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To study the mortality, cause and risk indicators of death in German patients with traumatic spinal cord injury, patients with traumatic spinal cord injury admitted to Berufsgenossenschaftliches Trauma Hospital Hamburg between 1 January 1997 and 31 December 2018, aged between 16 and 60 with a minimal survival of one year after injury, were included. Further criteria were the absence of life-limiting comorbidities at the time of injury. 223 deceased patients with traumatic spinal cord injury were identified, investigated on and partly compared to the surviving subjects. We aimed to discover specific complications that were related to Spinal Cord Injury and responsible for a possibly limited life expectancy. Data collection was performed during in- and outpatient treatment. A statistical analysis was performed to compare groups. The post-injury life expectancy was 25.0 years with a significant correlation regarding the level of lesion and severity of injury. The leading causes of death were cardiovascular diseases and pneumonia. Bladder cancer was the most common fatal malignant tumor. The life expectancy of patients suffering from traumatic spinal cord injury is limited. The longer a patient survives after injury and the lower the level of lesion, the more likely an age-related cause of death becomes. Bladder cancer is significantly more frequent when compared to the overall distribution of tumor diseases in Germany.

Digitalisation now almost covers all areas of medical student teaching. Teaching videos are a good way to help students learn practical skills. The existing evidence is a recognised aid for the classification of the respective technology.This video presents the usual examination techniques of the knee joint on a patient with an unstable knee. The respective techniques, if available, were backed up with the appropriate evidence.The examination techniques presented allow students to view the examination techniques in a standardised manner on a patient. The evidence for the examination techniques can help with the classification of the respective technique.Die Digitalisierung erfasst inzwischen alle Bereiche der studentischen Lehre. Um die Studierenden im Erlernen praktischer Fertigkeiten zu unterstützen, sind Lehrvideos eine gute Methode. Für die Einordnung der jeweiligen Technik ist die vorhandene Evidenz eine anerkannte Hilfestellung.Das hier vorliegende Video stellt die üblichen Untersuchungstechniken des Kniegelenkes an einer Patientin mit einem instabilen Knie dar. Die jeweiligen Techniken wurden, wenn vorhanden, mit der jeweiligen Evidenz unterlegt.Die dargestellten Untersuchungstechniken ermöglichen es Studierenden, sich die Untersuchungstechniken standardisiert an einem Patienten anzuschauen. Die eingeblendete Evidenz für die Untersuchungstechniken kann hierbei eine Hilfestellung bei der Einordnung der jeweiligen Technik leisten.Die Digitalisierung erfasst inzwischen alle Bereiche der studentischen Lehre. Um die Studierenden im Erlernen praktischer Fertigkeiten zu unterstützen, sind Lehrvideos eine gute Methode. Für die Einordnung der jeweiligen Technik ist die vorhandene Evidenz eine anerkannte Hilfestellung.Das hier vorliegende Video stellt die üblichen Untersuchungstechniken des Kniegelenkes an einer Patientin mit einem instabilen Knie dar. Die jeweiligen Techniken wurden, wenn vorhanden, mit der jeweiligen Evidenz unterlegt.Die dargestellten Untersuchungstechniken ermöglichen es Studierenden, sich die Untersuchungstechniken standardisiert an einem Patienten anzuschauen. Die eingeblendete Evidenz für die Untersuchungstechniken kann hierbei eine Hilfestellung bei der Einordnung der jeweiligen Technik leisten.

Study Design: Biomechanical. Objective: This study evaluates the biomechanical properties of lag-screws used in vertebral pincer fractures at the thoracolumbar junction. Methods: Pincer fractures were created in 18 bisegmental human specimens. The specimens were assigned to three groups depending on their treatment perspective, either bolted, with the thread positioned in the cortical or cancellous bone, or control. The specimens were mounted in a servo-hydraulic testing machine and loaded with a 500 N follower load. They were consecutively tested in 3 different conditions: intact, fractured, and bolted/control. For each condition 10 cycles in extension/flexion, torsion, and lateral bending were applied. After each tested condition, a computed tomography (CT) scan was performed. Finally, an extension/flexion fatigue loading was applied to all specimens. Results: Biomechanical results revealed a nonsignificant increase in stiffness in extension/flexion of the fractured specimens compared with the intact ones. For lateral bending and torsion, the stiffness was significantly lower. Compared with the fractured specimens, no changes in stiffness due to bolting were discovered. CT scans showed an increasing fracture gap during axial loading both in extension/flexion, torsion, and lateral bending in the control specimens. In bolted specimens, the anterior fragment was approximated, and the fracture gap nullified. This refers to both the cortical and the cancellous thread positions. Conclusion: The results of this study concerning the effect of lag-screws on pincer fractures appear promising. Though there was little effect on stiffness, CT scans reveal a bony contact in the bolted specimens, which is a requirement for bony healing.

Ein Therapiegerat zur entlastenden Gangschulung (in diesem Beitrag als Medical Balancer benannt) wurde entwickelt, um die Behandlung unter Teilbelastung der Extremitaten zu ermoglichen. In dieser Arbeit wurde untersucht, ob eine physiologische Entlastung des Fuses wahrend des Ganges bei einer eingestellten Teilbelastung von 15 kg, 30 kg und 45 kg nachweisbar ist. Insgesamt wurden 30 Probanden (20 Manner und 10 Frauen) im Alter von 20 bis 30 Jahren untersucht. Gemessen wurde der Druck an der Fussohle bei einer auf der Apparatur eingestellten Entlastung von 15 kg, 30 kg und 45 kg Teilbelastung. Es wurden pedographische Messungen mit Messsohlen im Schuh durchgefuhrt. Das System wurde fur jeden der 30 Probanden konfektioniert. Es erfolgte eine Unterteilung des Fuses in 10 Areale, gefolgt von einem Vergleich der einzelnen Areale des Fuses wahrend des Gehens bei Vollbelastung sowie bei Teilbelastungen von 15 kg, 30 kg und 45 kg. Die Ergebnisse zeigen eine Entlastung in allen 4 Phasen in den einzelnen Entlastungsstufen. Die Bereiche Ferse, Mittelfus, Ballen1, Ballen2 sowie Zehe1 erreichten die starkste Belastung wahrend des Gehens, lagen jedoch unter den festgelegten Teilbelastungswerten. Die Belastungsstufen 15 kg, 30 kg und 45 kg unterscheiden sich signifikant zur Vollbelastung mit p

Digitalisation now almost covers all areas of medical student teaching. Teaching videos are a good way to help students learn practical skills. The existing evidence is a recognised aid for the classification of the respective technology.This video presents the usual examination techniques of the shoulder joint on a patient with an unstable shoulder. The respective techniques, if available, were backed up with appropriate evidence.The examination techniques presented allow students to view them in a standardized manner on a patient. The evidence for the examination techniques can help with the classification of the respective technique.Die Digitalisierung erfasst inzwischen alle Bereiche der studentischen Lehre. Um die Studierenden im Erlernen praktischer Fertigkeiten zu unterstützen, sind Lehrvideos eine gute Methode. Für die Einordnung der jeweiligen Technik ist die vorhandene Evidenz eine anerkannte Hilfestellung.Das hier vorliegende Video stellt die üblichen Untersuchungstechniken des Schultergelenks an einen Patienten mit einer instabilen Schulter dar. Die jeweiligen Techniken wurden, wenn vorhanden, mit der jeweiligen Evidenz unterlegt.Die dargestellten Untersuchungstechniken ermöglichen es Studierenden, sich die Untersuchungstechniken standardisiert an einem Patienten anzuschauen. Die eingeblendete Evidenz für die Untersuchungstechniken kann hierbei eine Hilfestellung bei der Einordnung der jeweiligen Technik leisten.

