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

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

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

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

Loss of articular cartilage surface integrity is considered the earliest sign of osteoarthritis; however, its reliable detection has not been established by clinical routine diagnostics. This study comprehensively assesses a set of 11 algorithm-based 2-D Optical Coherence Tomography roughness parameters and investigates their clinical impact. Histology and manual irregularity quantification of 105 human cartilage samples with variable degeneration served as reference. The majority of parameters revealed a close-to-linear correlation with the entire spectrum of degeneration. Surface integrity should therefore be assessed by a combination of parameters to improve current diagnostic accuracy in the determination of cartilage degeneration.

Purpose: Despite the high prevalence of low back pain during pregnancy there is still a lack in the understanding of its aetiology. Changes of the spinal posture due to the anatomical changes of the pregnant body seem to be in part responsible for the back pain. In this pilot study we assessed the potential to accurately measure the spinal posture and pelvic position during pregnancy without any harmful radiation using a spine and surface topography system., Methods: Thirteen pregnant women were examined during the second and third trimester of their pregnancy, and postpartum. Twenty female, non-pregnant volunteers comprised the control group. The spinal posture and pelvic position were measured with a radiation-free spine and surface topography system., Results: We found a significant increase in thoracic kyphosis during the course of pregnancy, but no increased lumbar lordosis. The lateral deviation of the spine also decreased significantly. However, we did not measure significant changes of the pelvic position during or after pregnancy., Conclusions: The results of our study show that pregnancy has an effect on the spinal posture, and that spine and surface topography can be used to measure these changes three-dimensionally and without any harmful radiation. In future studies this technique could allow to further evaluate the relationship between posture and low back pain during pregnancy, helping to understand the aetiology of low back pain in pregnancy as well as to identify methods for its prevention and treatment.

The purpose of this study was to examine the spinal posture in young athletes depending on training intensity. The spinal curvature of 245 children, age 8 to 12 years, was evaluated using rasterstereography. According to their weekly training time group 1 (mean age: 9.54 ± 1.18) did 2-6, group 2 (mean age: 9.49 ± 0.87) did 6-15 and group 3 (mean age: 9.68 ± 0.87) did over 15 hours of training. Group 1 had a significantly higher weight (p = 0.028) (33.86 ± 7. kg) than those of the more active groups (30.67 ± 6.49 kg and 29.46 ± 4.33 kg). The mean kyphotic angle decreased significantly (p < 0.001) with the amount of training per week from 46.86 ± 8.2° in group 1 to 40.08 ± 8° in group 3. We also found a significant decrease (p = 0.047) in lateral deviation with training from group 1 with 5.3 ± 3 mm to group 2 with 4.1 ± 1.6 mm. The results of our study suggest that higher training time can be associated with lower weight and decreases in thoracic kyphosis and lateral deviation of the spine.

Purpose: The purpose of this study was to investigate age differences in the response of the spine and pelvis to simulated leg length inequalities (LLIs)., Methods: A total of 107 subjects, separated into three age groups (group 1: 20-39 years, group 2: 40-59 years, group 3: >60 years), were used to evaluate for any age effects in the response to LLIs. LLIs of +10, +20, and +30 mm were simulated with a simulation platform on both sides, and the respective changes of pelvic position (pelvic obliquity, pelvic torsion) and spinal posture (lateral deviation, surface rotation, kyphotic, and lordotic angles) were measured with a rasterstereographic system., Results: In all three age groups an increase in LLI led to significant changes in the pelvic position as measured by the parameters of pelvic obliquity and torsion. No significant differences in the response of the pelvis to the LLIs were found between the age groups. In all age groups an increase in surface rotation and lateral deviation of the spine with increasing LLIs was found. However, none of these parameters responded significantly different between the three age groups., Conclusions: Under static conditions, LLIs lead to significant changes of the pelvic position and spinal posture. Despite all known age-related changes, no significant differences of the measured pelvic and spinal parameters in elderly patients as a response to the simulated LLIs occurred.

