaxe im Vordergrund. Zystische Knochenlasionen gehoren zu den haufigsten nichttraumatischen Knochenveranderungen. Bei differenzialdiagnostischer Unklarheit ist die Histologiegewinnung wegweisend. Im Falle einer chirurgischen Intervention besteht aktuell der Trend zur multimodalen Therapie, wobei die exakte Kurettage zumeist die Grundlage bildet.

Randomized clinical trials have generated doubts regarding the therapeutic effectiveness of spinal kyphoplasty to reduce pain and improve quality of life in patients with vertebral fractures. There is a paucity of data on the influence of kyphoplasty on spinal range of motion. To quantify early postoperative changes following kyphoplasty in spinal motion, a noninvasive, radiation-free measurement method was used and results related to clinical and radiological parameters. The study group included 30 patients with an overall number of 54 symptomatic pathological vertebral compression fractures. All patients were treated with balloon kyphoplasty. Clinical results were recorded using the visual analog scale, SF 36, Roland Morris Score and the Oswestry Disability Index, at three time points; preoperative, 2 days postoperative, and at 12 weeks postoperative. The kyphosis angle/sagittal index were determined with biplanar X-rays. Amplitude/velocity of motion in extension/flexion was measured at each time point by use of the EpionicsSPINE© system (Epionics Medical GmbH; Potsdam, Germany) using two external sensor strips. Preoperative magnetic resonance imaging scans showed bone marrow edema in all vertebral bodies indicative of a recent, non-consolidated fracture. Pain and quality of life was significantly improved by kyphoplasty, both for the immediate postoperative period, as well as at 12 weeks postoperative. Radiological parameters also showed significant improvement following surgery. Total ROM did not significantly change 2 days after kyphoplasty, but amplitude and velocity were found to be increased 12 weeks postoperatively. Significant positive correlations were observed between increased range of motion and improved clinical/radiological scores. Significant clinical and radiological improvement following kyphoplasty supports the rational for cement augmentation in patients with pathological vertebral body fractures. To the knowledge of the authors, no prior study has assessed the influence of preservation and improvement of spinal range of motion on clinical outcome following kyphoplasty.

Die fruhen Arbeiten von Judet und Letournel in den 70er und 80er Jahren fuhrten zu einem Paradigmenwechsel in der Behandlung von Azetabulumfrakturen – weg von der rein konservativen hin zur operativen Therapie. Die komplexe dreidimensionale knocherne Anatomie und der periazetabulare Weichteilmantel mit engem topographischem Bezug zu intra- und extrapelvinen neurovaskularen/viszeralen Strukturen implizieren eine erhohte Rate sowie ein vergleichsweise erhohtes Risiko intra- und postoperativer Komplikationen bei gleichzeitig bestehender Anforderung an eine sorgfaltige anatomische Rekonstruktion mit einer Gelenkstufen-/spalttoleranz von weniger als 1–2 mm. Gleichzeitig sind Frakturen des Azetabulums vergleichsweise selten, sodass eigentlich nur entsprechende Zentren uber die entsprechende Erfahrung sowie die Infrastruktur zur Versorgung von Azetabulumfrakturen verfugen. Ziel dieser Arbeit war es daher, die potenziellen intra- und postoperativen Komplikationen im Rahmen der operativen Versorgung von Azetabulumfrakturen darzustellen sowie praktische Ansatze zur Therapie und Prophylaxe aufzuzeigen.

