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The role of classification systems for the choice of surgical approach and the management of tibial plateau fractures remains unclear. The purpose of this study was to investigate the potential of classification systems to choose the appropriate operative approach. Current surgical management strategies were investigated in a large multicenter assessment. In this study, we retrospectively analyzed all patients with tibial plateau fractures that have received surgical treatment in one of the five Level I trauma facilities between 2012 and 2015. Fractures were classified in each center by a senior orthopedic surgeon using the AO/OTA and the Luo classification. Demographics, trauma mechanism, as well as the surgical approach were recorded. 538 patients (46.1% male, 53.9% female) were included. The anterolateral approach was used most frequently with 54.8% of all single approaches; 76.2% of all combined approaches used anterolateral as part of the approach. Combined approaches were used in 22.5% of the cases; a combination of the anterolateral and medial (10%), anterolateral, and posteromedial approach (5.8%) were used most frequently. The lowest number was found for the posterolateral (1.3%) and the combined approaches dorsal/anterolateral and medial/dorsal (1.7%, 1.1%). The AO/OTA classification showed a peak for 41.B2 (21.9%) and B3 (35.5%) fractures. Regarding the Luo classification, the dorsal column was involved in 45.7%. In contrast, only 14.7% of the surgical approaches used were able to address the dorsal tibial plateau potentially. The use of dorsal approach seems to be of minor importance than expected in daily clinical practice in this multicenter study. It was not possible to specify whether the AO/OTA or the Luo classification can reliably predict the choice of surgical approach. The operative treatment strategy of tibial plateau fractures seems to rather rely on the surgeons' experience, education, and preferences.

Tibial plateau fractures are common fractures in adults and can be extremely challenging for surgeons. State-of-the-art therapy is open reduction and internal fixation (ORIF), although major complications of ORIF are surgical site infections (SSIs). This is especially critical on the proximal tibia, which is only sparsely covered by soft tissue and has a close relation to the knee joint. We analyzed SSIs after ORIF to correlate established laboratory parameters to the occurrence of SSIs. A monocentric case–control study in a Level 1 Trauma Center was conducted. Data were acquired from electronic medical records from 2011 until 2016. White blood cell count (WBC) and C-reactive protein (CRP) were used as laboratory parameters and statistically analyzed. In total, 97 patients were included, with four patients suffering from SSIs. Patients with SSIs had a significantly increased WBC count and CRP levels on the third postoperative day. Infection was diagnosed after rehospitalization, 12 ± 4 weeks after initial surgery. Furthermore, a large bony destruction through trauma coincides with a rise of WBC count with no influence on CRP level. We highly recommend a laboratory analysis with WBC count and CRP on the third day after ORIF. Patients with a CRP level above 100 mg/l should be closely watched, even if laboratory parameters few days later are adequate—since a one-time increase above this landmark might be a hint regarding the development of a SSI.

Biomechanical studies of the pelvis are usually performed using dissected pelvic specimens or synthetic bones. Thereby the stabilising effect of the surrounding soft tissues is analysed insufficiently. Biomechanical data for isolated anterior pelvic ring fractures are currently missing. Therefore, the purpose of this study was to develop a novel testing device for biomechanical analyses of the pelvis and to investigate two different anterior pelvic ring fractures in a cadaveric model with intact peripelvic soft tissues. A new biomechanical table construction which enables the fixation and testing of complete cadaveric specimens was developed. It was used to investigate the relative motion and stiffness changes due to unilateral osteotomy of the superior and inferior pubic ramus. Five cadavers with a mean age of 55.6 years (± 15.53 years) were included and loaded with a sinusoidal, cyclic (1 Hz), compressive force of up to 365 N over ten cycles for each condition. Biomechanical testing of the pelvis with complete appended soft tissues was feasible. Native stiffness without a pelvic fracture was 64.31 N/mm (± 8.33 N/mm). A standardised unilateral osteotomy of the superior pubic ramus reduced the stiffness under isolated axial load by 2% (63.05 N/mm ± 7.45 N/mm, p = 0.690). Additional osteotomy of the inferior pubic ramus caused a further, statistically not significant, decrease by 5% (59.57 N/mm ± 6.84 N/mm, p = 0.310). The developed test device was successfully used for biomechanical analyses of the pelvis with intact peripelvic soft tissues. In a first study, isolated unilateral fractures of the anterior pelvic ring showed no relevant biomechanical variation compared to the intact situation under isolated axial load. Only 7% of the measured stiffness was created by both unilateral pubic rami. Therefore, the clinical practice to treat unilateral anterior pelvic ring fractures conservatively is supported by the results of this study.

Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p

Background: Osteoporosis affects elderly patients of both sexes. It is characterized by an increased fracture risk due to defective remodeling of the bone microarchitecture. It affects in particular postmenopausal women due to their decreased levels of estrogen. Preclinical studies with animals demonstrated that loss of estrogen had a negative effect on bone healing and that increasing the estrogen level led to a better bone healing. We asked whether increasing the estrogen level in menopausal patients has a beneficial effect on bone mineral density (BMD) during callus formation after a bone fracture.Methods: To investigate whether estrogen has a beneficial effect on callus BMD of postmenopausal patients, we performed a prospective double-blinded randomized study with 76 patients suffering from distal radius fractures. A total of 31 patients (71.13 years ± 11.99) were treated with estrogen and 45 patients (75.62 years ± 10.47) served as untreated controls. Calculated bone density as well as cortical bone density were determined by peripheral quantitative computed tomography (pQCT) prior to and six weeks after the surgery. Comparative measurements were performed at the fractured site and at the corresponding position of the non-fractured arm.Results: We found that unlike with preclinical models, bone fracture healing of human patients was not improved in response to estrogen treatment. Furthermore, we observed no dependence between age-dependent bone tissue loss and constant callus formation in the patients.Conclusions: Transdermally applied estrogen to postmenopausal women, which results in estrogen levels similar to the systemic level of premenopausal women, has no significant beneficial effect on callus BMD as measured by pQCT, as recently shown in preclinical animal models.Trial registration: Low dose estrogen has no significant effect on bone fracture healing measured by pQCT in postmenopausal women, DRKS00019858. Registered 25th November 2019 - Retrospectively registered. Trial registration number DRKS00019858.

Background The skeletal disease osteoporosis affects primarily postmenopausal women. It is characterized by increased fracture risk due to defective remodeling of bone tissue and a pathological bone microarchitecture in response to the decreased levels of estrogen. Osteoporosis is clinically silent up until a first fracture occurs. Therefore, the diagnosis of the disease is usually late. Recent preclinical studies with mice, rats and rabbits suggested that estrogen treatment enhances the healing effect after bone fractures. Here we asked whether transdermally applied estrogen, which restores the systemic premenopausal level of estrogen, has a beneficial effect on fracture healing of postmenopausal women as observed in preclinical models. Methods To investigate whether estrogen has a beneficial effect on bone fracture healing of postmenopausal patients, we performed a prospective double-blinded randomized study with 76 patients suffering from distal radius fractures. A total of 31 patients (71.13 years ± 11.99) were treated with estrogen and 45 patients (75.62 years ± 10.47) served as untreated controls. Calculated bone density as well as cortical bone density were determined by peripheral quantitative computed tomography (pQCT) prior to and six weeks after the surgery. Results We found that unlike with preclinical models, bone fracture healing of human patients was not improved in response to estrogen treatment. Furthermore, we observed no dependence between age-dependent bone tissue loss and constant callus formation in the patients. Conclusions Transdermally applied estrogen to postmenopausal women, which results in estrogen levels similar to the systemic level of premenopausal women, has no significant beneficial effect on bone fracture healing.

