Search

Fragestellung: Die Implantation von Duokopfprothesen ist ein haufig verwendetes Verfahren zur Therapie von Schenkelhalsfrakturen und gilt als Standardverfahren. Wenig untersucht ist bisher der Einfluss der OP-Dauer, der Tageszeit und der Erfahrung des Operateurs auf die Komplikationsrate und das Outcome der Patienten. Ziel der Studie ist es zu untersuchen, ob ein Zusammenhang zwischen diesen Faktoren und dem Ergebnis besteht. Methode: Retrospektiv wurden 360 Duokopfprothesenimplantationen, die in der Zeit von Januar 2005- Oktober 2008 zur Therapie einer Schenkelhalsfraktur durchgefuhrt wurden, untersucht. Das Durchschnittsalter der Patienten betrug 81,49 Jahre (min. 29, max. 101, SD 9,49 [DD1]). 198-mal war die linke Seite, 162-mal die rechte Seite betroffen. Ermittelt wurde, wie viele Operationen von Assistenz- bzw. Ober- und Chefarzten durchgefuhrt wurden, sowie die Verteilung dieser Operationen auf das regulare Tagesprogramm und die Dienstzeit. Ebenso wurde das Auftreten von Komplikationen erfasst und in Relation zum Operateur und zur Tageszeit gestellt. Ergebnisse: Bei 360 durchgefuhrten Operationen entfielen 305 (84,7%) auf das regulare OP-Programm, 55 (15,3%) wurden wahrend der Dienstzeit vorgenommen. 136-mal war ein Assistenzarzt 1. Operateur, 224-mal ein Oberarzt- oder Chefarzt. Insgesamt betrug die durchschnittliche OP-Dauer 67min. (min. 23, max. 194, SD 23,06). Operierten Assistenzarzte, lag die Dauer im Schnitt bei 77min., Ober- und Chefarzte operierten 61,27 Minuten. Insgesamt kam es in 7,5% der Operationen (27) zu Komplikationen. Die postoperative Infektion stellte mit 40,7% die haufigste Komplikation dar, gefolgt von postoperativen Hamatomen (22,2%) und einer Luxation der Prothese (14,8%). 25 Patienten mussten operativ revidiert werden. Die Komplikationsrate der Assistenzarzte lag mit 9,56% oberhalb der der Ober- bzw. Chefarzte (6,25%). Ein signifikanter Unterschied besteht allerdings nicht (p=0,447). Wahrend der Dienstzeit traten in Relation zu der Anzahl der durchgefuhrten Operationen mehr Komplikationen auf als im regularen Tagesprogramm (11% vs. 6,9%). Schlussfolgerung: Eine statistisch signifikant hohere Komplikationsrate bei durch Assistenten durchgefuhrte Prothesenimplantation zeigte sich nicht. Das haufigere Auftreten von Komplikationen wahrend der Dienstzeit sollte Anlass geben, die nicht notfallmasige Versorgung von Schenkelhalsfrakturen mit einer Duokopfprothese im Regeldienst zu versorgen.

STUDY DESIGN Retrospective chart review. OBJECTIVES This study was performed to compare the outcome, especially the mortality rate, in patients with and without spinal cord injury (SCI) and necrotizing fasciitis (NF). SETTING Division of Spinal Cord Injury and Department of Plastic and Hand Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS Twenty-five patients with SCI and thirty patients without SCI treated with NF were included in the study. Mean length of hospital stay, mean age, mean laboratory risk indicator for necrotizing fasciitis (LRINEC) score, mean number of surgical debridements, co-morbidity factors and mortality rate were compared between both groups. RESULTS There were no differences for the mean LRINEC score (P=0.07), mean number of surgical debridements (P=0.18) and co-morbidities (odds ratio=2.32; 95% confidence interval =0.78-6.92) between both groups. Patients with SCI were significantly younger than patients without SCI (P=0.02). Patients without SCI had a higher mortality risk rate (n=9) than patients with SCI (n=2) (relative risk=1.71; 95% confidence interval =1.13-2.6). CONCLUSIONS In conclusion, SCI patients have a lower mortality rate than patients without SCI. Age may influence the mortality rate. Nevertheless, we believe that further unknown risk factors might influence the mortality, especially in patients with SCI.

Retrospective chart review. The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI). Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination. A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients. Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

Loss of joint mobility, resulting loss of function peripheral nerve entrapment and pressure sores are the known complications of heterotopic ossification.We reported about a 32-year-old male patient, referred to our clinic presenting with incomplete tetraplegia after a motorcycle accident. The patient developed a HO in both hips 19 days after injury. Single-dose radiation therapy with 7 Gy with an electrode voltage of 15 MeV was performed.One month after radiation therapy, the patient developed a fever of 104ºF and blood tests showed increased C-reactive protein (CRP), creatinine kinase (CK), serum myoglobin and dark-colored urine due to myoglobinuria. Further diagnostic measures showed only massive recurrent HO. With the suspicion of a possible case of rhabdomyolysis due to the severe muscular distension caused by the recurrent HO, the patient was transferred to our intermediate care unit for further treatment. Forced diureses were applied to reduce the high levels of CK in blood. However, laboratory monitoring showed a further increase in CRP, CK (15,000 U/l) and myoglobin. A repeated radiation therapy was undertaken in a time interval of 14 days. After radiation therapy, a control MRI was performed and no signs of florid HO were visualized, CRP, CK, myoglobin, as well as body temperature and urine colour, had returned to normal and the patient was feeling well.We report the case of our patient to increase awareness among physicians and training staff working with patients with a spinal cord injury to expedite the diagnosis of rhabdomyolysis in the setting of HO and SCI.