One possible alternative to the application of autologous bone grafts represents the use of autologous bone marrow concentrate (BMC). The purpose of our study was to evaluate the potency of autologous platelet-rich plasma (PRP) in combination with BMC. In 32 mini-pigs a metaphyseal critical-size defect was surgically created at the proximal tibia. The animals were allocated to four treatment groups of eight animals each (1. BMC+CPG group, 2. BMC+CPG+PRP group, 3. autograft group, 4. CPG group). In the BMC+CPG group the defect was filled with autologous BMC in combination with calcium phosphate granules (CPG), whereas in the BMC+CPG+PRP group the defect was filled with the composite of autologous BMC, CPG and autologous PRP. In the autograft group the defect was filled with autologous cancellous graft, whereas in the CPG group the defect was filled with CPG solely. After 6 weeks radiological and histomorphometrical analysis showed significantly more new bone formation in the BMC+CPG+PRP group compared to the BMC+CPG group and the CPG group. There were no significant differences between the BMC+CPG+PRP group and the autograft group. In the PRP platelets were enriched significantly about 4.7-fold compared to native blood. In BMC the count of mononuclear cells increased significantly (3.5-fold) compared to the bone marrow aspirate. This study demonstrates that the composite of BMC+CPG+PRP leads to a significantly higher bone regeneration of critical-size defects at the proximal tibia in mini-pigs than the use of BMC+CPG without PRP. Furthermore, within the limits of the present study the composite BMC+CPG+PRP represents a comparable alternative to autologous bone grafting.

Introduction: Systemic capillary leak syndrome is a rare and life threatening disease characterized by periodic episodes of hypovolemic shock due to leakage of plasma from the intravascular to the extravascular space. It is associated with hemoconcentration, hypoalbuminemia, and generalized edema. We report the case of a patient with idiopathic systemic capillary leak syndrome who developed an unexpected and potentially fatal abdominal and four-limb compartment syndrome. This was successfully treated with fasciotomies and medical treatment including terbutaline, theophylline, and corticosteroids. To the best of our knowledge this is the first report of this kind in the literature., Case Presentation: A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. Due to a massive emission of fluids and proteins from the intravascular to the extracellular compartments, he developed compartment syndromes in his upper and lower limbs and the abdominal compartment. The abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen within 24 hours after admission. After 60 days of treatment he was dismissed from the clinic. He was able to return to his previous occupation and reached the same level of athletic activity as before the illness., Conclusions: Systemic capillary leak syndrome is a very rare disease that can lead to a fatal clinical outcome. It is important to be aware of the fatal complications that can be caused by this disease. Despite the fact that systemic capillary leak syndrome represents a very rare disease it is still important to be aware of life threatening complications, like compartment syndromes, which need surgical intervention. However, early diagnosis and interdisciplinary treatment can lead to a good clinical outcome.

Background: All available treatment options for osteochondral and chondral defects do not restore hyaline cartilage and are limited to decreasing associated pain, and maintaining or improving joint function. The purpose of this study was to evaluate the potential of erythropoietin (EPO) in combination with bone marrow aspiration concentrate (BMAC) in the treatment of osteochondral defects of mini-pigs., Methods: 14 Goettinger mini-pigs, in which a 6 × 10 mm osteochondral defect in the medial femoral condyle of both knee joints was created, were randomized into four groups: biphasic scaffold alone, scaffold with EPO, scaffold with BMAC and scaffold in combination with EPO and BMAC. After 26 weeks all animals were euthanized and histological slides were evaluated using a modified ÓDriscoll Score., Results: In the therapy groups, areas of chondrogenic tissue that contained collagen II were present. Adding EPO (p = 0.245) or BMAC (p = 0.099) alone to the scaffold led to a non-significant increase in the score compared to the control group. However, the combination of EPO and BMAC in the implanted scaffold showed a significant improvement (p = 0.02) in the histological score., Conclusion: The results of our study show that in mini-pigs, the combination of EPO and BMAC leads to an enhanced osteochondral healing. However, additional research is necessary to further improve the repair tissue and to define the role of MSCs and EPO in cartilage repair.

