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Juxta- and intraarticular fractures of the knee (floating knee), intraarticular fractures with severe soft tissue damage and knee dislocations with vascular or soft tissue lesions are defined as complex knee trauma. A specific management protocol is required for these cases. Fractures should be treated with soft-tissue sparing minimal invasive reduction and fixation techniques to reduce the significant complication rate which is presently encountered. Percutaneous plate fixation, percutaneous screw osteosynthesis and hybrid fixation should be widely used in these cases. In knee dislocation, the central pivot with the two cruciate ligaments should be reconstructed using augmented repair or primary tendon grafting in every case, whereas the treatment of collateral ligament lesions depends on the specific injury type.

The treatment of joint injuries has seen a marked development in the last years. The surgical trauma of articular reconstruction was reduced and our deeper understanding of the mechanism of connective tissue healing influenced the rehabilitation program after joint injuries significantly. Indirect soft-tissue sparing reduction techniques can be applied to most joint fractures and improved fixation techniques using intraoperative fluoroscopy or arthroscopy allow to avoid vast exposures of the joint. The process of ligament healing requires joint movement and a certain stress to the healing tissue in order to achieve optimum scar strength, stiffness and remodeling. Immobilisation thus should be avoided completely after ligament injuries and certain lesions can be treated non-operatively with a high success rate (MCL rupture, ankle sprain, elbow dislocation). In other injuries, surgery should stabilize the joint thus allowing functional rehabilitation (cruciate ligament tears, shoulder dislocation).

Nail, plate and external fixator are since decades the most frequently and stabilizers for the surgical treatment of dia- and metaphyseal fractures. These elements are still present today. However, there were important changes in recent years. Together with better knowledge and understanding of fracture healing, fracture biology, implant metallurgy and mechanics and a more and more specified application of these techniques, this resulted in improved possibilities for the treatment of injured patients. Beside an overview about the current discussion of unreamed and reamed nail insertion new trends, techniques and nails are presented for the different long bones (retrograd nails, spiral blade, flex-nail humerus and a distal aiming device (DAD) for interlocking screws). In addition, new approach techniques for nailing (stab incision) and minimally invasive percutaneous plate osteosynthesis (MIPO) for metaphyseal fractures of the proximal and distal femur and proximal tibia are described including the necessary techniques for control of axes and rotation.

Complex joint trauma is a term reserved for specific and severe injuries that include two or more structural elements of the joint. These structural elements are the articulating bones, the major ligaments of the joint, the local soft tissue envelope and the neurovascular structures. Complex joint trauma has a high risk for complications and requires a special treatment algorhythm. A staged surgical protocol with initial soft tissue debridement, closed joint reduction and external fixation of the extremity followed by secondary reconstructive surgery after soft tissue recovery is suggested.

Therapy and prognosis of the slipped capital femoral epiphysis are discussed in connection with the results obtained in the authors' own patients. Reduction of a dislocated femoral head is always desirable. If closed reduction fails, it will be necessary to reduce in full view. In smaller children, fixation is effected by means of several Kirschner wires, in older ones via screw osteosynthesis. Bone pegging or osteotomy are not suited for treatment of an acute or subacute slipped capital epiphysis.

The initial stability of a reconstruction of an acute rupture of the ACL may be improved by a biodegradable augmentation with polydioxanon. This technique provides sufficient stability for a functional aftertreatment in a knee brace. The functional results of ACL reconstruction may be improved by this concept.

OBJECTIVE To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures. DESIGN Prospective, cohort study. SETTING Level I university trauma center. PATIENTS We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. INTERVENTIONS In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized. MEASUREMENTS AND MAIN RESULTS From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively. CONCLUSIONS Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.

Fragestellung. Analyse des Verletzungsmusters und -verteilung von Verkehrsteilnehmern bis 14 Jahren im Strasenverkehr, als Vorraussetzung zur Entwicklung prophylaktischer Masnahmen. Methode. In Verkehrsunfallakten und Krankenakten von Kindern (

Die Hannover Fracture Scale (HFS) wurde bereits im Jahr 1983 als Scoresystem fur offene Frakturen eingefuhrt. Mittlerweile wurden die Moglichkeiten zur Versorgung offener Frakturen erheblich optimiert, was nicht zuletzt auch auf neue Osteosyntheseverfahren zuruckzufuhren ist. Folglich verbesserte sich auch die Prognose offener Frakturen. Aus diesem Grund war es erforderlich, eine Neuevaluation dieses Scores durchzufuhren. Material und Methode. Retrospektiv wurden alle Parameter des HFS an 182 offenen Frakturen der oberen und unteren Extremitat evaluiert, die im Zeitraum von Juni 1994 bis Juni 1996 in der Medizinischen Hochschule Hannover behandelt wurden. Als statistische Verfahren kamen die Multivarianzanalyse, die ROC-Analyse sowie die Berechnungen von Sensitivitat, Spezifitat, Genauigkeit und pradiktiven Werten fur das Kriterium der primaren Amputation zur Anwendung. Als Ergebnis entstand die uberarbeitete HFS '98, die durch 8 Parameter gekennzeichnet ist (Knochenverlust, Hautverletzung, Muskelverletzung, Wundkontamination, Neurologie, Deperiostierung, lokale und systemische Durchblutung), eine Bandbreite von 0–22 Punkten umfasst und eine Amputationsgrenze ab dem Punktwert ≥11 vorschlagt. Dieser uberarbeitete Score wurde anschliesend prospektiv bei 87 offenen Frakturen des Zeitraums von Juli 1996 bis Dezember 1997 angewendet. Ergebnisse. Die Untersuchung der HFS '98 am prospektiven Kollektiv ergab eine Sensitivitat von 82% und eine Spezifitat von 99% (im Hinblick auf die Vorhersage einer primaren Amputation). Zum Vergleich wurden 2 weitere Scores prospektiv am gleichen Patientengut untersucht, der NISSSA und der MESS. Diese erzielten eine Sensitivitat von 71% (NISSSA) und 82% (MESS) sowie eine Spezifitat von 99% (NISSSA und MESS). Des Weiteren wurde der HFS '98 so verwendet, dass sich anhand der Scorepunkte eine Einteilung der offenen Frakturen nach Gustilo/Anderson vornehmen lasst. Als Gesamtergebnis entstand mit der HFS '98 ein verlasslicher Score zur Einschatzung des Schweregrades offener Frakturen und der Amputationswahrscheinlichkeit, der bei allen offenen Frakturen langer Rohrenknochen der oberen und unteren Extremitaten gleichermasen anwendbar ist.