The aim of this study was to assess the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in patients admitted into a level 1 German trauma centre with proximal femur fractures, to correlate this incidence with defined risk factors for MRSA colonisation and to determine its influence on morbidity and mortality. Between August and November 2006, 65 patients were included in the study. Cotton-tipped swab samples were taken from the nose, throat, groin and any skin defects in the emergency room. The following factors were recorded: age, gender, any concomitant diseases, the fracture type and treatment device, skin lesions, hospitalisation within the last year, any urinary or vascular catheters, a nasogastric or gastrostomy tube, an ileal stoma, the use of a respirator and antibiotic therapy within the last year. During follow-up, data concerning any surgical site infections; any chest, urinary or vascular catheter infections; the success of decontamination and death within 1 year after surgery were collected. The risk factors for MRSA colonisation were positive in 40 patients. The incidence of MRSA colonisation was 17%, which is higher than in most comparable studies but consistent with some very recent publications. The nosocomial infection rates, surgical site infection rates and mortality within the 1-year follow-up period were significantly higher in the MRSA-colonised patients. The high incidence of MRSA in this study supports the need for systematic detection of MRSA-colonised patients. In our hospital, any patient with positive risk factors for MRSA colonisation is swabbed in the emergency room and treated as MRSA positive until proven otherwise.

The use of surface demineralized micro-perforated femoral allograft (SDMFA), in the form of short diaphyseal segments, is of interest for anterior thoracic and lumbar spine reconstruction. Its reported osteoinductive capacity is enhanced by demineralization, though the mechanical strength is reduced. The strength of SDMFA segments was significantly higher at 24 h of demineralization time as compared to 48 h of demineralization time. The SDMFA segments from the junction of the proximal and mid-third of the femoral diaphysis had the greatest load to failure and stiffness.

Posterior dislocation of the shoulder is a rare injury and often misdiagnosed during the initial presentation to a physician. Misdiagnosis is due to a lack of clear clinical signs compared to anterior dislocation and inappropriate radiographs. In contrast to anterior dislocations, the humeral head defect accounts for recurrent instability. Depending on the size of the defect and the duration of dislocation, different treatment options include elevation of the defect, bone grafting, McLaughlin procedure, rotation osteotomy or arthroplasty.We reviewed 35 patients who presented to our institution with a locked posterior dislocation of the shoulder between January 1999 and August 2009. In 6 patients, the shoulder remained stable after closed reduction, so the treatment was conservative; 29 patients underwent surgery.The mean follow-up was 55 months (range 11-132 months). The interval between trauma and the diagnosis of posterior shoulder dislocation was 66 days (min. 0, max. 365). Patients treated conservatively achieved a Constant Score of 85 points; patients who underwent operative treatment had a slightly worse outcome with an average Constant Score of 79 points. There was a high correlation between the time to the correct diagnosis and the outcome.Although locked posterior shoulder dislocation is uncommon and often initially misdiagnosed, satisfying results can be achieved by different surgical treatment options. Early diagnosis by detailed clinical examination and sufficient radiographic evaluation with true anterior-posterior and axillary views is essential to improve clinical results. Levl of evidence: IV.

Background The biomechanical effect of indirect weight loading with the Ilizarov ring fixator using a weight-bearing platform has not yet been investigated. The problem of wire loosening and breakage occurs more frequently when patients are mobilised with a weight-bearing platform. Therefore, the aim of this research was to compare the influence of direct and indirect weight loading on the tensioned wires. Method A universal testing machine (UTS, Germany) was used in this study. A composite tibia model with a standard four-ring Ilizarov fixator and 1.8-mm wires in anatomical position was used to simulate a clinical situation. Wire strain was measured with two strain gauges positioned at the ring–wire interface of each wire. After a standardised 2-mm mid-diaphyseal osteotomy, an axial load of up to 1000 N was applied to the bone; the different methods of weight loading were evaluated in two experimental set-ups. Results A higher axial load was necessary to achieve an osteotomy gap closure at indirect loading. Mechanical stress on the tensioned wires was 400% higher on the proximal wires and 250% higher on the distal wires at a maximum axial loading of 1000 N. Mechanical stress remained on the wires in indirect loading, even after bone end contact, and led to excessive stress under higher weight-bearing amounts. Conclusion There is a substantial change in the biomechanical characteristics of the Ilizarov ring fixator when mobilising a patient with a weight-bearing platform. The considerable higher mechanical stress on the wires needs to be considered when patients are mobilised with a weight-bearing platform.