This biomechanical study is the first to compare 3 fixation methods-bilateral fixed-angle plate, modified anterior tension wiring, and cannulated lag screws with anterior tension wiring-in multifragmentary distal patella fractures. A T-shaped 3-part fracture simulating a multifragmentary articular distal patella fracture (AO/OTA 34-C2.2) was created in 18 human cadaver knee specimens. Three groups were created using homogenous ages and bone mineral densities based on the fixation method received. Repetitive testing over 100 cycles was performed by moving the knee against gravity from 90° flexion to full extension. Failure was defined as fracture displacement greater than 2 mm. In all patellae using fixed-angle plates, an anatomical fracture reduction could be maintained throughout cyclic testing, whereas anterior tension wiring and lag screws with tension wiring showed significant fracture displacement after 100 cycles, with mean fracture gaps of 2.0±1.3 and 1.9±1.6 mm, respectively. The differences in fracture gaps between the fixed-angle plate group and the other 2 groups were statistically significant. In both groups using tension wiring, half of the constructs (3 of 6 in each group) failed due to a fracture displacement greater than 2 mm. The bilateral fixed-angle plate was the only fixation method that sustainably stabilized a multifragmentary articular distal patella fracture during cyclic loading when compared with modified anterior tension wiring and cannulated lag screws with anterior tension wiring., (Copyright 2013, SLACK Incorporated.)

Background: Bone marrow aspiration concentrate (BMAC) may possess a high potency for cartilage and osseous defect healing because it contains stem cells and multiple growth factors. Alternatively, platelet rich plasma (PRP), which contains a cocktail of multiple growth factors released from enriched activated thrombocytes may potentially stimulate the mesenchymal stem cells (MSCs) in bone marrow to proliferate and differentiate., Methods: A critical size osteochondral defect (10×6 mm) in both medial femoral condyles was created in 14 Goettinger mini-pigs. All animals were randomized into the following four groups: biphasic scaffold alone (TRUFIT BGS, Smith & Nephew, USA), scaffold with PRP, scaffold with BMAC and scaffold in combination with BMAC and PRP. After 26 weeks all animals were euthanized and histological slides were cut, stained and evaluated using a histological score and immunohistochemistry., Results: The thrombocyte number was significantly increased (p = 0.049) in PRP compared to whole blood. In addition the concentration of the measured growth factors in PRP such as BMP-2, BMP-7, VEGF, TGF-β1 and PDGF were significantly increased when compared to whole blood (p<0.05). In the defects of the therapy groups areas of chondrogenic tissue were present, which stained blue with toluidine blue and positively for collagen type II. Adding BMAC or PRP in a biphasic scaffold led to a significant improvement of the histological score compared to the control group, but the combination of BMAC and PRP did not further enhance the histological score., Conclusions: The clinical application of BMAC or PRP in osteochondral defect healing is attractive because of their autologous origin and cost-effectiveness. Adding either PRP or BMAC to a biphasic scaffold led to a significantly better healing of osteochondral defects compared with the control group. However, the combination of both therapies did not further enhance healing.

Introduction: The assessment of spinal deformities with rasterstereography can enhance the understanding, as well as can reduce the number of x-rays needed. However, to date this technique only allows measurements under static conditions. Since it would be of great value to be able to also analyze the spine in dynamic conditions, the present study evaluated a novel rasterstereographic system., Materials and Methods: A new rasterstereographic device was evaluated in a comparison with the gold standard in motion analysis, the VICON system. After initial testing using 12 flat infrared markers adhered to a solid plate, the two systems were evaluated with the markers adhered onto the backs of 8 test subjects. Four triangles were defined using the markers, and the sides of each triangle were measured under static and dynamic conditions., Results: On the solid plate, the sides of the 4 triangles were measured with a measuring tape and then by the two optical systems. Rasterstereography showed a high accuracy in marker detection on the solid plate. Under dynamic conditions, with the subjects walking on a treadmill, the rasterstereographically-measured side lengths were compared with the lengths measured by the VICON system as an assessment of marker detection. No significant differences (p>0.05) were found between the systems, differing only 0.07-1.1% for all sides of the four triangles with both systems., Discussion: A novel rasterstereographic measurement device that allows surface and spine topography under dynamic conditions was assessed. The accuracy of this system was with one millimeter on a solid plate and during dynamic measurements, to the gold standard for motion detection. The advantage of rasterstereography is that it can be used to determine a three-dimensional surface map and also allows the analysis of the underlying spine.