The objective of this study is to report the institutions experiences with standardized 2D computer-navigated percutaneous iliosacral screw placement (CNS), as well as the conventional fluoroscopically assisted screw placement method (CF) over a period of 10 years. A total of 604 patients with sacral fractures (OTA B and C) were treated at the institution. Cases with both, a preoperative and postoperative CT scan were included for further analysis. With this prerequisite, a total of 136 cases were included. The quality of screw positioning, length of operation and intraoperative radiation exposure were recorded and compared. Moreover, it was analyzed whether the presence of dysmorphic sacra influenced the precision of screw positioning. Two hundred and thirty-two screws were implanted in 136 patients (100 navigated, 36 conventional). The duration of the average procedure was similar in the two groups [49.8 min (p = 0.7) conventional group (CF) vs. 48.0 min computer-navigated (CNS) group]. With computer navigation, radiation exposure was significantly reduced by almost half [128.3 vs. 65.2 s (p = 0.023)]. Screw placement was more accurate in the navigation group (79.03% CF vs. 86.47% CNS). The presence of dysmorphic sacral foramina or an increased alar slope increased the incidence of screw malpositioning. The conventional percutaneous method and a standardized 2D navigated method have similar rates of malpositioning. Dysmorphic upper sacral foramina and increased alar slope were identified as risk factors for screw malpositioning. Radiation exposure rates were reduced by half when using computer navigation. Therefore, computer navigation in iliosacral screw placement is recommended as method of choice.

Objectives: Anatomical acetabular plates the anterior intrapelvic approach (AIP) were recently introduced to fix acetabular fractures through the intrapelvic approach. Therefore, we asked the following: (1) Does the preshaped 3-dimensional suprapectineal plate interfere with or even impair the fracture reduction quality? (2) How often does the AIP approach need to be extended by the first (lateral) window of the ilioinguinal approach? Design: Observational case series. Setting: Two Level 1 trauma centers. Patients/Participants: Patients with unstable acetabular fractures in 2014. Intervention: Fracture fixation with anatomical-preshaped, 3-dimensional suprapectineal plates through the AIP approach ± the first window of the ilioinguinal approach. Outcome Measurements: Fracture reduction results were measured in computed tomography scans and graded according to the Matta quality of reduction. Intraoperative parameters and perioperative complications were recorded. Radiological results (according to Matta) and functional outcome (modified Merle d'Aubigne score) were evaluated at 1-year follow-up. Results: Thirty patients (9 women + 21 men; mean age ± SE: 64 ± 8 years) were included. The intrapelvic approach was solely used in 19 cases, and in 11 cases, an additional extension with the first window of the ilioinguinal approach (preferential for 2-column fractures) was performed. The mean operating time was 202 ± 59 minutes; the fluoroscopic time was 66 ± 48 seconds. Fracture gaps and steps in preoperative versus postoperative computed tomography scans were 12.4 ± 9.8 versus 2.0 ± 1.5 and 6.0 ± 5.5 versus 1.3 ± 1.7 mm, respectively. At 13.4 ± 2.9 months follow-up, the Matta grading was excellent in 50%, good in 25%, fair in 11%, and poor in 14% of cases. The modified Merle d'Aubigne score was excellent in 17%, good in 37%, fair in 33%, and poor in 13% of cases. Conclusion: The AIP approach using approach-specific instruments and an anatomical-preshaped, 3-dimensional suprapectineal plate became the standard procedure in our departments. Radiological and functional early results justify joint preserving surgery in most cases. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective The treatment of severe spinal deformities in pediatric patients is very challenging. Posterior only vertebral column resection (PVCR) allows for correcting of severe deformities of the vertebral column via a posterior only procedure. We analyzed radiologic outcome of PVCR performed on a series of pediatric patients with severe congenital and acquired spinal deformities. Methods A case series of 11 pediatric patients with severe spinal deformity who were treated by PVCR between 2009 and 2013 were retrospectively analyzed. All patients had posterior instrumentation and reconstruction of the anterior column with titanium cages filled with autologous bone. Seven patients had pure kyphosis or kyphoscoliosis, whereas 4 patients were treated because of scoliotic deformities. The patient records were reviewed for demographic and general clinical data. Complications and adverse events, transfusion rates, and surgical time were recorded. Radiologic analysis included Cobb angles and percentage of correction, analysis of sagittal profile, time to fusion, and possible complications related to instrumentation. Results Average preoperative scoliosis of 61° was corrected to 32°, resulting in a 50% correction at final follow-up. Coronal imbalance was improved to 36% at the most recent follow-up. Mean preoperative kyphotic deformity was 90° and was corrected to 43° at the last follow-up evaluation. Intraoperative complications included loss of the neuromonitoring signals in 2 cases and pleural laceration in 1 case. Conclusions PVCR for children is an effective and safe technique providing a successful correction of complex pediatric spinal deformities. Nevertheless, it remains a technically highly demanding procedure, implying the possibility of severe complications.