The pelvic ring and lumbar spinal transition zone provide our trunk and lower extremities with a sound structural foundation and conduit for neurovascular structures, as well as a floor to our intestines and uro-genital structures. Injuries to this area are typically the result of high-energy injuries, neoplastic disease, or insufficiency fractures in the presence of impaired bone substance. Due to its unique reliance on a combination of firm bony structures encased by strong ligamentous support structures, the pelvic ring and lumbosacral juncture are exposed to a wide variety of possible injury constellations in terms of musculoskeletal injuries and associated organ system injuries. Ultimately, preservation or restoration of the three-dimensional alignment of this region with a solidly healed injury zone is desirable. The goals of surgical treatment of pelvic ring and lumbosacral zone injuries are providing an environment to allow for best possible regeneration of neural injury and facilitating the recovery process through early pain-free mobilization without interfering with the care of other injured organ systems.

Of 48 patients with spinal metastases treated at the Kenneth J. Norris Cancer Center at The University of Southern California Medical Center in Los Angeles, California between 1984 and 1987, 19 consecutive patients with cervical metastatic disease were identified and followed until death or remission. Prostate, breast, and lung neoplasms accounted for 57% of the cervical metastases. Associated nonspinal skeletal, extraskeletal, or multiple-level spinal metastases were seen in 95% of patients. Mean time from diagnosis of primary tumor to cervical metastasis was 29 months and mean survival after that was 14.7 months. Pain was the initial symptom in 89% of cases. No patient had neurologic deficit and three (16%) had slight radiographic collapse and deformity. Only one (5%) patient had documented instability. All patients had nonoperative treatment with radiotherapy, chemotherapy, or a combination. Irrespective, the pain recurred in all patients by 6 months. Nonoperative treatment may be appropriate in the absence of significant neurologic deficit or instability. The return of symptoms by 6 months warrants alternative modes of therapy.

The purpose was to evaluate inflammatory and microcirculatory reactions after implantation of various calcium phosphate bone substitutes in an in vivo model. Calcium phosphate-based bone substitutes were implanted in dorsal skinfold chambers of mice. Intravital fluorescence microscopy was performed to measure inflammatory and microcirculatory reactions based on functional vessel density (FVD), capillary leakage, and relative white blood cell velocity (rWBCV). An increase of FVD was observed in all groups and the capillary leakage grew with a level of significance (p

Background Primary sacral tumors are rare and experience related to accompanying effects of these tumors is therefore limited to observations on a small number of patients. Case presentation In this case report we present a patient with a history of primary sacral chondrosarcoma, an infection of an implanted spinal stabilization device and discuss the challenges that resulted from a colonic fistula associated with large, life threatening abscesses as late complications of radiotherapy. Conclusion In patients with sacral tumors enterocutaneous fistulas after free musculotaneous free flaps transfer are rare and can occur in the setting of surgical damage followed by radiotherapy or advanced disease. They are associated with prolonged morbidity and high mortality. Identification of high-risk patients and management of fistulas at an early stage may delay the need for subsequent therapy and decrease morbidity.

Displaced intra-articular fractures of the glenoid are rare and frequently result from high-energy injuries. Types IV, V, and VI fractures have in common a fracture line which extends medially into the scapular body. These fracture patterns present unique challenges for surgical approaches and reduction and fixation strategies. A modified posterior approach allows for the simultaneous exposure of the medial scapular border and the glenoid articular surface. An initial reduction of the medial fracture indirectly restores the scapular relationship, allowing for subsequent completion of the articular reduction via a limited approach to the posterior shoulder using the same incision.

We analyzed leukocyte functions and cytokine response of human leukocytes toward porous tantalum foam biomaterial (Trabecular Metaltrade mark, TM) in comparison to equally sized solid orthopedic metal implant materials (pure titanium, titanium alloy, stainless steel, pure tantalum, and tantalum coated stainless steel). Isolated peripheral blood mononuclear cells (PBMC) and polymorphonuclear neutrophil leukocytes (PMN) were cocultured with equally sized metallic test discs for 24 h. Supernatants were analyzed for cytokine content by enzyme-linked immunosorbent assay. Compared to the other used test materials there was a significant increase in the release of IL (interleukin)-1ra and IL-8 from PMN, and of IL-1ra, IL-6, and TNF-alpha from PBMC in response to the TM material. The cytokine release correlated with surface roughness of the materials. In contrast, the release of IL-2 was not induced showing that mainly myeloid leukocytes were activated. In addition, supernatants of these leukocyte/material interaction (conditioned media, CM) were subjected to whole blood cell function assays (phagocytosis, chemotaxis, bacterial killing). There was a significant increase in the phagocytotic capacity of leukocytes in the presence of TM-conditioned media. The chemotactic response of leukocytes toward TM-conditioned media was significantly higher compared to CM obtained from other test materials. Furthermore, the bactericidal capacity of whole blood was enhanced in the presence of TM-conditioned media. These results indicate that leukocyte activation at the surface of TM material induces a microenvironment, which may enhance local host defense mechanisms.