Die Entwicklung eines kinematischen Modells des Unterarms, das es erlaubt, systematische Aussagen uber den Einfluss von Fehlstellungen von Ulna und Radius auf die Pro- und Supination zu machen, setzt eine genaue Kenntnis der Pro- und Supinationsbewegung voraus. Die Kinematik der Umwendbewegung des Unterarms wird in zwei parallelen Studien untersucht. In der ersten kernspintomographischen Untersuchungsreihe an 18 Probanden (36 untersuchte Unterarme) wird wahrend der Umwendbewegung eine Ausweichbewegung (laterale Abduktion) der Ulna nach lateral von im Schnitt 7,14° gemessen. Zum Nachweis, ob die Ausweichbewegung durch eine Drehung des Humerus oder durch Auslenkung in der Articulatio humeroulnaris zu Stande kommt, wird eine weitere Studie an 30 Praparaten durchgefuhrt. Die Vermessung der Umwendbewegung erfolgt dabei nach Fixierung des Humerus in einem speziell entwickelten Versuchsaufbau bei Gewahrleistung der freien Bewegungsmoglichkeit der Unterarmknochen. Auch dabei zeigt sich in allen Fallen eine Ausweichbewegung im selben Ausmas. Damit wird nachgewiesen, dass die Ulna wahrend der Umwendbewegung des Unterarms eine fur die Kinematik der Pronations-Supinationsbewegung nicht unbedeutende laterale Abduktion durchfuhrt, deren Ursprung in der Articulatio humeroulnaris zu finden ist. Pro- und Supination erfolgen demnach um instantane Achsen.

To analyze the mechanism of injury for foot and ankle fractures resulting from automobile accidents to create a basis for developing an improved design for protection.Retrospective.Level I trauma center with accident research unit.Automobile accident reports and medical records of individuals injured in the accidents.Technical indicators (collision type, impulse angle, deltav, and extent of vehicle deformation) and clinical data (injury location and severity [abbreviated injury scale and injury severity score] and long-term outcome).From 1973 to 1996, 15,559 car accidents were analyzed. Two hundred sixty-one front seat occupants sustained fractures of the foot and ankle (ankle, 41 percent; forefoot, 29 percent; midfoot, 20 percent; and hindfoot, 10 percent). Seventy-five percent of the fractures were classified abbreviated injury scale(foot) 2. The incidence, location, and abbreviated injury scale(foot) category of fractures were similar between driver (n = 210) and front seat passenger (n = 51). Fifty percent of the fractures occurred in head-on collisions and 34 percent occurred in accidents with multiple collisions. The deltav ranged in 82 percent of car crashes between fifteen and sixty kilometers per hour. The deltav and extent of foot compartment deformation correlated with the abbreviated injury scale. During our investigation, deltav increased; the injury severity score decreased; and the extent of deformation did not differ significantly.Although overall car passenger safety has improved, the relative incidence of foot and ankle fractures has increased. Comparing drivers and front seat passengers, the foot pedals, steering wheel, or the asymmetric design of the dashboard did not influence injury incidence, mechanism, or severity. Foot fractures are mainly caused by the foot compartment deformation in head-on collisions, and therefore improvements in foot compartments are essential for fracture prevention.

Ziel der Untersuchung war es, durch (pra-) klinisch erhobene Daten pradiktive Aussagen uber die Spatresultate polytraumatisierter Patienten mit schwerem Schadel-Hirn-Trauma zu treffen. 58 Patienten im Alter von 27±10 Jahren wurden durchschnittlich 5,8 Jahre nach dem Unfall untersucht. Die Verletzungsschwere betrug nach dem Hannoverschen Polytraumaschlussel 34±11 Punkte, die initial erhobene Glasgow Coma Scale (GCS) lag bei 6,2±3,2 Punkten, die Komadauer belief sich auf 15,4±14,4 Tage. Die primare stationare Behandlung dauerte durchschnittlich 33,4 Tage, dabei entfielen 22,9 Tage auf die Intensivbehandlung und 20,2 Tage auf die Beatmung. Die Patienten wurden im Schnitt weitere 223 Tage in der Neurologischen Klinik Hessisch Oldendorf behandelt. Neben unterschiedlichen neurologischen Ausfallerscheinungen konnten psychometrische Tests in allen Bereichen Defizite aufzeigen, die insbesondere die Informationsverarbeitungsgeschwindigkeit, die Konzentrationsleistung und die Merkfahigkeit und Lernleistung betrafen. 33% der Patienten wiesen eine freie Beweglichkeit aller Gelenke auf, wobei verletzungsbedingt an Ellenbogen- und Sprunggelenk die schwersten Beeintrachtigungen beobachtet wurden. Weitere Ursachen stellten zentrale Lahmungen und heterotope Ossifikationen dar. Veranderungen im sozialen Umfeld wurden bei der Halfte der Patienten festgestellt. Die berufliche Reintegration war in starkem Mase altersabhangig, insgesamt kehrten 42% in ihren fruheren Beruf zuruck, 5% befanden sich in Ausbildung oder Studium, 32% wurden umgeschult, 16% waren arbeitslos und 5% vollberentet. In der Korrelations- und Regressionsanalyse konnten als geeignete Pradiktoren das Alter, die Verletzungsschweren der GCS sowie Koma- und Weaningdauer festgestellt werden. Nach schwerstem Schadel-Hirn-Trauma trugen, gemessen an der Glasgow Outcome Scale 53% der Patienten keine bzw. eine geringfugige Behinderung davon, eine teilweise in 33% und eine vollstandige Abhangigkeit in 14% der Falle.