Eine 27-jahrige Patientin mit Salmonellenosteomyelitis stellte sich mit dolenter Kniegelenkschwellung und externer Verdachtsdiagnose eines ossaren Lymphoms vor. Anamnestisch war ein mit Prednisolon therapierter Morbus Crohn zu eruieren. Mittels Biopsie wurden im ossaren Material Salmonellenspezies der Gruppe C nachgewiesen. Die Therapie erfolgte durch Ceftriaxon i.v., Cotrimoxazol p.o. sowie chirurgische Wunddebridements. Bei Verdacht auf ein malignes Geschehen sollte bei immunsupprimierten Patienten stets auch eine Infektion berucksichtigt werden.

At the present time, it is generally recommended to use hip replacement in dislocated fractures to avoid failure after internal fixation. A problem is that previous research has demonstrated that observers have problems in discriminating between dislocated and undislocated fractures. A possible solution to this problem would be to use arthroplasty in the majority of the cases. However, this also means that many fractures with the potential for uneventful healing would be replaced. In the current investigation, the mid-term outcome was recorded for patients with intracapsular hip fractures who were treated with either internal fixation or arthroplasty. A novel treatment algorithm was employed. After careful exclusion of cases with known risk factors for failure after internal fixation, a technique called on-table decision was used to identify suitable patients for internal fixation. A total of 72 patients with intracapsular hip fractures were studied with a median follow-up time of 12 months (IQR 8–15.25 months). Nineteen (19) patients (26 %) were excluded in the selection process, leaving 53 (74 %) for on-table decision-making. Thirty patients (42 %) were identified as suitable for internal fixation and gave anatomically stable closed reductions. Two of these patients (7 %) exhibited non-unions and one (3 %) avascular necrosis. The mid-term outcome after internal fixation is promising. The careful selection process may be helpful in identifying fracture patterns for which internal fixation may be considered as a safe and less invasive alternative to hip arthroplasty.

The aim of this study was to prepare an injectable DNA-loaded nano-calcium phosphate paste that is suitable as bioactive bone substitution material. For this we used the well-known potential of calcium phosphate in bone contact and supplemented it with DNA for the in-situ transfection of BMP-7 and VEGF-A in a critical-size bone defect. 24 New Zealand white rabbits were randomly divided into two groups: One group with BMP-7- and VEGF-A-encoding DNA on calcium phosphate nanoparticles and a control group with calcium phosphate nanoparticles only. The bone defect was created at the proximal medial tibia and filled with the DNA-loaded calcium phosphate paste. As control, a bone defect was filled with the calcium phosphate paste without DNA. The proximal tibia was investigated 2, 4 and 12 weeks after the operation. A histomorphological analysis of the dynamic bone parameters was carried out with the Osteomeasure system. The animals treated with the DNA-loaded calcium phosphate showed a statistically significantly increased bone volume per total volume after 4 weeks in comparison to the control group. Additionally, a statistically significant increase of the trabecular number and the number of osteoblasts per tissue area were observed. These results were confirmed by radiological analysis. The DNA-loaded bone paste led to a significantly faster healing of the critical-size bone defect in the rabbit model after 4 weeks. After 12 weeks, all defects had equally healed in both groups. No difference in the quality of the new bone was found. The injectable DNA-loaded calcium phosphate paste led to a faster and more sustained bone healing and induced an accelerated bone formation after 4 weeks. The material was well integrated into the bone defect and new bone was formed on its surface. The calcium phosphate paste without DNA led to a regular healing of the critical-size bone defect, but the healing was slower than the DNA-loaded paste. Thus, the in-situ transfection with BMP-7 and VEGF-A significantly improved the potential of calcium phosphate as pasty bone substitution material.