Introduction: Multipotent mesenchymal stromal cells (MSC) are of high potency to renew distinct tissues. In combination with appropriate biomaterial carriers (such as porous β-tricalcium phosphates) these cells may be used for the therapy of large bone defects. First clinical experience has demonstrated optimal handling in combination with autologous fibrin as cell/biomaterial carrier matrix. It was the purpose of this in vitro study to analyze the effect of a fibrin matrix on the proliferation and osteogenic differentiation of mesenchymal stromal cells. Materials and Methods: Bonemarrow derived human mesenchymal stromal cells (hMSC, Cambrex Bio Science, 3rd–6th passage) were cultured in 6-well plates using RPMI1640 cell culture medium supplemented with 10 % FCS and 4 mM glutamine. Blood plasma was obtained by centrifugation of citrate-anticoagulated peripheral blood from volunteers. 5 ml plasma and 5ml RPMI1640 cell culture medium (or 5 ml supplemented RPMI1640 containing peripheral mononuclear leukocytes-PBMC obtained by Ficoll separation, 1 × 10E6/ml) were mixed and the coagulation was started by the addition of a 10 % calcium chloride solution and then left for 15 min at room temperature. The obtained fibrin clot or fibrin/leukocytes clot were laid upon subconfluent hMSC and were further cultured (1–3 weeks). Migration of cells was analyzed by fluorescence microscopy (calcein staining). Cell proliferation and alkaline phosphatase activity were measured fluorophotometrically (alamarBlue, AttoPhos). Osteogenic differentiation was determined by mineralization (Alizarin red) and by the release of osteocalcin, osteoprotegerin, and C-terminal peptide (CICP) of collagen type I (ELISA, Metra Biosystems). Results: Mesenchymal stromal cells migrated actively into the overlying fibrin clots. The proliferation of hMSC was significantly increased in the presence of fibrin clots. In the presence of leukocytes-containing clots hMSC proliferation was decreased after three weeks culture. The activity of alkaline phosphatase and the release of osteocalcin were significantly increased showing maximal values in the presence of leukocytes-containing clots. Alizarin-positive cells were only detected in the presence of leukocytes-containing clots. Differences in the release of osteoprotegerin or CICP were not detected. Conclusions: An autologous fibrin matrix is clinically suitable to apply cells locally. Due to the three-dimensional structure additional MSC are able to migrate into the matrix. Cell proliferation of hMSC is promoted by the fibrin clot. The osteogenic differentiation of hMSC is increased by the addition of leukocytes to the fibrin matrix.

Haemophilia A is a coagulopathy with an absence or functional deficiency of coagulation factor VIII. The disease can be subdivided into a congenital form (incidence 1:10,000-1:20,000) and an acquired form (incidence 1:1,000,000). Both forms present an increased risk of bleeding even in low-impact trauma in severe cases of haemophilia A. The course of a man with haemorrhagic shock after a fall from a height of more than 3 m is described. After the secondary survey in the intensive care unit, several interventions (laparotomy, mass transfusion) were performed to stop the bleeding. A history of haemophilia was belatedly reported by relatives. The activity of factor VIII was determined, and substitution was initiated. No recurrent signs of bleeding occurred. The patient survived in good condition and presented for follow-up 3 years later with no disabilities.

The authors report on an important differential diagnosis of back pain in a pregnant woman caused by an atraumatic insufficiency sacral fracture. This diagnosis is a rare entity in pregnant patients and may often be overlooked due to nescience by the treating physicians. The authors discuss the diagnostic and treatment options in undisplaced sacral fractures and their successful natural treatment result. Although this patient report is not the third case of an atraumatic sacral fracture during pregnancy in the literature,1 2 and despite a considerable number of other reports of pregnancy-related sacral fractures in the immediate postpartum period, it is nevertheless important to present such rare medical entities occurring during and shortly after pregnancy, so that these patients are not inadvertently treated incorrectly. The authors refer to the rare possibility of pregnancy-related osteoporosis and the altered posture and load-bearing capacity of the posterior pelvic ring during pregnancy as preconditions for atraumatic sacral fracture. The pathomechanism for prepartum sacral fracture may also be differentiated into (1) insufficiency fractures due to transient osteoporosis of the sacrum associated with pregnancy or (2) fatigue fractures due to unaccustomed stress related to rapid and excessive weight gain in the last trimester of the pregnancy.3 Bone mineral density measurement might help in this differentiation. Treatment options for atraumatic sacral fractures especially in a pregnant patient are very limited, and cases are typically handled nonoperatively during pregnancy as described; however, the importance of a cesarean section for delivery should again be highlighted to avoid intrapartum worsening of the fracture.4 5 Independently of that, most of the time surgical stabilization of an atraumatic insufficiency fracture seems to be unnecessary in the postpartum period. Surgical intervention would only be indicated in lasting instability of the pelvic ring or in the presence of progressive deformity and certainly in the case of sacral nerve dysfunction due to fracture impingement.