Das Perthes-Syndrom, im angloamerikanischem Sprachraum als “traumatic asphyxia” bezeichnet, ist gekennzeichnet durch die Trias: 1. Subkonjunktivale Einblutungen, 2. Petechien, 3. Zyanose im Kopf-Hals-Bereich. Ursachlich ist ein schweres Thoraxkompressionstrauma. Die Diagnosestellung erfolgt durch Anamneseerhebung und klinische Inspektion. Typische Begleitverletzungen intrathorakal und intraabdominell konnen zu einem lebensbedrohlichem Zustand fuhren. Anhand eines illustrativen Fallbeispiels wird dieses in der unfallchirurgischen bzw. notfallmedizinischen Praxis seltene Krankheitsbild naher beschrieben.

For primary evaluation, classification and indication of pelvic ring injuries the exact knowledge of the injury mechanism and the clinical and radiological signs is mandatory. Clear injury definitions are proved for prognostical reasons and for the timing of the specific treatment. The simple classification of stable A-type injuries, rotational B-type injuries and translationally stable C-type injuries is the basis for further treatment. Whereas A-type fractures normally need no surgical stabilization, except in severely displaced fractures or possible organ injuries due to fracture fragments, in B-type injuries solely stabilization of the anterior pelvic ring provides sufficient stability for early ambulation with partial weight bearing. In C-type injuries a combined posterior and anterior stabilization is required for anatomical reduction and early ambulation. With this concept the pelvic girdle can be reconstructed anatomically in the majority of cases.

Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma.A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS]or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISSor = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated.A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693).Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.

Die rechtliche Grundlage fur einen operativen Eingriff ist die Einwilligung des Patienten auf der Basis einer ausfuhrlichen Aufklarung, da ein Heileingriff eine Korperverletzung darstellt, die einer besonderen Rechtfertigung bedarf. Hintergrund ist das im Grundgesetz verankerte Recht auf Selbstbestimmung des Menschen. Somit ist die Art des Heileingriffs vom Patientenwillen abhangig. Den Patientenwillen gilt es auch beim alten Patienten und beim Patienten, der nicht mehr eigenstandig einwilligungsfahig und dadurch abhangig von der Entscheidung Dritter ist, herauszufinden. Im Aufklarungsgesprach ist dem Patienten auf jeden Fall die bestmogliche Behandlung unter Berucksichtigung seiner individuellen Lebenssituation nahezubringen. Das Gesprach dient auch der Einschatzung des Patientenwillens und seiner Einwillungsfahigkeit. Es ist die Moglichkeit Angste und Hilflosigkeit abzubauen und Vertrauen aufzubauen. Die Problematik des Aufklarungsgesprachs beim hochbetagten Patienten liegt in den moglicherweise herabgesetzten geistigen Fahigkeiten alter Menschen. Physiologische Alterungsprozesse mussen von Demenzerkrankungen oder psychiatrischen Erkrankungen abgegrenzt werden, da letztere ein gesondertes Vorgehen uber eine Betreuung erfordern.

Zusammenfassung Das komplexe Gelenktrauma ist definiert als Fraktur bzw. Luxation eines Gelenks mit ¶begleitendem schweren Weichteilschaden ¶(> zweitgradig) und/oder Serienverletzung und/oder Gefas- oder Nervenverletzung. Insbesondere beim Ellbogengelenk fuhrt dies haufig zu einer schwerwiegenden und manchmal dauernden Beeintrachtigung der oberen Extremitat. Es ist daher von besonderer Bedeutung, ein standardisiertes Behandlungskonzept zu beachten. Eine Analyse unseres Patientenkollektivs zeigte bei insgesamt 773 Frakturen des Ellbogengelenks im Zeitraum von 1981–1991 224 Komplexverletzungen (29%), davon 68% bei polytraumatisierten Patienten. Distaler Humerus und proximaler Unterarm waren annahernd gleichermasen beteiligt. Ein Sonderfall stellt der Floating elbow mit 6% dar. Die Halfte der Patienten hatte einen schweren Weichteilschaden, 82% davon offen. Neben einem Kompartmentsyndrom (23,8%) sahen wir in 63,5% der Falle eine Nerven- und in 25,4% eine Gefasverletzung. Bei der primaren operativen Therapie ist moglichst eine definitive Versorgung aller Verletzungen der oberen Extremitat anzustreben. Eine stabile Osteosynthese ermoglicht die rasche Mobilisierung, eine Transfixation des Gelenks ist nur in Ausnahmefallen gerechtfertigt. Im Bereich des distalen Humerus haben sich, wie am proximalen Unterarm, die Prinzipien der AO bewahrt. Fur eine adaquate Rekonstruktion des Gelenks sind haufig erweiterte operative Zugange angezeigt. Insbesondere bei der Versorgung der proximalen Ulna haben sich indirekte Repositionstechniken etabliert. Radiuskopfchen und Coronoid stellen wichtige dynamische Stabilisatoren dar. Bei der Weichteilversorgung sind meist nur lokal rekonstruktive Masnahmen erforderlich. Die Indikation zur Kompartmentspaltung des Unterarms sollte bei diesen Verletzungen groszugig gestellt werden. Die Diagnose und Therapie einer begleitenden Gefasverletzung sollten aufgrund der sonst resultierenden prolongierten Ischamiezeit rasch erfolgen. Bei Verzogerung ist ein intraluminaler Shunt indiziert. Bei den Nervenverletzungen ist eine initiale operative Versorgung nur im Einzelfall (bei scharfer Durchtrennung) angezeigt, ansonsten erfolgt eine sekundare Versorgung im Intervall nach 3 Monaten. Das Rehabilitationsergebnis wird durch die Art der initialen Behandlung stark beeinflust. Nur bei rascher Mobilisierung und intensiver krankengymnastischer Anleitung kann bei diesen schweren Verletzungen ein zufriedenstellendes Ergebnis erzielt werden. Eine geplante Arthrolyse spatestens nach 6 Monaten, ggf. mit Teilimplantatentfernung, kann dieses Ergebnis noch deutlich verbessern.