Until recently, no study had compared the quality of life of persons with transfemoral amputation treated with osseointegration to socket prosthesis users.Comparison of quality of life in two types of prostheses users: a cohort of patients with osseointegration and patients equipped with a socket prosthesis who were group-matched for age, body mass index and mobility grade.A cross-sectional study that compared METHODS:: The quality of life of 39 participants (22 in the osseointegration group and 17 in the socket prosthesis group) was measured using the Questionnaire for Persons with Transfemoral Amputation (Q-TFA) and European Questionnaire 5-dimension 3-level (EQ-5D-3L) surveys.Compared with the socket prosthesis group, the osseointegration group had a significantly higher 'Global' score (p = 0.022) and a significantly lower 'Problem' score (p 0.001) of the Q-TFA. The 'Mobility' (p = 0.051) and 'Use' scores (p = 0.146) of the Q-TFA, the EQ-5D-3L index (p = 0.723), and EQ-5D visual analog scale (p = 0.497) showed no significant differences between groups.Patients with osseointegration experienced less prosthesis-associated problems than socket prosthesis users and had a higher prosthesis-associated quality of life when assessed with the Q-TFA. General quality of life, as assessed with the EQ-5D-3L, was not different between groups.

The German practical year is the last clinical placement period during Medical School. However, it remains unclear how medical students evaluate the practical year in orthopaedics and traumatology (Orthopädie und Unfallchirurgie; O U) and whether it has an impact on becoming an O U specialist.We analysed data of 146 medical students (46,7% female) who completed the placement in O U. From the evaluation, 37 items were included in the analyses. Participants who could imagine becoming an O U specialist (O U-Ja) following graduation were statistically compared to those who could not (O U-Nein).Overall 123 (83.7%) trainees indicated that they would like to become an O U specialist (O U-Ja), 18 (12.8%) negated (O U-Nein) and 6 (4.1%) were undecided. Groups did not differ for sex and age (sex: Chi² = 2.50, p = 0.114; age: F [1.93] 1, p = 0.764). Group differences were found for practical orientation, independency, acquisition of anamnesis and diagnostics skills and problem-solving expertise with students who could imagine becoming an O U specialist (O U-Ja) giving the highest ratings.Evaluations of the last medical year are essential in order to continuously improve the internship experience and to attract students towards a certain medical field and, moreover, to post-graduate specialist training. Clinics and institutions who already emphasize on the factors derived from this evaluation, or are continuously working on improvement, might be more able to attract young professionals, since personnel acquisition is starting early in the medical field.Das Praktische Jahr (PJ) ist die letzte Ausbildungsstation im Medizinstudium. Unklar ist sowohl die Praktikumswahrnehmung seitens der Medizinstudierenden als auch die Identifikation von Motivatoren für eine anschließende Weiterbildung in Orthopädie und Unfallchirurgie (O U).Wir analysierten die Angaben von 146 PJlern (46,7% weiblich), die ihr Tertial in O U absolviert hatten. Aus der Evaluation flossen 37 Items in die Analyse ein. Die Teilnehmer, die sich nach ihrem PJ vorstellen konnten, auch die Weiterbildung in O U zu absolvieren (O U-Ja) wurden getrennt von denen analysiert, die dies verneinten (O U-Nein) und miteinander verglichen.Insgesamt gaben 123 (83,7%) PJler an, auch ihre Weiterbildung in O U machen zu wollen (O U-Ja), 18 (12,8%) verneinten dies (O U-Nein), 6 (4,1%) waren noch unentschlossen. In Geschlecht und Alter unterschieden sich diese beiden Gruppen nicht (Geschlecht: Chi² = 2,50, p = 0,114; Alter: F [1, 93] 1, p = 0,764). PJler mit einer positiven Einstellung zur Weiterbildung in O U (O U-Ja) evaluierten ihr Tertial bei Praxisbezug, Selbstständigkeit, Sicherheit in Anamnese und Diagnosefindung und klinischen Problemlösungsfähigkeiten signifikant besser.Beurteilungen zur Zufriedenheit im Praktischen Jahr sind erforderlich, um diesen Studienabschnitt kontinuierlich zu verbessern und die Studierenden durch ein erfolgreiches PJ-Tertial für die Weiterbildung in diesem Bereich zu gewinnen. Womöglich werden Ausbildungsstätten, die die in dieser Evaluation gezeigten Faktoren bereits in der PJ-Ausbildung betonen, zukünftig eher in der Lage sein, den fachlichen Nachwuchs an sich zu binden, werden doch in der personellen Akquise die Weichen bereits sehr früh gestellt.

Osteosynthesis plate removal is one of the most commonly performed procedures in orthopaedic surgery. Due to technological advances and the quality of increasing osteosynthesis material, more and more locked plates have been implanted over the last 20 years. The aim of this study was to determine whether the complication rate during plate removal differs between conventional and locked plates.In this retrospective cohort study, 620 patients were included and divided into two groups based on the type of plate (locked and conventional). Technical complications during implant removal included screw breakage, destroyed screw head, implant breakage, remaining implant material, refracture, bony or soft tissue overgrowth. The following plate-associated complications were identified: osteosynthesis plate not detachable, plate bent or broken, necessity of special tools or plate loosened. Three types of screw-related complications were observed: screw not detachable, screw broken or screw dislocated.Overall, complications related to the plate or screws were documented in 110 of the 620 cases. These complications occurred in 48 of the 382 cases involving conventional osteosynthesis (7.7% of all removals, 12.6% of all conventional removals) and in 62 of the 238 cases involving locked plate osteosynthesis (10.0% of all removals, 26.1% of all locked plate removals). The statistical analysis showed a significantly higher implant-related complication rate with locked plates compared to the conventional plates (p 0.01).Hardware removal can be a complication-afflicted operation, especially cases involving locked-plate removal should only be performed if a strong indication is evident. Possible benefits of the procedure should be considered carefully, taking the cost-benefit ratio into account.

Hintergrund Ziel der Studie war ein Vergleich der Passform von durch Chirurgen individuell vorgebogenen Rekonstruktionsplatten mit der Passform von zwei neuen, anhand von CT-Datensatzen menschlicher Schlusselbeine entwickelten und bereits vorkonturierten Platten (VariAx Clavicle, Fa. Stryker GmbH & Co.KG, Duisburg).