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.

Objective: To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction. Design: Retrospective clinical study. Setting: Level 1 trauma center. Patients: During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions. Main Outcome Measurements: Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane. Results: Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity. Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated. Conclusions: Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.

Summary Objectives To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. Method We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries. Results A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1 min) and Montreal, Canada (median 16.1 min) reported the shortest and Germany (median: 30 min) and Austria (median: 26 min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). Conclusion This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.

Study design Retrospective evaluation of 19 consecutive patients with sacral fracture dislocations and cauda equina syndrome. Objective To review the safety and patient impact of early surgical decompression, and rigid segmental stabilization in patients with high-grade sacral fracture dislocations. Summary of background data The ideal treatment for patients presenting with fracture dislocations of the sacrum resulting from high-energy mechanisms remains unknown. Previous studies consisted of multicenter case reviews that showed satisfactory outcomes with either nonoperative or a variety of surgical methods. However, over the last 20 years, no consistent treatment algorithm for these severe injuries has emerged. The advent of rigid, low-profile segmental fixation of the lumbar spine to the pelvic ring has offered a solution to many of the surgical challenges. This study evaluates the rate of complications of this method. It is intended to serve as a foundation for further evaluation and development of this treatment strategy, and as a basis for future comparison studies. Methods Patients were treated with a formally established algorithm, including resuscitation, and clinical assessment with detailed neurologic assessment and radiographic workup with pelvic computerized tomography and reformatted views. Electrophysiologic testing was conducted to confirm the presence of sacral plexus injuries in patients who were unable to be examined. Patients received neural element decompression and open reduction with segmental internal fixation through a midline posterior approach by connecting lower lumbar pedicle screws to long iliac screws when the patient's general medical condition allowed for surgical intervention. A formal sacroiliac arthrodesis was not performed. For the purposes of this study, patients were assessed specifically for the following adverse events: (1) infection, (2) wound healing, (3) neurologic deterioration following surgical treatment, (4) postoperative loss of sacral fracture reduction, (5) instrumentation failure, (6) axial lumbopelvic pain requiring further treatment, and (7) unplanned secondary surgery. Results There were 19 patients with an average age of 32 years treated according to this algorithm. Fracture reduction was successfully maintained in all patients. During the index surgical intervention, 14/19 patients (74%) had had either a traumatic dural tear or nerve root avulsion. Major complications involved fracture of the connecting rods in 6/19 patients (31%) and wound healing disturbances in 5/19 (26%). There were no lasting complications such as chronic osteomyelitis noted. In patients followed over a 1-year period, the visual analog score, referable to the sacral injury, averaged 5.5 on a scale of 0-10. Conclusions Rigid segmental lumbopelvic stabilization allowed for reliable fracture reduction of the lumbosacral spine and posterior pelvic ring, permitting early mobilization without external immobilizaton and neurologic improvement in a large number of patients. Complications were primarily related to infection, wound healing, and asymptomatic rod breakage, and were without long-term sequelae.

Human leukocytes (peripheral blood mononuclear cells, PBMC) were overlaid on calcium phosphate bone cement (CBC, Norian SRS®) and allowed to settle for 1 h under cell culture conditions. Subsequently, the cells were either left unstimulated (i.e. sham stimulation using cell culture medium), or stimulated with toxic shock syndrome toxin-1 (TSST-1, 10 ng/mL), staphylococcal enterotoxin B (SEB, 10 ng/mL), or concanavalin A (ConA, 2 μg/mL) for further 24 h using cell culture conditions. Supernatants were then analyzed for cytokine content (interleukin-1 receptor antagonist, IL-1ra; IL-2; IL-6; IL-10; IL-12) by enzyme-linked immunosorbent assay. While the spontaneous generation of cytokines was not influenced, the IL-2 release from stimulated PBMC was significantly decreased in contrast to other analyzed cytokines after contact to the curing CBC compared to control incubations without CBC. This decrease in IL-2 release was not due to known inhibitors of IL-2 synthesis platelet factor-4 (PF-4), IL-10, TGF-β, or elevated calcium ion concentrations. © 2006 Wiley Periodicals, Inc. J Biomed Mater Res, 2006