In an analysis of 3,838 restrained car drivers, the proportion of acceleration related injury of the cervical spine increased from under 10 % in 1985 to over 30 % in 1997. These injuries occurred mainly in the case of head-on or multiple collisions. Letters were sent to 1,136 of the injured persons, and of the 138 patients who returned the questionnaires, 121 (88 %) were still suffering from their symptoms. It was a question of pain (74 %), tension (6 %) and stiffness (5 %) in the head (27 %), neck (55 %) and shoulder (8 %) area. The duration of the complaints was the longest after multiple collisions. In addition to a slight influence of the accompanying injuries on the duration of complaints, the individual constitution seems to be an important determining factor. In order to resolve the difficulties of conducting of this retrospective study, prospective studies are necessary which include documentation of diagnosis, treatment protocols, duration and type of complaints.

Einleitung: Eine sekundare Operation bei polytraumatisierten Patienten wird unter anderem als auslosender Faktor fur die Entwicklung einer Organfunktionsstorung diskutiert. Wir untersuchten die Auswirkungen des Zeitpunkts einer ausgedehnten ( > 3 Std) Sekundaroperation auf den posttraumatischen Verlauf. Methodik: In einer retrospektiven Analyse (Januar 1975 bis Januar 1999) wurden 4314 Patienten unserer Klinik diesbezuglich untersucht. Patienten mit Multiorganversagen ( + MOV; Goris-Kriterien) und ohne Multiorganfunktionsstorung (-MOV) wurden verglichen. Ergebnisse: Bei vergleichbarer Rettungszeit und Verletzungsschwere sowie Incidenz und Dauer der Erstoperation waren + MOV-Patienten hochsignifikant haufiger (p < 0,0001) einer sekundaren Operation zwischen dem 2.–4. Tag post Trauma unterzogen worden als Patienten ohne MOV; letztere wurden haufiger am 6.–8. Tag post Trauma operiert. Die initialen Laborparameter waren bei beiden Gruppen vergleichbar. Bei denen, die trotz einer Sekundaroperation am 6.–8. Tag ein MOV entwickelten, waren die initialen Laborparameter signifikant different; diese Patienten waren somit schon praoperativ in einem schlechteren Zustand. Schlusfolgerung: Schwerverletzte sollten nach Abschlus der primaren Phase einer ausgedehnten Sekundaroperation nur dann unterzogen werden, wenn der Zustand sicher stabil ist. Fur planbare, ausgedehnte Sekundaroperationen bei schwerverletzten Patienten sollte aufgrund dieser Ergebnisse der 2.–4. posttraumatische Tag vermieden werden.

Extracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.

Primary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named “borderline patients”. In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.

Von besonderer Bedeutung ist die schnelle Integration von sofort verfugbaren klinischen Versorgungsmoglichkeiten in die akute Lage vor Ort. Das in Deutschland auserst dichte Netz der praklinischen Rettungsmedizin mit seinen Versorgungs- und Transportkapazitaten macht eine optimierte Ausnutzung der regionalen und uberregionalen klinisch-traumatologischen Versorgungsmoglichkeiten moglich. Hierzu sollen Uberlegungen uber Konzepte angestellt werden, die zukunftig auch im Grosschadens- oder zivilen Katastrophenfall eine moglichst fruhzeitige und komplette individualmedizinische Versorgung von allen Geschadigten ermoglichen.

Objectives/Hypothesis: Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model. Study Design/Methods: Ten fresh human cadavers underwent lateral conventional plate osteosynthesis (CPO) through a standard lateral approach on one side and minimally invasive plate osteosynthesis (MIPO) through two three-centimeter incisions on the contralateral side. After injection of silicone dye, a dissection was performed bilaterally to identify the femoral perforating and nutrient arteries. Results: All MIPO specimens showed intact perforating and nutrient arteries, whereas the CPO specimens had a variable incidence of vessel disruption. The MIPO group demonstrated better periosteal perfusion in each of the cadavers and improved medullary perfusion in 70 percent of the MIPO specimens compared with the CPO specimens. Conclusion: A percutaneous minimally invasive plating technique disrupts the femoral blood supply less than the traditional open method. Such minimally invasive methods may be more advantageous biologically than the traditional method.

Although the free hand technique remains the most popular method for distal interlocking screw insertion, proximally mounted radiation independent devices that compensate for implant deformation recently have been developed for the femur. However, the benefits of such systems have not been determined. This study prospectively compared the duration of the nailing procedure, the length of radiation time, and the accuracy of interlocking screw placement when using a radiation independent distal aiming system with those using the free hand technique. In 20 paired intact anatomic specimen femurs, one surgeon experienced only in the free hand technique performed statically locked intramedullary nailing using the two methods. For the aiming system and free hand technique, respectively, the total operation time was 19.1 +/- 8.4 minutes versus 20.9 +/- 11.3 minutes, the distal locking time was 6.6 +/- 2.4 minutes versus 4.8 +/- 1.5 minutes, the total fluoroscopy time was 23 +/- 17 seconds versus 69 +/- 34 seconds, and the distal locking fluoroscopy time was 0 versus 37 +/- 15.5 seconds. There were no failures in either group. Drill nail contact and distal screw damage were greater with the free hand technique. This study suggests that the main advantages of the aiming arm compared with the free hand technique include the elimination of radiation during distal interlocking and more precise screw placement with decreased insertion related hardware damage.