Bei der Behandlung des Hallux rigidus im fortgeschrittenen Stadium werden neben der endoprothetischen Versorgung die Arthrodese und die Operation nach Keller-Brandes propagiert. In den Ergebnissen scheint die Arthrodese einen Vorteil gegenuber der Endoprothese zu haben. Durch die fortschreitende Entwicklung und aufgrund des gestiegenen Patientenanspruchs ist die Implantation einer Endoprothese weiterhin im Fokus der Diskussion. Vergleichende Studien zur Patientenzufriedenheit und zu klinischen Ergebnissen finden sich kaum. Zwischen 1995 und 2005 sind insgesamt 27 Patienten in einer chirurgischen Praxis mit insgesamt 28 Endoprothesen am Groszehengrundgelenk (Bio-Action Great Toe Implant, Fa OsteoMed, Addison, Texas, USA) versorgt worden. Das Durchschnittsalter der 27 Patienten betrug 63,7 Jahre. In der retrospektiven Studie erfolgte nach einer durchschnittlichen Nachuntersuchungszeit von 8,8 Jahren eine klinische und radiologische Kontrolle und die Patienten wurden anhand eines konzipierten Fragebogens nach der Zufriedenheit des Operationsergebnisses gefragt. Nach endoprothetischer Versorgung geben 15 (53,6 %) Patienten Schmerzfreiheit an und weitere 8 (28,6 %) berichten uber eine deutliche Schmerzbesserung. Zwolf (42,9 %) Patienten haben postoperativ keinerlei Aktivitatseinschrankung, weitere 5 (17,9 %) haben keine Einschrankung im taglichen Leben. Die maximale Gehstrecke ist bei 21 (75 %) Patienten postoperativ verbessert und das Gehen auf unebenem Gelande bei 24 (85,7 %) Patienten. Elf (39,3 %) haben postoperativ eine gute Beweglichkeit des Groszehengrundgelenks, 13 (46,4 %) geben eine leichte Einschrankung an. Vierundzwanzig der 27 Patienten sind mit dem postoperativen Ergebnis zufrieden bis sehr zufrieden, 22 Patienten wurden erneut eine endoprothetische Versorgung durchfuhren lassen. Der Wilcoxon-Test ergibt eine hochsignifikante Verbesserung des modifizierten AOFAS-Scores (American Orthopaedic Foot and Ankle Society) postoperativ gegenuber praoperativ. In 3 Fallen (11 %) ist es zu einer Luxation oder Lockerung der phalangealen Komponente gekommen, 2-mal erfolgte deshalb eine Revisionsoperation. Die Arthrodesebehandlung bei fortgeschrittenem Hallux rigidus hat in vielen Studien gute bis sehr gute Langzeitergebnisse ergeben. Die endoprothetische Versorgung kann durch einen erfahrenen Fuschirurgen bei strenger Indikationsstellung gute mittel- und langfristige Ergebnisse erreichen.

A biomechanical study was performed to test the hypothesis that a new anatomically preformed, thinner, soft-tissue protecting plate system for distal humeral fractures (Tifix®-hybridplate [HP]) would show comparable results in the quasi-static and dynamic testings compared to two conventional implants: The 3.5-mm reconstruction plate (RP) providing primary stability with normal bone mineral density (BMD), and a multidirectional locking plate (Tifix(®)-plate [P]) which can be used with poor bone quality.The Tifix(®)-HP was developed by the working group. The biomechanical testing was performed on a C2-fracture-model in 24 synthetic humeri. Three groups, each with eight bone-implant-constructs, were analysed in quasi-static and dynamic tests.The quasi-static measurements showed that under extension loading both locking plates (Tifix(®)-P, Tifix(®)-HP) were significantly stiffer than the reconstruction plate, and that the Tifix(®)-HP had a significantly lower stiffness than the two other implants under flexion loading. In the dynamic tests the Tifix(®)-P allowed significantly less fracture motion compared to the Tifix(®)-HP and the reconstruction plate. In an osteopaenic bone model locking plates failed only under much higher dynamic force than the reconstruction plate. The reconstruction plate and the Tifix(®)-P always failed through screw loosening, whereas the newly developed Tifix(®)-HP showed screw loosening in only one third of cases.The hypothesis that the newly designed plate system showed comparable results in the quasi-static and dynamic tests compared to the conventional implants with a significantly lower implant volume and thickness was confirmed.

Background Stability of threshold currents during long-term use of phrenic nerve stimulation has been questioned. Methods and Results Between January 5, 1988, and March 5, 2008, 49 patients with functional C2-tetraplegia received an Atrostim PNS (Atrotech Ltd., Tampere, Finland) as treatment of their respiratory insufficiency; a follow-up of 35 of such patients was carried out exclusively in our institution for 6.3 (4.44) 0.04–15.75 years (mean [standard deviation (SD)] range). The device employed four-pole sequential nerve stimulation, which provided four threshold currents subsequently evaluated for each phrenic nerve. Stimulation data were prospectively recorded. The differences between threshold currents recorded 1 year after implantation and the last recorded values were 0.33–0.43 (0.44–0.63) 0–2.9 mA. After having excluded the data of eight patients with values >1 mA (= mean + SD), we registered the differences for the remaining patients of 0.15–0.24 (0.14–0.24) 0–0.95 mA, which is just twice the adjustment accuracy of the device. Out of the eight problem cases one had, and two were suspected to have, surgical trauma; all three nerves recovered. In two cases the values steadily increasing over years might have been caused by unspecific foreign body reaction. Two cases with values >1mA for different durations at different electrodes might be caused by biofilm, and one patient displaying steadily increasing values lived, unwilling to live, only 2 years after the implantation. Conclusion Thus, there was no permanent nerve injury and in 77% of the presented cases threshold currents remained stable.

Introduction A prospective clinical investigation was carried out in order to clarify whether Matrix-associated autologous chondrocyte implantation (MACI) results in clinical improvement at long-term follow-up. Hypothesis MACI will result in clinical improvement at long-term follow-up. Study Design Case series; level of evidence, 4. Methods Thirty-eight patients were treated with MACI. These patients were evaluated for up to a mean of 16 years (range 15-17 years) after the intervention. Three different scores (Lysholm-Gilquist score, International Cartilage Repair Society score, and Tegner score) formed the basis of this study. Overall, we were able to obtain valid preoperative and postoperative results from 18 (47%) of 38 patients. In 1 patient, both knees were treated. In 4 patients, an arthroplasty was implanted over the course of time; thus they were excluded from this case series. In conclusion, follow-up of 15 knees was performed in the recent series. Results In subjective rating, 12 out of 14 patients (86%) rated the function of their knee as much better or better than before the index procedure. All numerical outcome scores showed significant improvement compared to the preoperative value (preoperative/postoperative at 5 years/postoperative at 15 years): Lysholm score 59.6 (±24.6)/78.6 (±21.5)/82.7 (±11.3), International Knee Documentation Committee score 50.6 (±22.7)/64.7 (±21.6)/69.7 (±18.7), Tegner score 3.0 (±2.2)/3.6 (±1.5)/5.2 (±1.7). Conclusion The significantly improved results on 3 scores after 15 years suggest that MACI represents a suitable treatment of local cartilage defects in the knee.

Anterior screw fixation has been widely adopted for the treatment of type II dens fractures. However, there is still controversy regarding whether one- or two-screw fixation is more appropriate.We addressed three questions: (1) Do one- and two-screw fixation techniques differ regarding shear stiffness and rotational stiffness? (2) Can shear stiffness and rotational stiffness after screw fixation be restored to normal? (3) Does stiffness after screw fixation correlate with bone mineral density (BMD)?We randomly assigned 14 fresh axes into two groups (seven axes each): one receiving one-screw fixation and another receiving two-screw fixation. Shear and torsional stiffness were measured using a nondestructive low-load test in six directions. A transverse osteotomy then was created at the base of the dens and fixed using one or two screws. Shear and torsional stiffness were tested again under the same testing conditions.Mean stiffness in all directions after screw fixation was similar in both groups. The stiffness after one- and two-screw fixation was not restored to normal: the mean shear stiffness restored ratio was less than 50% and the mean torsional stiffness restored ratio was less than 6% in both groups. BMD did not correlate with mean stiffness after screw fixation in both groups.One- and two-screw fixation for type II dens fractures provide similar stability but neither restores normal shear or torsional stiffness.One-screw fixation might be used as an alternative to two-screw fixation. Assumed BMD should not influence surgical decision making.