Introduction: The expanding potential of mesenchymal stem cells (MSCs) for tissue repair and regeneration stimulates clinical research to develop novel and improved therapeutical strategies. However, due to low numbers of MSCs e.g. within bone marrow these progenitor cells may be expanded for clinical use if necessary. The maintenance and propagation of culture cells are crucially dependent on the cellular pattern of the inoculum and cell culture conditions including exogenous medium supplements. Materials and methods: For validation of a clinical study density-gradient isolated mononu-clear cell (MC) fractions of bone marrow (BM) taken from the iliac crest of healthy volunteers (n=4) were inoculated into the automated AastromReplicell™ Cell Production System (Aastrom Biosciences, Inc, Ann Harbor, MI) which encompasses a closed and sterile cell production bioreactor for clinical use. The MC cells (255 × 10E6) were cultured for 12 days within a single-use disposable cell cassette which contained the cell-chamber using supplemented medium (IMDM containing FCS, HS, EPO, PIXY321, Flt-3-ligand, L-glutamine, gentamicin, and vancomycin). BM-aspiration, MC isolation and cell expansion protocol were the same as intended for patients treatment. To evaluate the quality of the expanded cell products inoculum and harvest cells were characterized by flow cytometry (FACSCalibur), immunohistochemistry (Vector Stain), and magneto bead separation (Miltenyi). Results: Total cell expansion was in the range from 906 × 10E6 to 1440 × 10E6 cells. The respective expression of CD45, CD90, CD105 and the occurrence of lineage (Lin)-specific markers (CD3, CD11b, CD14, CD15, CD20, CD235a-GlyA) were analyzed. The cell culture conditions led to an expansion of CD45−CD90+Lin− up to 63.8 fold and CD45−CD105+Lin− up to 21.2 fold in absolute cell numbers. The expansion of myeloids was maximal 6.0 fold and of erythroids was maximal 11.2 fold. Compared to inoculum cells lymphocytes analyzed as CD3+-cells were decreased more than 100 fold in the harvest cell fraction. In addition, harvest cells which were conventionally cultured (6 months) without further addition of exogenous growth factors showed an increasing number of CD90+ cells and a decreasing number of CD45+ cells. Conclusions: The used ex vivo cell production system is applicable for clinical use, it requires about 30 ml BM aspirate for a broad expansion of cells bearing MSC-typical markers concomitant with large numbers of harvest cells.

Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale.This was a retrospective study conducted at a Level I trauma center.Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures.This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.

To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period.Twelve preserved human cadaveric lumbopelvic specimens were cyclicly tested in a single-limb-stance model. A transforaminal sacral fracture combined with ipsilateral superior and inferior pubic rami fractures were created and stabilized. Loads simulating muscle forces and body weight were applied. Fracture site displacement in three dimensions was evaluated using an electromagnetic motion sensor system.Specimens were randomly assigned to either an iliosacral and superior pubic ramus screw fixation or to a triangular osteosynthesis consisting of lumbopelvic stabilization (between L5 pedicle and posterior ilium) combined with iliosacral and superior pubic ramus screw fixation.Peak loaded displacement at the fracture site was measured for assessment of initial stability. Macroscopic fracture behavior through 10,000 cycles of loading, simulating the early postoperative weight-bearing period, was classified into type 1 with minimal motion at the fracture site, type 2 with complete displacement of the inferior pubic ramus, or type 3 with catastrophic failure.The triangular osteosynthesis had a statistically significantly smaller displacement under initial peak loads (mean +/- standard deviation [SD], 0.163 +/- 0.073 cm) and therefore greater initial stability than specimens with the standard iliosacral screw fixation (mean +/- SD, 0.611 +/- 0.453 cm) ( = 0.0104), independent of specimen age or sex. All specimens with the triangular osteosynthesis demonstrated type 1 fracture behavior, whereas iliosacral screw fixation resulted in one type 1, two type 2, and three type 3 fracture behaviors before or at 10,000 cycles of loading.Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.

The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention.In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively.Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010).The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.

Severe joint depression-type calcaneal fractures cause dramatic distortion of hindfoot anatomy, including gross shortening of the heel and lateral translation of the tuberosity. This displacement may alter the mechanics of the foot, interfere with tendon function, or put the medial soft tissues under tension. The displacement is typically corrected by open reduction. However, surgical intervention may be delayed because of soft tissue involvement, higher priority musculoskeletal injuries, or the presence of life-threatening injury. When treatment has been delayed, it may be difficult to restore the height and length of the calcaneus. Application of an external fixator is one option to allow for early indirect fracture reduction of the hindfoot and initial soft tissue healing. However, a percutaneous screw reduction technique reduces the risk of pin tract infection with the external fixateur and allows the soft tissue to regenerate. Bony reduction is gained with the help of a push screw, which allows controlled and gradual reconstitution of the length and height (Bohler's angle) of the hindfoot. This technique, though, is only recommended as a temporary salvage procedure in situations in which a delayed primary subtalar fusion is the only treatment of choice in a severely comminuted high-energy calcaneal fracture.

Lumbopelvic fixation in spinal and pelvic surgery relies on rods or screws as an iliac anchor. Secure placement of screws with maximum diameter and length for the greatest pullout strength requires knowledge of the iliac structure and of intraoperative fluoroscopic landmarks for secure placement. Therefore, the authors evaluated the intrailiac length, inner width, and cortical thickness of three different transiliac screw anchor paths aimed toward the anterior inferior iliac spine and initiated at the iliac tubercle, posterior superior iliac spine, or posterior inferior iliac spine. Measurements were made using two- and three-dimensional computed tomographic reformations in 40 consecutive trauma patients (27 measurements in 21 males, 16 to 75 years old; 28 measurements in 19 females, 16 to 78 years old). In addition, fresh and dry human cadaveric specimens were marked with metal wires at the previously determined optimal screw path to determine fluoroscopic landmarks for easiest and best controlled transiliac screw placement. The posterior superior iliac spine-anterior inferior iliac spine path had the largest bony canal lengths, with 141 mm in male and 129 mm in female patients. Two stereotypic iliac constrictions allowed placement of 8-mm implants in male and 6- to 7-mm implants in female patients. Cortical thickness at that optimal extraarticular path was 5.2 mm in the male and 4.7 mm in the female patients. Transiliac screws can be placed during operation under fluoroscopic control using standard lateral and obturator oblique-outlet views, the latter presenting a stereotypical teardrop figure above the acetabulum.