Purpose: Leg length inequalities (LLIs) can result in an increased energy consumption, abnormal gait or osteoarthritis of the hip. In a previous study we simulated different LLIs of up to 15 mm and evaluated their effects on the pelvic position and spinal posture. We found a correlation between LLIs and resulting changes of the pelvic position. Despite suggestions in the literature we were not able to detect significant changes of the spinal posture. Therefore, the purpose of this study was to determine the amount of LLI that would in fact alter the spinal posture., Methods: The subjects were placed on a simulation platform, whose height could be precisely controlled by the measuring device, to simulate different LLIs of up to 20 mm. For LLIs >20 mm, additional precision-cut wooden blocks were used under one foot. After an adaptation period the resulting changes of the pelvis and spine were measured with a rasterstereographic device., Results: We found a significant correlation between platform height changes and changes of the pelvic position. The frontal spinal parameters surface rotation and lateral deviation changed significantly when simulating differences greater than 20 mm. No changes of the sagittal spinal curvature were measured, however, a trend to decreasing kyphotic angles was noted., Conclusions: Our study has shown for the first time that LLIs >20 mm will lead to significant changes in the spinal posture of healthy test subjects. However, these changes were only found in frontal (surface rotation and lateral flexion) spinal parameters, but not in sagittal parameters. Here for the kyphotic angle only a tendency to decreasing angles was noted. We have also found a significant correlation between different leg lengths and changes of the pelvic position. Further, females and males seem to react in the same way to LLIs.

Background: Arthroscopic suture fixation of tibial eminence fractures using FiberWire is a favorable therapeutic option. The application of biodegradable material may be of advantage especially during childhood. The aim of this study was to evaluate the biomechanical properties using the biodegradable suture materials PDS II and Vicryl compared with FiberWire., Methods: Bone mineral density was evaluated by pqCT in 18 human knee specimens and 3 similar groups were formed. A standardized anterior tibial eminence fracture was created and suture fixation was performed using each suture material (PDS II, Vicryl, FiberWire) in 6 specimens. Cyclic testing and destructive loading to failure was conducted., Results: Both testing modalities showed PDS II to be inferior to the other evaluated suture materials. Although significantly higher failure loads were seen with FiberWire sutures, Vicryl yielded comparable stiffness in load-to-failure testing. No significant differences between Vicryl and FiberWire could be observed under nondestructive cyclic conditions., Conclusions: Even though FiberWire yields a superior ultimate failure load, Vicryl presented comparable results under cyclic conditions., Clinical Relevance: For tibial eminence fractures in children, Vicryl should be considered as an alternative biodegradable suture material. The use of PDS II cannot be advocated.

Children's posture has been of growing concern due to observations that it seems to be impaired compared to previous generations. So far there is no reference data for spinal posture and pelvic position in healthy children available. Purpose of this pilot study was to determine rasterstereographic posture values in children during their second growth phase. Three hundred and forty-five pupils were measured with a rasterstereographic device in a neutral standing position with hanging arms. To further analyse for changes in spinal posture during growth, the children were divided into 12-month age clusters. A mean kyphotic angle of 47.1°±7.5 and a mean lordotic angle of 42.1°±9.9 were measured. Trunk imbalance in girls (5.85 mm±0.74) and boys (7.48 mm± 0.83) varied only little between the age groups, with boys showing slightly higher values than girls. The trunk inclination did not show any significant differences between the age groups in boys or girls. Girls' inclination was 2.53°±1.96 with a tendency to decreasing angles by age, therefore slightly smaller compared to boys (2.98°±2.18). Lateral deviation (4.8 mm) and pelvic position (tilt: 2.75 mm; torsion: 1.53°; inclination: 19.8°±19.8) were comparable for all age groups and genders. This study provides the first systematic rasterstereographic analysis of spinal posture in children between 6 and 11 years. With the method of rasterstereography a reliable three-dimensional analysis of spinal posture and pelvic position is possible. Spinal posture and pelvic position does not change significantly with increasing age in this collective of children during the second growth phase.