In recent years, decisions regarding the treatment of individual patients have increasingly been affected by economic considerations. The G-DRG system reimburses sledge endoprosthetic implantations at a much lower rate than surface replacements and at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, TKA produces higher gains. Taking only these revenues alone into consideration, however, does not provide the basis of an economically sound decision-making process. The target of this research was to present a comparison between variable costs of the two procedures.The mean cost and performance data of 28 Endo-Modell (Link company) sledge implantations (UKS) and of 85 NexGen CR surface replacement total knee arthroplasties (TKA; Zimmer company) were compared in 2007.From the perspective of the hospital, UKS treatment is of greater economic advantage when the medical indication is given. In preferring UKS marginal contribution can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of TKA. Based on the length of stay required for each procedure the average daily CW for UKS can be calculated as 0.1728, while being 0.1955 for TKA. The earlier release of the first patient results in another patient being admitted 1.5 days earlier and thus an increase in case mix. Meanwhile, the case-mix index and the costs of care per case decrease ceteris paribus.Assuming the correct medical indication, the hospital seeking to maximize its marginal contribution would be wise to select sledge endoprosthesis implantation. Considering the economic perspective of gains and costs, the assumption that TKA is advantageous could not be confirmed in the present study.

Development of novel implants in orthopaedic trauma surgery is based on limited datasets of cadaver trials or artificial bone models. A method has been developed whereby implants can be constructed in an evidence based method founded on a large anatomic database consisting of more than 2.000 datasets of bones extracted from CT scans. The aim of this study was the development and clinical application of an anatomically pre-contoured plate for the treatment of distal fibular fractures based on the anatomical database.48 Caucasian and Asian bone models (left and right) from the database were used for the preliminary optimization process and validation of the fibula plate. The implant was constructed to fit bilaterally in a lateral position of the fibula. Then a biomechanical comparison of the designed implant to the current gold standard in the treatment of distal fibular fractures (locking 1/3 tubular plate) was conducted. Finally, a clinical surveillance study to evaluate the grade of implant fit achieved was performed. The results showed that with a virtual anatomic database it was possible to design a fibula plate with an optimized fit for a large proportion of the population. Biomechanical testing showed the novel fibula plate to be superior to 1/3 tubular plates in 4-point bending tests. The clinical application showed a very high degree of primary implant fit. Only in a small minority of cases further intra-operative implant bending was necessary. Therefore, the goal to develop an implant for the treatment of distal fibular fractures based on the evidence of a large anatomical database could be attained. Biomechanical testing showed good results regarding the stability and the clinical application confirmed the high grade of anatomical fit.

Background The G-DRG system reimburses sledge endoprosthetic implantations (UKA) at a much lower rate than surface replacements (TKA), at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, the complete endoprosthesis implantation produces higher gains. An orientation on these revenues alone, however, does not provide the basis for an economically sound decision-making process. The aim of this study is to present a comparison of the variable costs of the two procedures. Material and methods The mean cost and performance data of 28 Endo-Model UKA implantations and of 85 NexGen CR TKA replacements were compared with each other in 2007. Results From the perspective of the hospital, when the correct medical indication is present, UKA treatment is of greater economic advantage. In this way the total unit contribution margin can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of the TKA. Conclusion For the desired maximisation of the unit contribution margin, assuming that it is the proper medical indication, the recommendation for the hospital would be implantation of the UKA. Considered from the economic perspective of gains and costs, the assumption that a TKA would be advantageous could not be confirmed in the present study.

Die Ruptur des vorderen Kreuzbandes (VKB) ist die haufigste Bandruptur des Korpers, die eine Operation nach sich zieht. Die Gutachten zur Zusammenhangfrage fuhren immer wieder zu Reibungen zwischen arztlichem Gutachter, auftraggebendem Trager der gesetzlichen oder privaten Unfallversicherung und Versichertem. Die Kriterien zur Beurteilung des Ursachenzusammenhangs nach VKB-Ruptur werden vor dem Hintergrund von Daten des eigenen Patientengutes und der Literatur diskutiert. Hierbei werden die unterschiedlichen Kausalitatsbegriffe der gesetzlichen und privaten Unfallversicherung erlautert. Die Bemessung der Leistung liegt im Rahmen der Begutachtung der gesetzlichen Unfallversicherung zumeist zwischen „unter 10–30 v. H.“. Die Einschatzung der Invaliditat in der privaten Unfallversicherung betragt haufig zwischen 1/10 bis 2/10 Beinwert, kann aber in Ausnahmefallen auch daruber liegen.

Claviculectomy is a rare and poorly described event in the surgical therapy of diseases of the clavicle. We present a case series and functional results of patients who underwent total claviculectomy.From 1995 to 2006 a total of 26 patients diagnosed with osteitis of the clavicle underwent surgery in our unit. Of these, five patients (all female) needed a total resection of the clavicle in order to ensure permanent healing from infection. The data collection was prospective. The data gathered preoperatively and at follow-up included clinical examinations, laboratory findings, radiographs and the Constant shoulder scores. The mean follow-up period was 7.5 months.The surgical concept described was able to eliminate infection in all cases studied within an average hospital stay of 13.4 days (8-18 days). Only one patient showed complications; suffering from chronic pain syndrome requiring surgical revision. After total resection of the clavicle four of five patients showed very good functional results. The average Constant score showed a significant increase from 82 before surgery to 95 at follow-up.The surgical technique described for total claviculectomy, along with the insertion of local antibiotic beads, was able to eliminate infection in every case. Good functional results and a low complication rates were observed. For good functional results and the permanent elimination of infection, adjacent joints have to be addressed, the periosteal tube should be preserved and early functional treatment is essential.

Bei den seltenen Frakturen und Luxationen in der Umgebung des Ellengelenks sind die fruhe Diagnose und adaquate Therapie eminent wichtig. Die distalen Humerusfrakturen Typ B und C nach AO (Arbeitsgemeinschaft fur Osteosynthesefragen) gehen gehauft mit neurologischen Verletzungen einher und werden in der Regel osteosynthetisch versorgt. Auch die Klassifikation nach Schatzker, die das am besten geeignete Osteosyntheseverfahren berucksichtigt, findet bei Olekranonfrakturen Anwendung. Frakturen des Processus coronoideus sind sehr haufig mit Ellenbogenluxationen vergesellschaftet und werden nach Regan und Morrey eingeteilt. Sie werden je nach Frakturtyp und Stabilitatsgrad des Gelenks konservativ oder operativ behandelt. Radiuskopfchenfrakturen werden nach Mason eingeteilt. Die einfache Frakturform kann konservativ behandelt werden, dislozierte sowie Mehrfragmentfrakturen erfordern eine Osteosynthese oder eine partielle bzw. komplette Resektion. Bei Gelenkinstabilitat nach Resektion kann eine Radiuskopfchenprothese notwendig werden. Gesondert wird auf Monteggia-, Essex-Lopresti- und „terrible triad“-Verletzungen eingegangen. Ein luxierter Ellenbogen muss rasch in Analgosedierung reponiert werden.