Aufgrund des geringen periartikularen Weichteilmantels und des hohen Risikos einer begleitenden Weichteil- bzw. Protheseninfektion stellen Weichteildefekte im Bereich der kniegelenksnahen Region nach endoprothetischem Kniegelenksersatz immer ein relevantes chirurgisches Problem dar und verlangen ein suffizientes Komplikationsmanagement. Neben der Berucksichtigung von patientenspezifischen, intra- und postoperativen Risikofaktoren muss den Deckungskonzepten fur die einzelnen Defektstadien haufig ein dezidiertes Infektionsmanagement vorangehen, das bei fortgeschrittenen Defekten den Ausbau der Prothese mit sekundar geplantem Wiederaufbau beinhalten kann. Es werden insgesamt 4 Stadien unterschieden (Typ A–D), welchen als Unterscheidungskriterien die allgemeine Weichteildeckung, die Exposition bzw. Nekrose des Streckapparats, der Erhalt oder die Eroffnung der Gelenkkapsel und/oder die begleitende septische Lockerung des freiliegenden Implantats zugrunde liegen. Das Konzept der plastischen Deckung folgt einem stadiengerechten Algorithmus und fuhrt uber einen sekundaren Wundverschluss oder eine Spalthauttransplantation bei einfachen Defekten, uber fasziokutane Verschiebelappen bei mittleren Defekten, bis hin zu gestielten oder freien Muskellappenplastiken bei tiefgreifenden Defektsituationen mit begleitender intrakapsularer Ausbreitung. Masgeblich entscheidend fur eine erfolgreiche Therapie ist, neben einer soliden Infektbekampfung, das fruhe Erkennen und die korrekte Analyse der Defektcharakteristika, die sorgfaltige Vorbereitung des Wundbetts mit seriellen Debridements und die saubere Durchfuhrung der Lappendeckung durch rechtzeitige/fruhe Konsultation plastisch-chirurgischer Expertise.

Fortschritte der onkologischen und chirurgischen Therapien haben zu einer deutlich steigenden Lebenserwartung von Patienten mit malignen Erkrankungen mit verlangertem Uberleben bei bestehender Metastasierung gefuhrt. Das Skelettsystem, mit Praferenz der Wirbelsaule, ist als Fernmetastasierungsort dabei mit am haufigsten betroffen. Durch Nutzung neuartiger bildgebender Verfahren mit hoherer Auflosung und Verwendung metabolischer Signaturen hat sich das Screening von Tumorpatienten deutlich verbessert, sodass die Diagnose einer Metastasierung zunehmend eher und sensitiver gestellt wird. Daher, aber auch aufgrund der effektiveren Polychemotherapieprotokolle werden singulare/solitare Metastasen immer haufiger entweder im Anfangsstadium oder aber als Zeichen einer kontrollierten malignen Tumorerkrankung („stable disease“) beobachtet. Inwieweit eine „solitare Metastase“ wirklich existiert („Illusion oder Realitat?“) und deren radikale onkologische und chirurgische Behandlung als umschriebene singulare Tumormanifestation uberhaupt prognoserelevant ist, bleibt weiterhin stark umstritten. Evident ist jedoch, dass eine prognostisch gunstige zugrundeliegende Tumorbiologie, die radikale Behandlung des Primartumors und ein langes metastasenfreies Intervall valide Pradiktoren fur eine gute onkologische Prognose sind. Bei Vorliegen einer solitaren Metastase unter diesen Umstanden (klassisches Beispiel: solitare Nierenzellkarzinommetastase etliche Jahre nach radikaler Tumornephrektomie) kann dann ein radikal chirurgisches Vorgehen (En-bloc-Spondylektomie) in Verbindung mit adjuvanter Chemo- und/oder Radiotherapie die Langzeitprognose dieser Patientengruppe signifikant verbessern. Hierbei sind die grundliche Evaluation der Uberlebensprognose, ein luckenloses Staging und die interdisziplinare Therapieentscheidung im Tumorboard von entscheidender Bedeutung.

To review the long term clinical outcomes in the treatment of osteoid osteoma (OO) using radiofrequency ablation (RFA).Our retrospective study included 59 patients who were treated in the period from April 2001 to December 2012 due to a symptomatic OO using RFA. Here, the occurrence of complications and postoperative recurrence, as well as postoperative patient satisfaction were examined. Patients satisfaction was assessed by means of a telephone interview with the visual analogue scale (VAS).Mean follow-up was 50 months (2 - 116 months). The average size of the nidus was 6 mm (range 2 - 14 mm). After initial radiofrequency ablation 11.8 % (7/59) of patient showed a recurrence of symptoms. Symptoms could successfully be treated by a second ablation in 5 patients. Assisted success rate was therefore 96.6 % (57/59). The complication rate was 5.1 % (2 major and one minor complication). Furthermore we report a very high patient satisfaction and acceptance of therapy.RFA is a very successful therapy of symptomatic OOs with a high patient satisfaction.▶ Osteoid osteomas (OO) are rare benign bone tumors of the childhood and adolescence. ▶ Treatment of OOs with minimal-invasive radiofrequency ablation (RFA) shows a high patient satisfaction. ▶ RFA is by now the standard therapy of symptomatic OOs.