Acute traumatic pelvic ring instability causes severe pain and associated hemorrhage. Circumferential pelvic sheeting provides patient comfort and noninvasive, rapid, and temporary pelvic ring stability. A bed sheet is readily available, inexpensive, easily applied around the pelvis, and disposable.

Thoracic injury following a major trauma can be life threatening. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) can be used as a support to mechanical ventilation when acute respiratory distress syndrome is present. We report the case of an 18-year-old male driver who strayed from the road and fell 15 m into a backyard by landing on the roof of its car. The injury severity score was 51 for his pattern of injuries (hemopneumothorax left, sternum fracture, pneumothorax right, pneumomediastinum, intracerebral bleeding, scalping injury occipital, fracture of the ninth thoracic vertebral body, and complete paraplegia). The patient was transferred to our hospital 12 hours after the accident. As we started the secondary survey, the patient was cannulated for vv-ECMO due to deterioration in his oxygenation status. We implanted a double-lumen cannula (Avalon31F catheter, right internal jugular vein) during fluoroscopy. The patient developed posttraumatic systemic inflammatory response syndrome, which began to resolve after 72 hours, and he started breathing spontaneously. After 7 days, he was weaned from vv-ECMO and recovered in a rehabilitation facility. The use of vv-ECMO therapy in cases of major trauma has become a rescue strategy. The use of vv-ECMO was performed without anticoagulation because of his traumatic brain injury and severe spinal cord injury.

The ability to mechanically reinforce an osteoporotic vertebral body could impede spinal compression fracture and the associated pain and complications. Previous studies have shown that reinforcement of fractured vertebrae with conventional acrylic cement can relieve symptoms and avoid further collapse. In this study, we explored the use of a carbonated apatite cement combined with a minimally invasive injection technique to improve the compressive mechanical properties of cadaveric vertebral bodies. After establishing the biomechanical characteristics of cement formulations intended to have appropriate viscosities, we evaluated the infiltration of the cements into thoracic vertebral bodies using a combined suction-injection technique. The energy-absorption capabilities of the reinforced vertebral bodies were then measured during axial compressive tests and compared with those of nonreinforced vertebrae. The ultimate compressive strength of the cement formulations averaged from 11.6 to 17.7 MPa, depending on curing conditions. The suction-injection technique allowed from one-half to two-thirds of each vertebral body to be infiltrated with cement. Energy absorption was significantly higher (p < 0.05) between 25 and 70% collapse of the vertebral body in the specimens that received the apatite injection as compared with the controls. These results suggest that osteoporotic vertebral-body augmentation with the injection of apatite cement could prevent further collapse after initial failure has occurred. The osteoconductive nature of the cement and its ability to be remodeled by bone, together with its compressive strength, which is higher than that of cancellous bone, could provide better clinical results than those of current treatments with acrylic cement.

The ability of the osteoinductive protein and recombinant human bone morphogenetic protein-2, combined with polylactic glycolic acid porous microspheres and autologous blood clot to heal a large segmental defect was tested in a rabbit diaphyseal defect model. Two centimeter nonuniting defects were surgically created in the bilateral ulnae of 50 male New Zealand white rabbits. Each defect was then implanted with a pastelike polylactic glycolic acid/blood clot combination that was mixed with 5 different concentrations of recombinant human bone morphogenetic protein-2. The forearms were radiographically assessed on a biweekly schedule for 8 weeks. At 8 weeks, all animals were sacrificed and forearms radiographed. Radiographs were then scored by 3 independent observers for bone formation and union rates. United limbs were tested in torsion for mechanical strength using a Burstein torsion tester. All nonunited limbs were analyzed histologically as were 2 united limbs from each dosage group. Radiographic evaluation revealed that there was a dose dependent response in healing of the ulnar defect with a higher bone formation rate in the 2 higher dose limbs than in the lower dose limbs. Union was achieved in 100% of the highest dose limbs, whereas only 50% of the lowest dose limbs achieved bony union. No defects implanted with carrier alone achieved union. Biomechanical studies revealed significantly stiffer bone than age matched controls. Histologic analysis demonstrated normal bone formation with abundant normal appearing osteoid. These dose response data further support the role of recombinant human bone morphogenetic protein-2 as a potent morphogen in bone regeneration.