During 1973 and 1989, 6,378 car accidents with 8,931 injured persons were evaluated in the area of Hannover. 3,267 car drivers and passengers sustained fractures overall and 148 (4,5 %) fractures of the foot. A major role in the ethiology of the foot fractures evolves from the deformation of the foot room. Driver and front seat passenger showed similar injuries. Among the 286 single fractures, the forefoot was affected most often (45 %), followed by ankle (38 %), midfoot (11 %) and hindfoot (6 %). 5 % were open fractures. The long term results were estimated upon the limitation of working ability caused by the foot injury in relation to the entire working ability. The evaluation concludes that the foot fractures especially in combination with other injuries were frequently not recognized within the primary examination and therefore underestimated. The long-term outcome leaded to a high degree of impairment due to foot fractures.

Significant progress has been made in terms of the management of calcaneal fractures. This is reflected in the marked decrease in complication rates associated with the current intervention of these potentially devastating injuries. The treatment priorities that, in the authors opinion, are key to achieve best results in a displaced calcaneal fracture are anatomic reconstruction of the entire calcaneus: articular surfaces, height, alignment, and length, with a function directed postoperative management. The value of these priorities are confirmed by the authors longterm follow-up results as presented here. To reemphasize, conservative treatment should be considered only in cases of extraarticular fractures, minor displaced intraarticular fractures in nonambulatory patients, and in cases where there is a clear contraindication for surgery. Regarding the technical requirements for an anatomic reconstruction, the os calcis fracture should be categorized as a procedure for experts. In two-part fractures, according to the Sanders classification, an anatomical reduction is obtainable in more than 80 %–90 % of cases. However, in consideration of the articular cartilage damage, a 70 % rate of good to excellent clinical results seems realistic. In three-part fractures, anatomic reduction is attainable in about 60 % of cases with a 70 % rate of good results. These two subgroups comprise about 90 % of all calcaneus fractures. It is the authors recent experience to optimize the extended lateral approach using posteromedial and anterolateral windows, so that an anatomic reduction in more than 60 % of Sanders Type III os calcis fractures can be achieved. Further scientific work in this area of trauma orthopedics would benefit most from a general consensus on a fracture classification system and on a clinical scoring system, with 5 year follow-up studies using these treatment methods and evaluation systems.

Trotzdem wird in den letzten Jahren immer haufiger uber unnotige Einsatze und Fehlentscheidungen berichtet, so das auch hier eine Qualitatsanalyse gefordert wird [32]. Dieses Konzept wird unter dem Begriff „Medical Control” bereits seit Jahren in den Vereinigten Staaten erfolgreich praktiziert [23]. Zielgrosen um die Qualitat zu definieren und diese im Sinne der Qualitatssicherung einzusetzen, erfordert die Festschreibung von Standards [32]. Im Rahmen der Notfallmedizin sind Qualitatsstandards bereits von verschiedenen deutschen Organisationen (DGU, DIVI, DGNC, DGAI) zusammengestellt worden. Ein Bundeseinheitliches Notarztprotokoll konnte eingefuhrt werden [13] (Abb. 1). Es gilt nun die Daten der praklinischen Behandlung unter Berucksichtigung dieser Standards zu dokumentieren und eine Qualitatskontrolle vorzunehmen [12, 23, 32]. Anhand einer Fehleranalyse im eigenen Patientenkollektiv soll auf kritische Punkte der notarztlichen Versorgung von Unfallpatienten hingewiesen werden. Neben der immer wieder zu beobachtenden unzureichenden Versorgung von Traumapatienten, haufen sich in den letzten Jahren auch Falle in denen nicht indizierte invasive Masnahmen durchgefuhrt werden.

The classification of acetabular fractures and especially the diagnosis of additional lesions can be misleading, when the personal experience is limited and the decisions are based only on conventional radiographs. The introduction of Spiral-CT with multiplanar reformations and 3-D views has improved the quality of visualization. Due to their higher costs, the need of these additional diagnostic tools is frequently questioned. This paper discusses the relevance of plain radiographs, 2-D-CTs, 3-D-CTs and Femursubtraction-CTs (FsCT) for the classification of acetabular fractures, based on a controlled study. Methods: Thirty physicians with different levels of experience in acetabular surgery were divided in three groups of 10 each: group I comprised residents without operative experience in acetabular surgery, group II was physicians with 3–10 years of operative experience, and group III was experts in acetabular surgery. A total of 10 complete radiographic cases of high quality providing all levels of preoperative diagnostics (plain radiographs, 2-D-CT, CT with multiplanar reformation, 3-D-CT, Fs-CT) of different acetabular fracture types were prepared. The task for each candidate was to classify the fracture according to Letournel and to identify all additional injuries within the hip joint (e. g. marginal impaction, head fractures, etc.). The different diagnostic “levels” could be ordered stepwise according to personal need and no time limit was given. The case was finished when the candidate presented his final diagnosis. The use of the different radiographs, the preliminary diagnosis, the changes in diagnosis, and the final decisions were recorded. These findings were correlated with the different levels of experience and against a “consensus classification” which was generated by thorough discussion, and the use of intraoperative information and postoperative radiographs not accessible to the candidates. Results: The “correct” fracture classification based on plain radiographs was: group I, 11 %; group II, 32 %; group III, 61 %. Based on 2-D-CT a “correct” diagnosis was reached by 30 % in group I, by 55 % in group II, and by 76 % in group III. With consideration of the “transient forms” in acetabular fractures based on Letournel and the 3-D-CT used mainly by group I, the rate of “correct” classifications rose to 65 % in group I, 64 % in group II and 83 % in group III. The modifiers were diagnosed “correctly” in group I by 37 %, in group II by 56 %, and in group III by 73 %. The use of the 3-D-CT and especially the Fs-CT by group I resulted in an improvement in the rate of correct classifications to 61 %, whereas in group II the Fs-Ct was used only exceptionally. The 2-D-CT was the basis for the diagnosis of the additional lesions in acetabular fractures within all groups resulting in 73 % complete diagnoses in group III. This study showed the importance of CT for the exact analysis and classification of acetabular fractures. In particular, the secondary reformations in CT and the 3-D-views dramatically improved the rate of “correct” classifications in the group of surgeons with limited personal experience in acetabular surgery. This allows the less experienced an acceptable level of “correct” diagnoses, so that the treatment options can be weighed correctly. Among the “experts” a rate of divergent classifcations of approximately 20 % was observed, especially in “transient” forms of acetabular fractures.