Background: Despite progress in implant design and surgical technique, the reported number of periprosthetic ankle fractures following total ankle joint replacement continues to increase. A treatment-oriented classification of these fractures has not yet been reported. The purpose of this study was to evaluate the prevalence, cause, and location of periprosthetic fractures and the stability of the associated prosthetic components after total ankle replacement and to develop a method of classification. Methods: Data regarding 503 total ankle replacements with a mean follow-up of 14.7 months were reviewed. The prevalence, location, and possible cause of the fractures as well as prosthesis stability were analyzed and a systematic method of classification based on these factors was developed. Results: Twenty-one patients (4.2%) with a periprosthetic fracture were identified. The fracture was intraoperative (Type 1) in eleven patients (2.2%) and postoperative in the remaining ten (2.0%). Two of the latter fractures were traumatic (Type 2) and eight were stress fractures (Type 3). Two-thirds (fourteen) of the twenty-one fractures occurred in the medial malleolus. Conclusions: The prevalence of periprosthetic fractures following primary total ankle replacement was relatively low. We propose a classification system for these fractures that is based on more than 500 cases. We believe that this classification can facilitate therapeutic decision-making, as it allows for differential analysis of the cause and guides the choice among operative and nonoperative treatment options. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Study design Written mail-out survey. Objective To determine current practice in high-dose methylprednisolone succinate (MPSS) administration for treatment of acute spinal cord injury (SCI) in Germany. Summary of background data Reanalysis of the National Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of the use of high-dose MPSS for treatment of acute SCI. Subsequently, SCI treatment guidelines were revised leading to a reduction in MPSS use across North America. The impact of these revisions on SCI treatment in Germany is not known. Methods A questionnaire was sent to all trauma, orthopedic and neurosurgical departments of German university centers, affiliated teaching hospitals, and specialized SCI care centers. Survey included 6 questions about the administration of MPSS after acute SCI. Results Three hundred seventy-two respondents completed the survey (response rate: 51% overall, 76% university hospitals, 85% specialized SCI care centers). Overall, 55% of departments that treat SCI prescribe MPSS. Among them, 73% are "frequent" users administering MPSS to more than 50% of their patients. Ten percent prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III, and 13% "generic protocols." As justification for MPSS treatment, "effectiveness" ranked before "common practice" and "medicolegal reasons." "Specialized" SCI care centers differ in that (1) MPSS is administered less frequently, (2) NASCIS I doses are not used, and (3) during the past several years, practice patterns are more likely to have shifted away from the treatment of SCI with MPSS. Conclusion About one-half of the institutions continue to prescribe MPSS in the setting of acute SCI. A need for further education in almost one-fourth of German departments treating acute SCI is demonstrated through responses indicating use of the outdated NASCIS I protocol, a "legal need" or "unchanged MPSS application during the last years." "Specialized" SCI centers are more likely to change their practice in accordance with evolving literature. Level of evidence 3.

Die Anzahl tumoroser Neubildungen an der thorakolumbalen Wirbelsaule ist uber die letzten Jahrzehnte gestiegen. Durch ein verbessertes interdisziplinares Management der Patienten konnte die durchschnittliche Lebenserwartung deutlich gesteigert werden. Dies ging einher mit einer Weiterentwicklung der radikalen Tumorresektionen und der rekonstruktiven Wirbelsaulenchirurgie. Nach dem Erreichen suffizienter Resektionsgrenzen gibt es eine Reihe von Optionen zur Wiederherstellung der Wirbelsaulenintegritat. Vor allem bei komplexen Resektionen sind die biomechanischen Prinzipien entscheidend fur den rekonstruktiven Erfolg des Eingriffs. Die Rekonstruktionen sind dabei abhangig vom Ausmas des Korpusdefekts, von der Lokalisation, Knochendichte und Defektstrecke sowie dem eingesetzten Implantat. Im folgenden Artikel soll auf die biomechanischen Aspekte verschiedener Defektsituationen und die daraus zu ziehenden Schlussfolgerungen fur die Rekonstruktion nach Tumorresektion im klinischen Alltag eingegangen werden. Ein spezieller Fokus wird auf die En-bloc-Spondylektomie gelegt, da diese den radikalsten onkochirurgischen Eingriff an der Wirbelsaule darstellt.