Introduction Fractures of the lower extremity are a common type of childhood injury and many can be treated without surgery. Dislocated and open fractures are an indication for fracture stabilization via either intramedullary nailing or, in the case of complicated fractures, external fixation. But if complications are likely because of diseases and disabilities (for example, a neuropathy) that can complicate the post-operative procedure and rehabilitation, what options does one have? Case presentation We report a nine-year-old Caucasian girl who had hereditary motor and sensory neuropathy type I and who was admitted with a grade I open tibia fracture after a fall from a small height. Plain radiographs showed a dislocated tibia and fibula fracture. An open reduction with internal fixation with a compression plate osteosynthesis was performed, and soft tissue debridement combined with an external fixateur was undertaken. Three months later, she was re-admitted with localized swelling and signs of a local soft tissue infection in the middle of her tibia. Plain radiographs showed a non-union of the tibia fracture, and microbiological analysis confirmed a wound infection with cefuroxime-sensitive Staphylococcus aureus. Because of the non-union, the osteosynthesis was replaced with an Ilizarov external fixateur, and appropriate antibiotic therapy was initiated. Four months after the initial accident, the fracture was consolidated and we removed the external fixateur. Conclusions If there is a pre-existing neuropathy and if disease makes it difficult for a child to follow all post-operative instructions, salvage procedures should be kept in mind in case of complications. There are multiple therapeutic options, including osteosynthesis, intramedullary nailing systems, cast therapy, or an external fixateur like the Ilizarov or Taylor spatial frame system. The initial use of an external fixateur such as an Ilizarov or Taylor spatial frame in patients with pre-existing neuropathies should be kept in mind as a possible treatment option in complicated fractures, especially in a child with pre-existing neurological or endocrine pathologies.

A rare case of hibernoma about the nipple in a 9-year-old boy is presented: the tumour was peculiar not only for the age and region, but also for its superficial, subepidermal site.

Der spiralformig verlaufende Ausenknochelbruch in Syndesmosenhohe ist in Ubereinstimmung mit der Lauge-Hansen-Klassifikation stabil, wenn die Gelenkstellung durch eine intakte hintere Syndesmose und unverletzten Innenknochel sowie medialen Kapsel-Bandkomplex gesichert wird. Zwischen 12/1990 und 6/1993 wurden von 93 Patienten mit einem Weber-B-Bruch 30 operativ, 21 konservativ-immobilisierend und 42 funktionell-konservativ behandelt. Wahrend des durchschnittlichen Nachuntersuchungszeitraumes von 15,8 Monaten kam es zu keinem Therapieversagen. Bei der stabilen Weber-B-Fraktur mit Fragmentverschiebung ≤ 2 mm empfehlen wir das funktionell-konservative Vorgehen.

Background A weight-bearing platform applied at the distal end of an Ilizarov external frame allows patients with hindfoot transfixations, foot deformities or plantar skin lesions to bear weight. This leads to an indirect loading of the fracture or osteotomy site. However, the effect on the fracture/osteotomy site's motion or compressive loads is unknown. The aim of this study was to analyze the mechanical effects of a weight-bearing platform on the traditional all-wire, four-ring frame in comparison to a two-ring frame consisting of half-pins. Methods Two frame configurations, with either anatomically positioned wires or half-pins, were analyzed with and without a weight-bearing platform applied underneath the distal ring. Composite tibiae with a mid-diaphyseal osteotomy of 3.5 mm were used in all the experiments. An axial load was applied with the use of a universal test machine (UTS®). Interfragmentary movements, the relative movements of bone fragments and movements between rings were recorded using displacement transducers. Compressive loads at the osteotomy site were recorded with loading cells. Results Indirect loading with a weight-bearing platform altered the force transmission through the osteotomy. Indirect loading of the tibiae decreased the extent of the axial micro-motion by 50% under the applied weight load when compared to direct weight loading (p < 0.05). The half pin frame was 25% stiffer than the wire frame under both direct and indirect loading of the tibiae (p < 0.05). Compressive loads under indirect loading were reduced by 67% in the wire frame and by 57% in the half-pin frames compared to direct loading of the bones (p < 0.05). While axial loading in the wire frames resulted in plain axial movements at the site of the osteotomy, it was coupled with translational movements and angular displacements in the half pin mountings. This effect was more apparent in the case of indirect loading. Conclusions A weight-bearing platform has substantial influence on the biomechanical performance of an Ilizarov external fixator. Half-pins induce greater stiffness to the Ilizarov external fixator and allow the usage of only one ring per bone segment, but shear stresses at the osteotomy under axial loading should be considered. The results allow an estimation of the size and direction of interfragmentary movements based on the extent of weight bearing.

Operative treatment of periprosthetic humeral fractures in elderly patients with osteoporotic bone requires a stable fixations technique. The combination of 3.5 cortical screws with washers in a 4.5 Arbeitsgemeinschaft für Osteosynthesefragen, Limited-contact dynamic compression plate or Locking plate, allows a stable periprosthetic fixation with the small 3.5 screws and 4.5 screws above and below the prosthesis, respectively. This combination is a cost-effective technique to treat periprosthetic humeral fractures.