Background: Fractures of the femoral head and neck in children have a risk of severe complications, especially femoral head necrosis. We performed a long-term follow-up study of patients treated at our institution. Methods: Patients were reexamined at least 3 years after trauma and were included if they were younger than 17 years old at the time of injury, if there was no history of previous fracture, and if there was no history of underlying bone disease. Fractures were classified according to Delbet, and outcome was graded according to Ratliff. Anterior capsulotomy was not performed, and stabilization devices were placed short of the epiphysis except for type I fractures. Results: Of 32 patients, 28 were reexamined. Among these patients, the mean age at the time of injury was 11.8 years and the mean follow-up time was 11.1 years (range, 3-21 years). There were 3 patients with type I fractures, 8 patients with type II fractures, 12 patients with type III fractures, and 5 patients with type IV fractures. Thirteen patients had Injury Severity Scores > 18. At last follow-up, 20 patients presented with good function, 5 with fair outcome, and 3 with poor results; all of the latter suffered type I fractures. Eighteen patients had no restrictions in activities of daily living or during sports activities. In six other patients, the inability to participate in sports was attributable to head trauma, amputation, or peripheral neurologic damage. Conclusion: We found favorable long-term outcome in type II to type IV fractures. In these patients, restrictions of function were usually caused by other associated injuries. All patients with type I fractures presented with poor outcome secondary to their proximal femoral fractures, and not because of other associated injuries. Type I fractures during childhood and adolescence represent an unsolved problem.

In a long-term follow-up we evaluated 40 patients out of 55 (73 %) with a subtalar fusion. The operations took place from 5/84 to 5/91. In all cases the indication for the fusion was a post-traumatic arthritis after an intra-articular os calcis fracture. The evaluation of the overall results was carried out with three different scoring systems: a. The Hannover Scoring System. b. The Outcome-questionnaire, rating patient's complaints and the functional status based on the severity-symptom scale and functional status described for Carpaltunnel-syndrome by Levine et al. c. The clinical rating system (CRS) described by Kitaoka et al. The statistical evaluation was performed by analysis of variance (ANOVA). Level of significance was based on P = 0.05 and calculation of Pearson's correlation coefficient. The Os calcis fracture was the cause for the subtalar arthritis in all 40 patients (33 males and 7 females). The primary treatment of the calcaneal fracture was conservative (cons.) using a plaster in 23 patients (57.5 %), while 17 patients (42.5 %) underwent open reduction and plate fixation (op.). The interval between trauma and subtalar fusion averaged 3.5 years (3 months to 20 years). The interval between subtalar fusion and follow-up averaged 5.2 years (4–14 years). The mean age at the time of reexamination was 47 years (26–61 years). In the present study, complete pain relief could be achieved in 21 (52.5 %; 58 % op., 50 % cons.) patients. A relevant restriction in the range of motion in the ankle joint was found in 26 (65 %; 76 % op., 58 % cons.). In 23 patients (62 %; 65 % op., 59 % cons.) the radiological evaluation revealed a grade 1 ° arthritis of the ankle joint, in the talonavicular joint in 17 patients (42.5 %; 41 % op., 45 % cons.), and in the calcaneo-cuboid joint in 14 patients (35 %; 47 %., 27 % cons.). The statistical analysis revealed a better outcome in the operative group compared with the conservative group, although the operated os calcis fractures in the majority were the more severe fracture types. In all evaluation systems a score between 61 and 69 points could be achieved with no significant difference between the operatively and conservatively treated groups and between the newly developed questionaire and the clinical-radiological scoring systems. For the questionaire this fulfills the requirements for a reliable outcome evaluation.

Previous studies concerning ruptures of the lateral ligaments of the ankle dealt with acute first ruptures. There are a few articles about chronic instability of the ankle but no prospective investigations have been reported concerning the treatment of recurrent ruptures. Good results were obtained following after non-operative treatment of acute ruptures of the fibular ligaments of the ankle joint. This prospectively randomized study was commenced to test whether recidivations of the rupture of the lateral ligaments can also be treated non-operatively or if they are in need of operative repair. The second question to be answered was whether these injuries should be treated differently dependening on the treatment of the first rupture. From December 1986 to November 1989, 109 patients with a recidivation of a rupture of the ankle joint lateral ligaments were included in this prospective trial at the Department of Trauma Surgery, Hannover Medical School. They were divided into two groups depending on the therapy used to treat the first injury: The relapse was classified as a second-stage-rupture in cases where treatment of the first ligament rupture did not involve an operation and as a rerupture if the initial rupture was surgically repaired. Half of each group was treated randomly either with surgical ligament repair or without. A total of 100 patients (92 %) at an average age of 24 years (11 to 49 years) was seen for follow-up examination one year after the relapse: The follow-up included the patient's subjective assessment, a clinical examination, and stress radiography. A 70 point score was used for evaluation of the total result. Two wound infections requiring reoperation were observed in the operative treatment groups. The follow-up examination revealed better results in both operative treatment groups (A and C), which was statistically significant (P < 0.05). Patients with a second-stage-rupture showed a significantly higher (P < 0.001) stability by stress radiography after surgical treatment (group A) in contrast to non-operative treatment (group B). In addition, the subjective and clinical results indicated a tendency towards better results which were not statistically significant (P < 0.09 and P < 0.07). In cases of rerupture the patient's subjective assessment revealed significantly more (P < 0,05) complaints after non-operative treatment (group D). Clinical results were comparable, and radiologic assessment showed a tendency towards higher joint stability after surgical treatment (group C), although it was not statistically significant (P < 0.07). Based on the results presented, the authors recommend the surgical repair of ankle joint ligaments in cases of second-stage- or rerupture.