Primary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewing's sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.

Hintergrund Die Einhaltung einer Rettungszeit

Total en-bloc spondylectomy (TES) offered a new therapeutic approach by applying the radical oncosurgical concepts of Enneking’s compartment-oriented resections to the thoracolumbar spine. It thereby demonstrated encouraging oncosurgical results by achieving marginal to wide resection margins in the treatment of primary spinal tumours and solitary spinal metastases of biologically favourable tumours. Our own study results support the notion that en-bloc spondylectomy is a technically demanding and risky operation but feasible treatment option for primary malignant vertebral bone tumours and solitary spinal metastasis of certain tumour entities. En-bloc spondylectomy for mono-level tumours followed by defect reconstruction allowed radical resections with negative margins in all investigated patients. While low recurrence rates and an encouraging overall survival rate were achieved new distant metastatic disease was evidenced. For extra — compartmental and multisegmental tumour localisations of sarcomas and clinical evident solitary metastases it could also be demonstrated that an oncosurgical sufficient resection is possible by TES. By achieving wide to marginal resection margins the combination of surgical procedure and adjuvant therapies demonstrated low local recurrence rates. Development of metastatic disease in contrast was seen in one third of the patients at the midterm follow-up underscoring the necessity for further advances in (neo-) adjuvant therapies. Careful patient selection, interdisciplinary surgical planning and cooperation, aggressive management of complications together with extensive experience in spine tumour surgery and reconstruction are essential prerequisites for good oncological results, low complication rates and acceptable functional results.

The descriptions of total spondylectomy and further development of the technique for the treatment of vertebral sarcomas offered for the first time the opportunity to achieve oncologically sufficient resection margins, thereby improving local tumor control and overall survival. Today, single level en bloc spondylectomies are routinely performed and discussed in the literature while only few data are available for multi-level resections. However, due to the topographic vicinity of the spinal cord and large vessels, the multisegmental resections are technically demanding, represent major surgery and only few case reports are available. Surgical options are even more limited in cases of revision surgery and local recurrences when en bloc spondylectomy was considered to be not feasible due to high risk of vital complications in expanding resection margins. Deranged anatomy, implants in situ and extensive intra-/paraspinal scar tissue formation resulting from previously performed approaches and/or radiation are considered the principal complicating factors that usually hold back spine surgeons to perform revision for resection leaving the patient to palliative treatment. We present two patient cases with previously performed piecemeal vertebrectomy in the thoracic spine due to a solitary high-grade spinal sarcoma. After extensive re-staging, both patients underwent a multi (4)-level en bloc spondylectomy in our department (one patient with combined en bloc lung resection). Except a local wound disturbance, there was no severe intra- or postoperative complication. After multilevel en bloc spondylectomy both patients showed a good functional outcome without neurological deficits, except those resulting from oncologically scheduled resection of thoracic nerve roots. After a median follow-up of 13 months, there was no local recurrence or distant metastasis. The reconstruction using a posterior screw rod system that is interconnected to an anterior vertebral body replacement with a carbon composite cage showed no implant failure or loosening. In summary, the approach of a multilevel en bloc surgery for revision and oncologically sufficient resection in cases of spinal sarcoma recurrences seems possible. However, interdisciplinary decision making in a tumor board, realistic evaluation of surgical resectability to attain tumor free margins, advanced experiences in spinal reconstructions and involvement of vascular, visceral and thoracic surgical expertise are essential preconditions for acceptable oncological and functional outcome.