Purpose: A bilateral fixed-angle plate was biomechanically compared to the two currently preferred methods of osteosynthesis for transverse patella fractures. It was hypothesized that the new angle-stable implant would provide a secure and sustainable fracture fixation, superior to the established standard techniques., Methods: Twenty-one identical patellae made of polyurethane foam (Sawbones(®)), osteotomized to create a transverse two-part fracture, were fixed with modified anterior tension wiring, cannulated lag screws with anterior tension wiring or bilateral polyaxial 2.7-mm fixed-angle plates. The testing protocol consisted of 10,000 repetitive cycles using a non-destructive physiological load between 100 and 300 N at a simulated knee flexion of 60°., Results: All 21 Sawbone(®)-patellae sustained repetitive loading up to 10,000 cycles without failing. The anterior tension wire group displayed significant displacement of the fracture gap (0.7 ± 0.2 mm) during cyclic loading, while both lag screws with tension wiring and bilateral fixed-angle plates showed no fracture gap widening at all (p < 0.01)., Conclusion: The bilateral fixed-angle plate and cannulated lag screws with anterior tension wiring preserved a constantly reduced fracture gap over 10,000 tensile cycles in contrast to modified anterior tension wiring, which exhibited significant widening of the gap after initial loading. Results of in vitro testing indicate that bilateral fixed-angle plates provide sustainable fixation stability offering a promising new option in the treatment for transverse patella fractures.

Purpose: The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty., Methods: Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated., Results: Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age., Conclusion: Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected.

Introduction: Leg length inequalities (LLI) are a common finding. Rasterstereography offers a non-invasive, contact-free and reliable method to detect the effects of LLIs on spinal posture and pelvic position., Materials and Methods: A total of 115 subjects were rasterstereographically examined during different artificially created leg length inequalities (5-15 mm) using a platform. The pelvic obliquity and torsion and the lateral and frontal deviation of the spine, as well as the surface rotation, were measured., Results: Changes in platform height led to an increase of the pelvic tilt and torsion. Only minor changes in the spinal posture were found by different simulated leg length inequalities., Conclusions: Our study showed that there was a correlation between an artificial leg length inequality up to 15 mm and pelvic tilt or torsion, but only minor changes in the spinal posture were measured. Further studies should investigate the effects of greater leg length inequalities on spine and pelvis.

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

Introduction: A tibial nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular proximal tibial fractures. The goal of this study is to analyze if the angle stable tibial nail (ASN) is biomechanically more stable than an established conventional standard nail (CN)., Methods: Two types of nails were compared on a series of ten matched pairs of human tibiae. After setting a proximal tibial defect fracture, the intramedullary stabilized tibiae were axially loaded starting from 100 N increasing in steps of 100 N after every 200 cycles until failure was reached. Failure was defined as deformation of the fracture gap, fracturing of the bone or the implant., Results: The two types of nails showed no significant difference in terms of maximum tolerated load, maximum cycles repeated or axial deformation of the bone-implant construct. The mean load at failure was 1,365 N for the CN and 1,195 N for the ASN. The mean axial deformation for conventional (19 mm) and angle stable nail (21 mm) did not differ significantly. Slightly less nail or screw loosening was noticed with the fixed-angle nail., Conclusion: No significant difference in stability between the two compared implants could be demonstrated. A trend could be shown indicating that the rate of nail loosening in the proximal osteotomized part of the bone was lower for the angle stable nail. This trend, however, could not be substantiated statistically.