Although the free-hand technique remains the most popular method for distal interlocking screw insertion, proximally mounted “radiation-independent” devices which compensate for implant deformation recently have been developed for rotationally stiff, unslotted femoral nails. However, the benefits of such systems have not been determined. This study prospectively compared the duration of the nailing procedure, the length of radiation time, and the accuracy of interlocking screw placement with a radiation-independent distal aiming system to those using the free-hand technique. In twenty paired intact cadaveric femora, a single surgeon experienced only in the free-hand technique performed statically locked intramedullary nailing using the two methods. For the aiming system and free-hand technique respectively, the total operation time was 19.1 ± 8.4 versus 20.9 ± 11.3 minutes (p = 0.9), the distal locking time was 6.6 ± 2.4 versus 4.8 ± 1.5 minutes (p = 0.002), the total fluoroscopy time was 23 ± 17 versus 69 ± 34 seconds (p < 0.0001), and the distal locking fluoroscopy time was 0 versus 37 ± 15.5 seconds (p < 0.0001). There were no failures in either group. Drill nail contact (p < 0.0001) and distal screw damage (p = 0.02) were both greater with the free-hand technique.

Pulmonary complications after intramedullary femoral nailing have been attributed to bone marrow fat embolization and a variety of cascade effects. We investigated whether the coagulatory response after intramedullary femoral nailing in merino sheep is altered after severe trauma.Adult merino sheep were submitted to hemorrhagic shock (2 hours, 50 mm Hg) and unilateral lung contusion. After recovery (day 3 of the study), reamed femoral intramedullary nailing (RFN), unreamed femoral intramedullary nailing (UFN), or plate osteosynthesis of the femur (P) was performed. Pulmonary artery pressure, central venous levels of factor V, protein C, antithrombin III, and fibrinogen, were determined. At 1 and 3 days before and after femur instrumentation, pulmonary capillary permeability was assessed on the basis of the comparative albumin content in bronchoalveolar lavage fluid.Group RFN, n=8; group UFN, n=7; group P, n=6. A significant (p0.05) postoperative increase in the relative albumin content in terms of the BAL/plasma albumin ratio was measured in group RFN (day 3 preoperatively: 0.38+/-0.05 day 3 postoperatively: 0.53+/-0.06, p0.05 (RFN vs. P), which contrasted with group UFN (day 3 preoperatively: 0.44+/-0.09, day 3 postoperatively: 0.46+/-0.09, no significant difference). This evidence of increased pulmonary permeability occurred in association with evidence of increased activation of coagulation factors (data presented as percentage of day 3 preoperative baseline values). The data for fibrinogen (15 min postoperatively) is as follows: group RFN, 74+/-9% (p0.05 vs. P); group UFN, 83+/-8% (not significant); group P, 98+/-6%. The data for antithrombin III (15 min. postoperatively) is as follows: group RFN, 72+/-6% (p0.05 vs. P); group UFN, 79+/-8% (not significant); group P, 92+/-8% (not significant).After severe trauma, an increase of pulmonary permeability after reamed femoral nailing was associated with increased consumption of coagulation factors. After unreamed nailing, a similar trend was apparent, but this was not found to be statistically significant. These data provide support for the theory that after severe trauma, unreamed femoral nailing reduces but does not abolish pulmonary sequelae when compared with reamed femoral nailing.

Operationsziel Knocherne Heilung von Femurschaftfrakturen in achsengerechter Stellung nach Osteosynthese mit unaufgebohrtem intramedullaren Verriegelungsnagel (UFN).

Knee proprioception was assessed in 20 healthy volunteers, 10 patients with acute anterior instability and in 20 patients with chronic anterior instability preoperatively as well as after 3 and 6 months postoperatively. To determine proprioception, an angle reproduction test was performed. There were no differences between the right and the left knee joint or between men and women. Best proprioception was measured near full extension. The acute trauma causes massive damage of the proprioception, which could be improved significantly by rehabilitation. However, rehabilitation could not restore proprioception. 3 months postoperatively, there was a slight decrease of proprioception as compared to the preoperative values, but 6 months after reconstruction, restoration of proprioception was documented near full extension and full flexion. In the mid range position, the proprioception could not be restored. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient's satisfaction.

Thirty-nine consecutive patients with 3- and 4-part proximal humeral fractures and fracture dislocations were treated with hemiarthroplasty. After an average of 42 months (range 5 to 98 months) of follow-up, 17 women and 8 men (average age 64.5 years) were evaluated with the University of California-Los Angeles (UCLA) scale, the Constant-Murley scale, the Hospital for Special Surgery (HSS) scale, and the visual analogue scale. Fair, good, or excellent results were achieved in 80% of the patients on the UCLA and Visual scales, in 72% of the patients on the HSS scale, and in 44% of the patients on the Constant-Murley scale. The highest correlation was between the HSS score and the Visual analogue score. According to the UCLA and Constant-Murley results, the outcome after early (4 weeks) humeral head replacement was significantly better than after late (or =4 weeks) humeral head replacement (UCLA score, P=.02; Constant-Murley score, P=.01). After early hemiarthroplasty active forward flexion was significantly better (P=.035). Thus the decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.