Derzeit wird ein Grosteil der in den Querschnittgelahmtenzentren erbrachten Leistungen mit krankenhausindividuell gestalteten Vertragen vergutet. Dies hat sich aufgrund der Inhomogenitat der Patientengruppen und der Verschiedenartigkeit der krankenhausspezifischen Leistungsangebote als sinnvoll erwiesen. Der Versuch, auch kleinste heterogene Patientengruppen in Fallpauschalen (DRG: „diagnosis related groups“) zu integrieren, gefahrdet die qualifizierte nachhaltige Versorgung gerade der am schwersten betroffenen Patienten.

Background The suture-bridging technique is a new arthroscopic technique to repair rotator cuff tears. Biomechanical advantages compared with double-row fixations have been described. Hypothesis The authors hypothesized that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation. Study Design Case series; Level of evidence, 4. Methods Fifty-one consecutive patients, with a median age of 62 years (range, 37-76 years), who had undergone an arthroscopic suture-bridging repair of an isolated supraspinatus tendon tear were evaluated in this prospective study 4, 12, and a median of 24 months postoperatively. Subjective and functional outcome was assessed using the simple shoulder test and Constant score. With magnetic resonance imaging 12 months postoperatively, the tendon integrity and potential predictors of failures were evaluated. Results The simple shoulder test scores improved significantly from 9 points (range, 1-12 points) at 4 months, to 12 points (range, 1-12 points) at 12 months, and 12 points (range, 5-12 points) at 24 months postoperatively. The Constant score increased significantly from preoperative 64% (range, 37%-92%) to 82% (range, 36%-100%) at 4 months, 96% (range, 49%-100%) at 12 months, and 96% (range, 64%-100%) at 24 months postoperatively. Magnetic resonance imaging 12 months after surgery showed retears in 28.9%. Two different types of retears could be observed: insufficiently healed and medially retorn supraspinatus tendons. The Constant score did not differ significantly between the groups with retears and intact repairs. A patient age of more than 60 years was found to influence tendon healing significantly. Conclusion The hypothesis, that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation, could not be confirmed. The functional outcome after the new suture-bridging technique was good and comparable with the reported results after double-row repair from the literature. A structural failure of tendon repair was not identical to clinical failure.

Bei Rotatorenmanschettenrupturen stellen vor allem massive Defekte auf dem Boden degenerativer Muskel-Sehnen-Veranderungen ein Problem dar. Der Delta-Flap bietet eine relativ simple Methode der operativen Versorgung, die insbesondere bei alteren Patienten eine rasche Linderung der starken Schmerzen verspricht. Von 01/2003 bis 06/2003 wurden an unserer Institution 23 Patienten mit einer Delta-Flap-Rekonstruktion versorgt. Insgesamt konnten 20 Patienten, 15 Manner und 5 Frauen, mit einem Durchschnittsalter von 62 Jahren (Spannweite 53–82) in die Studie eingeschlossen werden. Die Follow-up-Periode nahm im Durchschnitt 42 Monate (Spannweite 25–74) ein. Die Nachuntersuchung beinhaltete eine klinische Untersuchung, eine Magnetresonanztomographie (MRT) sowie eine Beurteilung mittels Constant Murley Score und Simple Shoulder Test. Im Constant Murley Score wiesen 13 Patienten ein gutes, 5 ein befriedigendes und 2 ein schlechtes Ergebnis auf. Der praoperative Constant Murley Score verbesserte sich signifikant von durchschnittlich 25,7±5,3 Punkten auf 72,3±7,8 Punkte bei der Nachuntersuchung. Es konnten eine deutliche Schmerzlinderung und Verbesserung der Schulterfunktion eruiert werden. Die Kernspintomographie zeigte bei allen Patienten eine subakromiale Bedeckung der Defekte. Der Delta-Flap stellt sich intakt dar. Jedoch wiesen alle Delta-Flaps einen bindegewebigen Umbau sowie eine fettige Degeneration und Atrophie auf. Wir sehen daher den Delta-Flap bei grosen Rotatorenmanschettendefekten des alten Patienten als Alternative zum einfachen Debridement. Die klinischen Ergebnisse sind ermutigend und auch die kernspintomographischen Untersuchungen sprechen fur ein Verfahren, das Bestandteil im Versorgungsprofil von Operateuren sein sollte, die Schulterchirurgie betreiben.

Purpose:This prospective case series evaluates the outcome, and the return to sports of young overhead athletes with a persistent, symptomatic multidirectional instability (MDI) with hyperlaxity type Gerber B5 treated with an arthroscopic anteroposteroinferior capsular plication and rotator interval closure.Methods:9 young overhead athletes (10 shoulders) with the rare diagnosis of MDI (Gerber B5) and an indication for operative treatment, after a failed physiotherapy program were physically examined 3, 6 and 12 months postoperatively by a physical examination, and got a final phone interview after median 39 months.Results:At the final follow-up all patients were satisfied; Rowe Score showed 7 “excellent” and “good” results; Constant Score was “excellent” and “good” in 6, and “fair” in 1 patient. 7/9 returned to their previous sports, 3/9 at a reduced level.Conclusion:Symptomatic MDI requires an individual indication for surgical treatment after a primary conservative treatment. The described arthroscopic technique stabilizes glenohumeral joint. A return to overhead sports is possible but often at a reduced level; returning to high-performance sports cannot be recommended because of the high risk of reinstability.

Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I-IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3-5 days. Gustilo II patients needed an average of 1.1 (0-3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0-16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3-28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up.

Twenty-eight patients with 31 closed fractures (27 acute fractures and four with malalignment after conservative treatment) of the metacarpal bones 2-5 were treated with only one elastic stable intramedullary nail and followed prospectively. Treatment protocol was without immobilization or physiotherapy. These patients were reviewed at a mean follow-up time of 15 months for ultrasound results as well as functional outcome concerning complications, pain, range of motion, and grip strength measured with a Vernier-Dynamometer. Satisfaction of the patients was investigated by Clients Satisfaction Questionnaire. Radiographs before nail removal, ultrasound, and clinical examination always showed complete union of the fracture without deviation of axis. All patients gained full range of motion without any limits in daily activity and sports. There was no loss of grip strength compared with the other hand. Patients' satisfaction was very high, especially because of almost no postoperative pain and lack of immobilization. This method can be offered as an effective and safe alternative in the treatment of closed displaced fractures of the 2-5 metacarpus without significant complications.

AIM The purpose of this study was to evaluate postoperative outcome and functional scores after single bundle anterior cruciate ligament (ACL) reconstruction with the use of quadriceps tendon autografts after a 16 (12-24) month follow-up. METHOD 54 patients (9 women, 45 men, body mass index [BMI] 25.3 [18.1-36.3 kg/m (2)]) were included in this prospective series, treated between January 2004 and December 2005. Ligament stability was assessed with the Lachmann and pivot-shift tests and a KT 1000 arthrometer. Tegner index, Lysholm-Gilquist score and the International Knee Documentation Committee (IKDC) were employed to evaluate the functional outcomes. In addition, the single leg hop test was performed. RESULTS Ligament arthrometry using the KT 1000 arthrometer demonstrated a mean side-to-side difference of 1.53 mm (0.2-4.1 mm). Regarding the Lachmann test, 17 patients (32%) showed 1+ laxity and no patient had an abnormal pivot-shift. The mean Tegner activity score was 4.22 (1-10), the mean Lysholm score was 80.8 (20-100) and the mean IKDC score 68.1 (29-87). Results of the single leg hop test revealed a mean decline of the treated leg to 87.7% (70-100%) of the contralateral side. The mean extension was reduced by 1.7 degrees (0-10 degrees) on the treated knee and the flexion by 2.1 degrees (0-10 degrees), compared to the contralateral knee. CONCLUSION Single bundle anterior cruciate ligament reconstruction using quadriceps tendon demonstrates highly satisfactory results. Due to a moderate donor site morbidity and preservation of the medial stabilizing structures of the knee a wider use in primary cruciate ligament reconstruction may arise in the future.