Objective: The management of knee osteoarthritis includes the use of wedged shoe insoles to unload the affected knee compartment. Although the biomechanical effects of shoe insoles on the knee joint are known and described, only little is known about their influence on the pelvis and spine. Therefore, the purpose of this study was to evaluate the effects of different foot positions, such as how they could be achieved by shoe insoles, on pelvic position and spinal posture., Methods: A total of 51 test subjects were measured for this study. The different foot positions (inner and outer margin increase, positive and negative heel height) were simulated with a specially designed stand platform. A rasterstereographic device was used to measure the immediate effects of the simulated foot positions on the pelvic position and spinal posture., Results: Positive and negative heel heights as well as an increase of the outer margin of the platform led to significant changes of the pelvic tilt. The pelvic torsion also changed significantly during positive heel height changes of 10 and 15 mm and increases of the outer margin of the foot. No significant changes were found between foot position and spinal parameters., Conclusion: The results of our study support the existence of a kinematic chain, where changes of foot position also led to significant alterations of the pelvic position. Whether these changes could lead to long-term pathologic alterations still needs to be evaluated. However, in our setting, no correlation between foot position and spinal posture changes was found., (Copyright © 2011 by the American College of Rheumatology.)

Surgical treatment of femoral neck fractures is associated with a significant impact on quality of life. The aim of this study was to determine the long-term influence of displaced femoral neck fractures treated by bipolar hemiarthroplasty on the activities of daily living, quality of life and social dependency. We studied 487 geriatric patients treated in the years 1989 to 2003. At the beginning of follow-up in 2004, 166 patients were alive and evaluation was carried out on 145 patients (87.3%) at 91.3 (14 - 244) months postoperatively by a standardized questionnaire. All enrolled patients had been treated with cemented bipolar hemiarthroplasty for a displaced femoral neck fracture. Patients were evaluated concerning their average pre- and postoperative ability to walk, the need for assisting devices, type of residency and the SF-12® Score. Femoral neck fracture and hemiarthroplasty had a significant influence on all recorded aspects of quality of life. Even though almost two thirds of the patients needed assisting devices to walk after surgery, about two thirds returned to their original type of accommodation and the majority reached their original degree of mobility. Compared to a normal population no significant impact was observed on the quality of life measured by the SF-12® score. We consider bipolar hemiarthroplasty an effective treatment option for displaced femoral neck fractures in geriatric patients. Most patients returned to their original type of accommodation and level of mobility, even though the majority required a number of assisting devices to do so.

Purpose of this study was to evaluate the reliability and validity of 4D rasterstereography under dynamic conditions. Therefore simulated anatomical fixed points on a wooden plate were measured during different movements. Seven different motion patterns in all three angles of space were evaluated. The simulated parameter trunk length was measured with an accuracy of 3.58 mm (SD±3.29 mm) and the dimple distance was detected with an accuracy of 0.88 mm (SD±1.04 mm). With this rasterstereographic prototype it is possible to examine dynamically the spinal posture with adequate accuracy., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: A distal femur nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular distal femur fractures. The goal of this study was to analyze whether the locked compression distal femur nail (LCN) was biomechanically more stable than a conventional standard distal femur nail (CN)., Methods: Both nails were compared on a series of 10 matched pairs of human femora. After setting a distal femur defect fracture, the intramedullary stabilized femur was axially loaded starting from 100 N, increasing in steps of 100 N after every 200 cycles with a triangular frequency of 1 Hz, until a predefined point of failure was reached., Results: The two types of nails showed no significant difference in terms of maximum tolerated load, maximum number of cycles repeated, or axial deformation of the bone-implant construct. The mean load at failure was 2,954 N for the CN and 2,483 N for the LCN. The mean axial deformation for the conventional (14.8 mm) and locked compression nail (15.3 mm) did not differ significantly. Mode of failure was a bony fracture in all specimens predominantly involving the proximal femur., Conclusions: No significant difference in stability between the two compared implants could be demonstrated. The LCN showed comparable characteristics under cyclic axial loading as the conventional distal femur nail. No migration into the articular space or implant failure was observed.