Background: The basic principles for the treatment of the polytraumatized patient is early resuscitation, followed by a physical examination and diagnostic studies. These are performed to establish the priorities for life-saving management and further treatment. Discussion: Trauma management regarding musculoskeletal injuries is discussed in four different distinguished periods: (1) acute or resuscitation period (0–3 h); (2) primary or stabilization period (3–72 h); (3) secondary or regeneration period (days 3–8); and (4) tertiary or rehabilitation period (beyond day 8). For management during the acute period, a trauma algorithm is described, which consists of four different steps: (1) first look; (2) shock treatment; (3) check up; and (4) control and diagnosis. During the acute period, decompression of organ cavities (tension pneumothorax, cardiac tamponade) is performed along with life-saving operations for hemorrhage control of thoracic, abdominal, pelvic or external bleeding. The primary period (3–72 h) of treatment starts when the vital functions have been stabilized. During this period, so-called `day-one' surgery is performed. During the secondary period (days 3–8), a phase of regeneration, a secondary deterioration of organ function must be prevented. During the tertiary phase (beyond day 8), in most cases, recovery usually continues and final reconstructive operations can be performed.

The association of a malunited clavicular fracture with a pattern of disability that includes not only pain but also impairment of shoulder function is rare. But in cases where such an association exists, correction of the clavicular deformity should be considered. We report on 4 patients with a malunited fracture of the clavicle after nonoperative treatment. In all 4 patients fracture union had occurred with shortening associated with pain and ipsilateral glenohumeral dysfunction. The deformity was not associated with neurovascular dysfunction. On preoperative radiographs the shortening of the malunited clavicle was between 0.9 and 2.2 cm compared with the contralateral clavicle. all patients underwent an extension osteotomy of the clavicle with interposition of an autogenous iliac crestbone graft secured with a plate and screws. The length of follow-up was 1 to 4 years in 3 cases and 6 weeks in 1 case. The functional outcome was evaluated with the Constant-Murley and University of California-Los Angeles scales. All patients had immediate pain relief after osteotomy and correction of the deformity. Shoulder function rapidly improved and functional outcome was good in 3 of the 4 patients. In cases of shoulder function impairment associated with malunited clavicular fractures, extension osteotomy combined with autogenous bone grafting is likely to produce good results.

A 3-year-old child was trapped under the heavy load of a forklift truck and sustained an unstable pelvic ring fracture (Tile type C) with complete SI disruption, disruption of the pubic symphysis and external rotation injury of the contralateral SI joint. An immediate internal fixation was performed, exposing the SI joint and the pubic symphysis simultaneously. For stabilization an H-plate was used for anterior plate fixation of the SI joint, while the pubic symphysis was stabilized by screws and cerclage wires. After one revision of the symphysis the clinical course was uneventful with anatomical healing of the pelvic ring. The implants were removed after 4 months. Clinical and radiological follow-up after 12 months showed no signs of maldevelopment of the pelvic ring.

ACL reconstruction with patellar tendon graft has become a standard procedure. The graft can be inserted either using two tunnels and a lateral femoral incision or with a femoral half tunnel drilled from the joint, thus avoiding the lateral incision. Advantages of the single-incision technique in the early rehabilitation period have been claimed. 40 patients with ACL deficiency were included in a prospective randomized trial comparing single and two-incision technique with a follow-up period of 4 years. Preoperative data did not show any significant difference between the two groups. At follow-up no differences were observed with respect to complications or the progress of rehabilitation. Evaluation after 1 and 4 years according to the IKDC form revealed good to excellent results in 70 % of all patients. The Tegner-score increased significantly, however most patients did not regain their former activity level. ACL-reconstruction reduced anterior translation of the knee significantly at 6 months follow-up. However, we observed a slight increase of anterior translation after 1 and 4 years in both groups; stability was comparable in both groups at all time periods. We conclude that an arthroscopic singleincision technique has no advantage compared to a mini-open two-incision technique for ACL reconstruction with patellar tendon graft in terms of subjective or objective parameters.

Between 1984 and 1991, 57 patients with diagnosis of an acute or recurrent patellar dislocation were treated operatively using proximal realignment with vastus medialis transfer and lateral release (Insall operation). A total of 45 patients (15 with acute and 30 with recurrent patellar dislocation) were reviewed at an average follow-up of 6.5 years (2–9.6 years). The average age at injury was 21.5 years, with a predominance of female patients. Follow-up examination included routine knee examination, clinical review using the modified knee scoring scale of Larsen and Lauridsen, sports activity level and subjective satisfaction. Radiographics from 27 patients (60 %) were evaluated. One patient from each group suffered recurrence of patellar dislocation. All patients had stable knee joints and a full range of motion. There was no statistical difference in the pre- and postoperative sports activity level in both groups. Three patients (19.9 %) with acute patellar dislocation and seven patients (23.3 %) with recurrent patella dislocation had excellent results using the Larsen and Lauridsen score scale. Ten patients (66.6 %) with acute and 12 (39.9 %) with recurrent dislocation had good results. One patient with recurrent patellar dislocation had a fair result. Subjective evaluation revealed the operative result in 93 % of cases as very good, good or satisfactory. Patellofemoral osteoarthritis was seen in 11 (40.7 %) of 27 patients. Our results show good clinical results for the treatment of acute patellar dislocation in young, active patients with the proximal realignment procedure. The recurrence rate of patellar dislocation can be reduced for acute and recurrent patellar dislocation. Subjective satisfaction with this procedure is rated very good.