Kypho- and vertebroplasty are widely accepted for treating patients suffering from pathologic thoracolumbar lesions, in particular diffuse metastatic-induced fractures. They provide rapid pain relief and the restoration of spinal stability. In the cervical spine, attempts have been made to use cement augmentation for these indications. However, the cervical spine's anatomy complicates the transpedicular approach, as well as the pre-formation of a vertebral body cavity and the application of bone cement. We report the case of a 46-year-old woman suffering from symptomatic C2 and C5 osteolysis caused by metastatic breast cancer. Following a surgical staging and classification (Tokuhashi-Score) that indicated palliative procedures, we performed a C2 and C5 kyphoplasty using one minimal-invasive anterior approach through a small incision. We observed an uneventful procedure and postoperative course as well as immediate pain relief and patient mobilization. Last patient follow-up at 3 months showed an excellent outcome. Our observations showed cervical spine kyphoplasty via a minimally invasive anterior approach to be feasible, successful and safe surgical method in the interdisciplinary palliative treatment.

Extremitatenerhalt. Standardisierte Wiederherstellung adaquater Weichteildeckung (isolierter Weichteilschaden) und Schaffung der Voraussetzungen fur eine Frakturheilung (beim Komplextrauma) als Basis fur die Wiederherstellung der Funktion. Begrenzung des sekundaren Weichteilschadens. Vermeidung einer Infektion. Isolierter flachiger Weichteilschaden (Quetschtrauma, Decollement) im Bereich von Schulter und oberer Extremitat. Frakturen mit Weichteilschaden Gustilo-Anderson IIIB/C bzw. Tscherne-Oestern GIII/IV. Segmentaler Knochen-/Weichteilverlust. (Teil-)Amputationen. Vital bedrohter, instabiler Patient (Polytrauma) mit Praferenz/ Prioritat lebensrettender Masnahmen/Eingriffe. Nicht erhaltungsfahige obere Extremitat bzw. Teile hiervon (ausgedehnter, nicht rekonstruierbarer Muskel-, Gefas-, Nervenschaden). Radikales, ggf. serielles Debridement, (temporare) Transfixation, Sicherung der Makrozirkulation, Dermatofasziotomie bei Kompartmentsyndrom, vorzugsweise primare Verkurzung bei zirkularem Knochen-/Weichteilschaden, temporare Weichteildeckung, systematische Weichteilkonditionierung, sekundare definitive Weichteilrekonstruktion, ggf. Verfahrenswechsel auf vorzugsweise innere Osteosynthesetechniken. Individuell adaptierte, fruhestmogliche passive oder assistierte Beubung nicht transfixierter Gelenke, fruhzeitiger Verfahrenswechsel und Aufgabe der Transfixation, ggf. weitere sekundare Rekonstruktionen (Knochendefektfullung, Lappenkorrekturen, Nervenrekonstruktion, Muskeltranspositionen, Arthrolysen). Rate offener rekonstruierter Gefase > 90%, Lappenuberlebensrate > 95%, Extremitatenverlust selten; prognoseentscheidend: Ausmas des Weichteilschadens, nervale Schadigung und Rekonstruktionsmoglichkeiten, Regenerationsfahigkeit, Alter und Allgemeinzustand des Patienten.

Intramedullary high-grade osteosarcomas are aggressive tumors with a high metastatic capacity. The many subtypes and variants of these tumors often make the differential diagnosis difficult. Therefore, a critical review of both radiology and histomorphology is mandatory. Low-grade central osteosarcomas are a completely different tumor group. Due to their strong similarity to benign bone tumors they are frequently misdiagnosed as such. The correct diagnosis followed by radical surgery, however, is essential to reduce the high risk of local recurrences, typically seen for of these lesions. Unlike conventional high grade osteosarcomas, distant metastases are much less frequent than in low grade osteosarcomas.

Patients suffering from sickle cell disease show an increased ischemic intolerance due to continuous pro-inflammatory activation and dysfunction of the endothelium by recurrent vaso-occlusive episodes. The presented case shows the manifestation of a postoperative compartment syndrome of the lower leg following the intraoperative use of blood arrest in a patient with previously unknown sickle cell disease. Preexisting vulnerability for tissue hypoxia in patients at risk should be a major concern for intraoperative use of blood arrest during surgery of the extremities.