Isolated fractures of the ossa cuneiformia are rare fractures of the foot and they usually occur in the context of a direct trauma. We report about a patient with a dislocation of the midfoot and concomitant fractures of the cuneiforme bones I-III due a car traffic accident. X-rays of the foot confirmed a lateral dislocation of the midfoot with multiple fractures of all ossa cuneiformia. An anterior-longitudinal approach was performed to access the ossa cuneiformia and the bases of the metatarsalia. Comminuted fractures of all ossa cuneiformia, a dislocation of the metatarsal bones I-III and a disruption of the Lisfranc ligament were found. The metatarsal bones I-III were stabilized by K-wires through the bases of the metatarsal bones into the os cuneiform. 6 months later the patient reached 92 points in the AOFAS-Score which correlates with a very good clinical result. We recommend a CT scan for the assessment of this injury since of the complex anatomy of the midfoot. Aim of all surgical procedures should be the restoration of anatomy, in particular of the longitudinal and the diagonal arch of the foot. The anterior, longitudinal approach provides a good overview and permits a direct access even to comminuted fractures., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

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

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%)., (Copyright 2010, SLACK Incorporated.)

The Matthiass posture test is a clinical test to detect posture changes in children and adolescents. Aim of this study was to objectify this test using a dynamic rasterstereographic measuring device. We examined 31 healthy athletes during a modified Matthiass test with a dynamic rasterstereographic measuring system. Hereby the trunk inclination, kyphosis and lordosis angle were measured. The trunk inclination decreased by about 50% of the basic value just by raising the arms. Additional weight loads of only 5% body weight (bw) resulted in significant changes of the posture (lordosis and kyphosis angle) during this test. With this rasterstereographic measuring device it seems to be possible to determine spinal posture changes under dynamic conditions. The results suggest that additional weights of 5% bw during the Matthias-test are enough to create significant deviations in posture parameters, even in healthy subjects.

The objective of this study comparing the proximal femoral nails Targon PF (Aesculap, Tuttlingen, Germany) and Proximal Femoral Nail Antirotation (PFNA; Synthes. Oberdorf, Switzerland) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation, with special attention devoted to the dynamic properties of both implants under physiological load in vivo. The survey was designed as a randomized, prospective study of 80 patients who had sustained a pertrochanteric femoral fracture (AO type 31.A2). Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail. Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group, which was significantly lower than in the Targon PF group (84.7 minutes and 164.5 seconds, respectively). No significant difference was found between the 2 groups in terms of range of motion (P=.26) or Harris Hip Score (P=.83). The femoral neck components of the Targon PF showed a significantly higher sliding ability (14.5 mm; P=.04) than the PFNA (11.1 mm).Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results. The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo. A disadvantage of the Targon PF, however, is the more complicated surgical technique and the longer operative time., (Copyright 2010, SLACK Incorporated.)

The use of platelet-rich plasma (PRP) for improving of bone defect healing is discussed controversially. The aim of this study was to assess the effect of PRP in combination with autologous cancellous graft on bone defect healing in a critical metaphyseal long bone defect. A critical size defect in the tibial metaphysis of 16 mini-pigs was filled either with autologous cancellous graft as control group or with autologous cancellous graft combined with autologous PRP. Compared to native blood platelets were enriched about 4.9-fold in the PRP. After 6 weeks, the specimens were assessed by X-ray and histological evaluation. Histomorphometrical analysis revealed that the area of new bone was significantly higher in the PRP group concerning the central area of the defect zone (p<0.02) as well as the cortical defect zone (p<0.01). All defects showed substantial new bone formation, but only defects of the PRP group regenerated entirely. The PRP group was superior to the control group even in the semi-quantitative assessment of the osseous bridging in both observed areas of the defect. Within the limits of the present study it could be demonstrated that PRP combined with autologous cancellous graft leads to a significantly better bone regeneration compared to isolated application of autologous cancellous graft in an in vivo critical size defect on load-bearing long bones of mini-pigs., (2009 Elsevier Ltd. All rights reserved.)

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

There are no reports in the literature about femoral fractures in adults with congenital femoral deficiency. We report on a femoral fracture in a 60-year-old patient with congenital femoral deficiency. Despite early difficulties in mobilisation and delayed union after an angle-stable plate osteosynthesis, full weight bearing was reached after 8 months. The treatment of fractures in combination with congenital femoral deficiency remains difficult and depends on the extent of the defect, the complexity of the fracture, and associated anomalies. The objective of the often demanding operative treatment of a femoral fracture in combination with a congenital femoral deficiency should be reestablishment of the patient's walking ability.