Zusammenfassung Die Lapidusarthrodese ermoglicht die korrigierende Stabilisierung des ersten Strahls bei mittel – bis schwergradiger Hallux valgus Fehlstellung. Auch wenn der Begriff der Instabilitat des ersten tarsometatarsalgelenks (TMT I) in der Literatur noch nicht eindeutig und reproduzierbar definiert werden konnte, erscheint deren Berucksichtigung fur die Korrektur des Hallux valgus bedeutsam. Die Einfuhrung der winkelstabilen Plattenosteosynthese hat zu einer fruheren Belastbarkeit der Arthrodese bei gleichzeitiger Verringerung der Pseudarthroserate gefuhrt. Es werden die modernen Techniken der Durchfuhrung dieser Operation sowie die Ergebnisse und Komplikation eines konsekutiven Patientengutes einer spezialisierten Fachklinik vorgestellt.

Operative therapy of intraarticular fractures of the calcaneus is an established surgical standard. The aim is an accurate reduction of the fracture with reconstruction of Boehler’s angle, length, axis and subtalar joint surface. Intraoperative 3D-fluoroscopy with the Siremobil Iso-C 3D® mobile C-arm system is a valuable assistant for accurate reconstruction of these anatomical structures. Remaining incongruities can be recognized and corrected intraoperatively. The achieved reduction can be fixed by the advantages of an internal fixator (locked-screw plate interface). In the period of October 2002 until April 2007 we operated 136 patients with intraarticular fractures of the calcaneus by means of anatomical reduction, and internal plate fixator under intraoperative control of 3D-fluoroscopy. All patients were supplied with an orthesis after the operation which allowed weight bearing of 10 kg for 12 weeks for the patients operated between October 2002 and October 2004 (Group A). Transient local osteoporosis was observed in all X-Rays at follow-up after an average of 8,6 months. Therefore we changed our postoperative treatment plan for the patients operated between November 2004 and April 2007 (Group B). Weight bearing started with 20 KG after 6 weeks, was increased to 40 KG after 8 weeks and full weight bearing was allowed after 10 weeks for these patients. In no case a secondary dislocation of the fracture was seen. No bone graft was used. At follow up the average American Foot and Ankle Society Score (AOFAS) were 81 for Group_A, compared to 84 for Group B, treated with earlier weight bearing. Autologous bone graft was not necessary even if weight bearing was started after a period of six weeks postoperatively. The combination of 3D-fluoroscopy with locked internal fixation showed promising results. If the rate of patients developing subtalar arthrosis will decrease by this management will have to be shown in long term follow up.

A procedure previously been described that has an effect on the image quality and radiation dose of conventional radiographs already at the time of acquisition [Paech A, Schulz AP, Hahlbrauck B, Kiene J, Wenzl ME, Jürgens C. Physical evaluation of a new technique for X-ray dose reduction: measurement of signal-to-noise ratio and modulation transfer function in an animal model. Physica Medica 23 (2007):33-40]. This development is using X-ray sensitization by optical re-exposure. Aim of this study was to establish if the results of optical re-exposure measured with SNR and MTF also meant that the subjective quality of 50% dose-reduced and re-exposed radiographs of bony structures was equal or better than conventional full dose radiographs of the same area. Freshly slaughtered anterior shoulders of lambs served as the animal model. A comminuted fracture in the middle of the shaft was artificially produced. After taking a normal exposed reference image, dose-reduced, five underexposed images were prepared. These underexposed X-rays were then optically re-exposed for a defined period of time before development. The subjective changes in the image quality (information loss or gain) of the images were compared to the reference image and evaluated by 16 physicians with large experience in diagnosis of orthopedic radiographs. The evaluation of the observers scoring showed a significant decrease in the subjective image quality regarding the detail recognition in all images apart from the images re-exposed for 60s. In conclusion, there is a possibility of reducing the collective radiation dose whilst keeping a high degree of diagnostic reliability. Film sensitization provides a technically simple and inexpensive procedure, which can be easily integrated into common film development processes and could considerably reduce patient radiation exposure as well as improve image quality and thus detail recognition.

Schmerzreduktion und Zunahme der Beweglichkeit im Grosszehengrundgelenk. Bei der Resektionsarthroplastik nach Valenti werden mechanisch storende und degenerativ veranderte Anteile des Metatarsale-I-Kopfchens und der Grundphalanx der Grosszehe unter Erhalt des Ansatzes der kurzen Beugesehne entfernt. Die Beweglichkeit des Grosszehengrundgelenks wird deutlich verbessert, und das Gelenk wird in seiner Funktion erhalten. Schmerzhafter Hallux rigidus im Stadium 2–3 nach Vanore. Ruckzug nach fehlgeschlagener Endoprothese am Grosszehengrundgelenk. Hallux rigidus im Stadium 4 nach Vanore. Erhebliche Elevationsstellung des ersten Mittelfussstrahls. Die Operation erfolgt bevorzugt in Blutleere. Dorsomediale Hautinzision uber dem Grosszehengrundgelenk. Darstellung und Langsinzision der Gelenkkapsel. Resektion der medialen und lateralen Osteophyten am Metatarsale I und an der Grundphalanx. Mobilisierung der Sesambeine. V-formige Resektion der dorsalen Osteophyten am Metatarsale I und an der Grundphalanx in einer Ebene von 45°. Die intraoperative Dorsalextension sollte mindestens 75° betragen. Abschliessend sanduhrformige Interposition der Gelenkkapsel in Gelenkhohe. Aktive und passive Krankengymnastik unmittelbar nach der Operation. Sofortige Vollbelastung. Pronierender Tapeverband bei ausgepragter Schonhaltung des Fusses. Thromboseprophylaxe fur 1 Woche. Bei der klinischen und radiologischen Nachuntersuchung von 162 Patienten mit einem Nachuntersuchungszeitraum von mindestens 2 Jahren (24–38 Monate) zeigte sich eine Steigerung der Dorsalextension um durchschnittlich 27°. Bei 80% der Patienten wurde eine vorubergehende Schmerzsymptomatik im Bereich der Sesambeine beobachtet. Von zwolf Patienten mit fortschreitender Arthrose erhielten zehn im Verlauf eine Endoprothese und zwei eine Arthrodese des Grosszehengrundgelenks als Zweitoperation. Klinisch zeigte sich eine deutliche Verbesserung der schmerzfreien Dorsalextension. Im Literaturvergleich war die Verbesserung ausgepragter als bei der traditionellen Cheilektomie. Die Arthrodese oder Endoprothesenimplantation am Grosszehengrundgelenk konnte primar vermieden werden.

Die subkapitale Humerusfraktur macht etwa 5% aller Extremitatenfrakturen aus, 75% der Betroffenen sind uber 65 Jahre alt. Die Frakturen werden nach der Neer-Klassifikation eingeteilt. Bei gering dislozierten und stabilen Frakturen sind durch konservative Behandlung in der Regel gute funktionelle Ergebnisse erzielbar. Die Indikationsstellung zur operativen Versorgung berucksichtigt verschiedenste Parameter, die teils patienten-, teils frakturabhangig sind. Eine ausreichende praoperative Diagnostik samt Bildgebung ist Grundvoraussetzung fur ein optimales postoperatives Ergebnis. Die korrekte Rekonstruktion der Rotatorenmanschette ist zwingend erforderlich. Ahnliches gilt hinsichtlich der fragilen Blutversorgung des Humeruskopfes, fur welche eine intakte mediale Periostverbindung entscheidend ist. Bei der Wahl der Versorgungsform – Osteosynthese mittels proximalem Humerusnagel, Plattenosteosynthese oder Endoprothese – sollten neben Frakturtyp, -stellung, Zahl der Fragmente usw. auch individuelle Besonderheiten des Patienten selbst sowie dessen Anforderungen berucksichtigt werden, um eine optimale Versorgung zu erreichen.

To analyse the results of the treatment of aseptic femoral non-unions using a singular locked implant. Consecutive case series. A level-1 trauma center with a high number of specialist referrals. The study is based on a consecutive series of patients with prospective data evaluation. From 1993 to 2003, 75 patients were treated with a wave plate. All patients had persistent non-union of the femoral shaft without clinical or laboratory signs of infection and previous unsuccessful attempts to treat the non-union. The method of treatment was standardized and included a lateral approach, cancellous bone hip grafting, osteosynthesis with a wave-shaped plate (PPF) and polyaxial locking screws as well as the application of a gentamicin-PMMA chain. Time to achieve union, rate of implant failure and number of remaining nonunions after treatment. A total of 75 patients had full follow-up and were included in the study. The union of the fracture was found in 64 patients after the initial procedure. In eight cases a second procedure was performed to achieve union in the form of a second bone graft because of a delay in callus formation. The mean time to union was 7.3 months with a range from 3 to 19 months. The implant failed in three cases accounting for 4% of the total. The locked wave plate offers a further reliable treatment for complex aseptic femoral non-unions.

Background A computerized robotic surgical system was developed from 1986 by the Thomas J. Watson Research Center. In 1992 the system unit Orthodoc® and the milling robot Robodoc® were first used on humans. We present the results achieved with Robodoc-assisted total hip arthroplasty in 97 hips. Methods Between 1997 and 2002, 143 total hip replacements (128 patients) were performed using the Robodoc system. This is a consecutive series. Complete follow-up was possible in 97 hips at a mean follow-up period of 3.8 years. Results Technical complications directly related to the robotic device occurred in nine cases (9.3%). The pre-operative Merle d'Aubigne score was determined at 8.1 points compared to a post-operative mean score of 16.2. There was no sign of femoral stem loosening on radiographs. Conclusions Robotic-assisted total hip arthroplasty with the Orthodoc/ Robodoc system achieves equal results as compared to a manual technique. However, there was a high number of technical complications directly or indirectly related to the robot. Copyright © 2007 John Wiley & Sons, Ltd.

Aim of this study was to record objective changes in image quality of optically re-exposed, radiation-reduced X-ray images in comparison to a normally exposed reference image in an animal model. Under investigation is the question if optical re-exposure of conventional, radiation-reduced X-ray images partially or even fully compensates the loss of information caused by underexposure. Dose-reduced, underexposed images were prepared by reducing the mAs product to 50% with constant anode voltage. Reproduction of the image was performed with a 52% decrease in the radiation dose. Comparing different re-exposure times, the optimal time was found to be 60 s. These underexposed X-rays were then optically re-exposed for a defined period of time before development. In all X-ray images of the animal model, different osseous structures were defined as regions of interest (ROI) for evaluation of the objective changes in image quality. The density curves were plotted with the two-beamed densitometer. The contrast transfer factors as the function of local frequency were determined from this, which served as the basis for calculating the modulation transfer factor. To establish if X-ray sensitisation by optical re-exposure leads to a change in the sensitometric gradation, the sensitometric curves were determined using a standardized aluminum scale and thermal luminescence dosimetry. In the comparison the lowest correlation with the standard technique film (X-ray 1) was seen in the purely dose-reduced X-ray. In the range of 1.6–3.4 Lp/mm, both SNR curves have an identical course. Despite a 52% dose reduction in the re-exposed image, both densitometry curves of the conventional and re-exposed X-ray show an almost identical distribution of the transmittance levels. In conclusion film sensitisation provides a technically simple and inexpensive procedure, which is easily integrated into previous film development processes and considerably reduces the patient radiation exposure as well as clearly improving the image quality.

Background A robotic system for the implantation of a total hip arthroplasty (THA) is currently under development. One of the goals of this system is non-invasive patient fixation, aiding the robotic system by an infrared tracking system. To determine the extent of fixation that can be achieved by non-invasive methods, an in vitro study was performed. Methods In cadaver testing, different non-invasive fixation methods (Arthrex leg holder with tourniquet mechanism; arthroscopic leg holder with disposable foam inserts; gynaecological leg holder; Goepel knee crutch) were evaluated under load in different directions. Results Deviation was measured in the range 0.33–18.1 mm with up to 20 N load. The testing showed the pneumatic leg holder system to provide the highest stability, followed by an arthroscopic leg holder system with foam inserts. Conclusions Use of a leg holder with foam inserts produced a stability that should enable tracking of the remaining deviation by the navigation system. We will therefore use this method in our future development of the robotic milling tool. Copyright © 2007 John Wiley & Sons, Ltd.

The operative therapy of intraarticular fractures of the calcaneus is now an established surgical standard. The aim is an accurate reduction of the fracture with reconstruction of the Boehler’s angle, the length and the subtalar joint. Intraoperative 3D-fluoroscopy with the Siremobil ISO-C-3D® mobile C-arm radiography system is a valuable assistant for the accurate reconstruction of these anatomical structures. Remaining incongruities can be recognized and corrected intraoperatively. The achieved reduction can be safely fixed by the advantages of an internal fixator (lockedscrew plate interface). In the period from October 2002 until October 2004, we operated 58 patients with intraarticular fractures of the calcaneus by means of anatomical reduction, an internal plate fixator under intraoperative control of 3D-fluoroscopy. In 22 cases the intraoperative 3D-fluoroscopy uncovered remaining incongruity over 1 mm, which could be corrected. The Boehler’s angle was raised on average by 16°. In no case a secondary dislocation of the fracture was seen.

Thoracic gunshot injuries are relatively rare in Western European Trauma Departments. In the case of a thoracic gunshot wound it is vital to establish if mediastinal structures are damaged. Non-mediastinal injuries often only require tube-thoracostomy followed by close observation. We report a case were the localisation of the gunshot wound together with the initial X-ray were suggestive of a transmediastinal injury pattern. A helical CT-scan could exclude this. A forensic reconstruction was performed retrospectively; the most likely chain of events and injury pattern is explained.

Resorbable materials have gained a considerable position in the daily routine of all surgical disciplines. Natural products like catgut and collagen have been used historically. Since the development of synthetical macromolecules more than 40 years ago, the range of indications for the use of such materials has widened significantly in our daily routine. Suture materials, mesh, tissue pads, clips, screws and anchors are in use. More recent developments in the field of orthopedic and trauma surgery include screw-plate systems, wound dressing materials and films for the prevention of adhesions and ossifications. This appears to be the beginning of an era of new materials as these implants not only fulfil a temporary biomechanical role but in theory also can release a controlled amount of biologically active substances at a set timeframe. Also they are potential carriers for transplants on a cellular level. This aspect will be of importance in the orthopedic field, where resorbable films only play a minor role so far. At the moment there are six resorbable or biodegradable films or foils on the market that are used or can be used in the field of orthopedic and trauma surgery. These are foils and films made of following materials: carboxy-methyl-cellulose and hyaloronic acid (Seprafilm®), oxydized regenerated cellulose (Interceed®), polydioxanon (PDS®) and copolymers of lactid und caprolacton (Topkin®, Oprafol®, Mesofol®). Main indications for their use are wound dressing, especially after split skin graft and thermal wounds, prophylaxis of adhesions and prevention of the formation of synostoses and heterotopic ossifications. The results of clinical trials are promising and the increasing number of publications in the last 5 years in this field is an expression of increasing demand of these materials. However, it could also be an expression of the growing interest in drug delivery techniques as well as in tissue engineering which are possible with these materials.

Winkelstabile Plattenfixateur-interne-Systeme haben in den letzten 20 Jahren zunehmend an Bedeutung gewonnen. Die aus der Winkelstabilitat resultierende flachenhafte Krafteinleitung und gleichmasigere Kraftverteilung fuhren zu einer besseren Knochenbruchheilung insbesondere im metaphysischen Bereich und bei Osteoporose. Bei Marknagelsystemen ist die Winkelstabilitat bislang nur partiell verwirklicht. Der vorgestellte winkelstabile Tibiamarknagel realisiert an jedem einzelnen Bolzen eine Winkelstabilitat mit dem einliegenden intramedullaren Krafttrager. Von Februar 2002–August 2004 wurden 21 Patienten mit ihm behandelt. In 13 Fallen wurden Frakturen stabilisiert, 6 Patienten hatten Fehlstellungen, 2 Patienten Pseudarthrosen. Zum Nachuntersuchungszeitpunkt waren alle Behandlungen abgeschlossen. Postoperative Komplikationen traten nicht auf. In allen Fallen wurde eine vollstandige Durchbauung erreicht. In 6 Fallen fand sich radiologisch eine verzogerte Knochenbruchheilung. Die ersten klinischen Erfahrungen mit dem winkelstabilen Tibiamarknagel zeigen, dass dieser aufgrund der hoheren Primarstabilitat insbesondere im metaphysaren Knochenbereich mit kurzen Fragmenten sowie bei Osteoporose Vorteile gegenuber anderen nichtwinkelstabilen oder nur partiell winkelstabilen Marknagelsystemen erbringt. Die verzogerten Knochenbruchheilungen bedurfen weiterer klinischer und biomechanischer Untersuchungen.

Medial clavicle fractures are the least common type of clavicular fractures. Although rare, such injuries deserve rapid diagnosis and effective treatment to avoid future complications. An optimal, standardized operative treatment has not been yet established. We report a case of medial clavicle fracture, where primary operative treatment was indicated due to gross dislocation. An open reduction and osteosynthesis with a modified hook plate was performed, leading to an excellent postoperative outcome after a sixteen-month follow-up. The hook plate seems to be a promising approach for the operative treatment of medial clavicle fractures.

Arndt P Schulz,1 Vivien Lange,2 Justus Gille,1 Christine Voigt,3 Susanne Fröhlich,4 Markus Stuhr,1 Christian Jürgens5 1Department of Orthopedics, Trauma, and Sports Medicine, University Hospital Lübeck, Lübeck, Germany; 2Department of Rehabilitation, Sana Regio Klinikum, Wedel, Germany; 3Department of Sports Medicine and Arthroscopy, Diakoniekrankenhaus Friederikenstift, Hannover, Germany; 4Department of Orthopedics, University of Rostock, Rostock, Germany; 5Department of Orthopedics, Trauma, and Sports Medicine, BG Trauma Hospital Hamburg, Hamburg, Germany Introduction: Although known as a possible graft option for decades, quadriceps tendon grafts have often been termed a second-line graft option. We report a consecutive case series using this method as the primary treatment line. The rationale for this study was to evaluate the midterm results of this method in a prospective and consecutive case series. The primary study question was to determine the clinical results 24–36 months after primary anterior cruciate ligament (ACL) reconstruction using a bone plug-free quadriceps tendon autograft fixed with bioabsorbable cross-pins. Materials and methods: The study population included 55 patients, of whom 24 were female (43.6%). The mean age at the index procedure was 31.7 years (15–58 years). All patients received an ACL construction using a bone block-free quadriceps tendon graft fixed with resorbable cross-pins. The postoperative regimen included partial weight-bearing for 3 weeks and flexion limited to 90° for six weeks; an orthosis was not used. The mean follow-up duration was 29.5 months (24.3–38.5 months) after the index procedure. The International Knee Documentation Committee (IKDC) subjective score and examination form was assessed, as well as the Lysholm and Gillquist score and the Tegner activity index. The Rolimeter arthrometer was used to assess the anterior laxity of the knee. Results: Graft harvesting was possible in all cases; a bony extension was never required. On average, graft length was measured at 8.8 cm (7.5–10 cm). The mean IKDC subjective score at follow-up was 80.44 points (55.17–100 points, standard deviation [SD] 12.05). The mean preinjury Tegner activity index was 4.98 (2–7) compared to a mean value of 4.16 (2–7, SD 0.8) at follow-up. There was a mean loss of 0.82 index points. The average Lysholm and Gillquist score was 89 points (65–100, SD 17.7). Of the results, 89.1% were in the good or very good groups; in one case (1.8%), the result was poor, while the rest were fair. Conclusion: ACL reconstruction using a bone plug-free quadriceps tendon autograft achieved satisfactory results in a midterm review. Keywords: ACL reconstruction, arthroscopic treatment, quadriceps tendon, clinical case series

Reconstructive osteotomies for the treatment of Hallux valgus are among the most prevalent procedures in foot and ankle surgery.The combination of biodegradable materials with an innovative method for fixation by application of ultrasonic energy facilitates a new bonding method for fractures or osteotomies. As clinical experience is still limited, the aim of this study was to assess the safety and performance of the SonicPin system for fixation of Austin/Chevron osteotomies.Chevron osteotomy was performed on 30 patients for the treatment of Hallux valgus. The used SonicPins were made from polylactide and are selectively melted into the cancellous bone structure during insertion by ultrasonic energy. Patients were followed for one year, which included X-ray and MRI examinations as well as evaluation of life quality by EQ-5D (EuroQol).The MRI after three months showed adequate bone healing in all cases and no signs of foreign body reactions, which was again confirmed by MRI 12 months postoperatively. The bony healing after 12 months was uneventful without any signs of foreign body reactions.In summary, based on the low complication rate and the significant improvement in health related quality of life (EQ-5D) reported in this study, fixation of an Austin/Chevron osteotomy with a SonicPin for treatment of Hallux valgus can be considered to be safe and efficient over the short term.Level of Clinical Evidence:Therapeutic Level III.

Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital’s, moreover operating department’s perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital’s, especially treating department’s rather than the society or healthcare insurance’s perspective. The average direct cost incurred by the hospital for a THR revision was €4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital’s indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider’s perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.