This video on the ilioinguinal approach presents its indications and techniques for the operative treatment of acetabular fractures. The principle of the ilioinguinal approach is to work through 3 different windows. The lateral window gives access to the pelvic bone from the sacroiliac joint to the lateral border of the iliopsoas muscle, the middle window accesses the medial border of the iliopsoas muscle to the femoral artery, and the medial window allows for control of the anterior pelvic ring medially from the femoral vein to the symphysis pubis. In this video, we demonstrate anatomical reconstruction of the acetabulum in a patient with an associated both-column fracture using the ilioinguinal approach. Indications are all acetabular fracture types, where in addition to anterior column fracture, a fractured posterior column is reducible through the middle window, that is, there is no involvement of the posterior column or wall that would necessitate a direct posterior approach. The ilioinguinal approach is a standard anatomical approach that gives an excellent visual and palpatory exposure of the anterior column up to the symphysis pubis and of the quadrilateral plate. Indications and techniques, how to develop this approach for the anatomical reduction and fixation of appropriate acetabular fractures, are demonstrated in this video.

Purpose To compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up. Patients and methods One hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36. Results No tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups. Conclusion Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.

To evaluate different stabilisation techniques for acromioclavicular (AC) joint separations, including direct AC repair, and to compare the properties of the stabilised and native joints.An established in vitro testing model for the AC joint was used to analyse joint stability after surgical reconstruction [double TightRope (DTR), DTR with AC repair (DTR + AC), single TR with AC repair (TR + AC), and PDS sling with AC repair (PDS + AC)]. Twenty-four human cadaveric shoulders were randomised by age into four testing groups. Joint stiffness was measured by applying an axial load during defined physiological ranges of motion. Similar tests were performed for the native joints, after dissecting the coracoclavicular and AC ligaments, and after surgical reconstruction. Cyclic loading was performed for 1000 cycles with 20-70 N and vertical load to failure determined after cyclic testing.Axial stiffness for all TR groups was significantly higher than for the native joint (DTR 38.94 N/mm, p = 0.005; DTR + AC 37.79 N/mm, p = 0.015; TR + AC 45.61 N/mm, p 0.001 vs. native 26.05 N/mm). The axial stiffness of the PDS + AC group was similar to that of the native joint group (21.4 N/mm, n.s.). AC repair did not significantly influence rotational stiffness. Load to failure was similar and600 N in all groups (n.s.).Reconstruction of AC dislocations with one or two TRs leads to stable results with a higher stiffness than the native joints. For the PDS + AC group, axial stiffness was similar to the native situation, although there might be a risk of elongation. Direct AC repair showed no significantly increased stability in comparison with reconstructions without direct AC repair. Thus, a direct AC repair seems to be dispensable in clinical practice, while TRs or PDS cerclages appear to provide sufficiently stable results.

Background Acetabular fracture surgery is demanding and screw placement along narrow bony corridors remains challenging. It necessitates x-ray radiation for fluoroscopically assisted screw insertion. The purpose of this cadaver study was to evaluate the feasibility, accuracy and operation time of a novel electromagnetic navigation system for screw insertion along predefined acetabular corridors. Methods A controlled laboratory study with a total of 24 electromagnetically navigated screw insertions was performed on 8 cadaveric acetabula. 3 peri-acetabular bony corridors (QSS, Quadrilateral Surface Screw; IAS, Infra-Acetabular Screw; PCS, Posterior Column Screw) were defined and screws were placed in a defined order without fluoroscopy. Operation time was documented. Postoperative CT scans were performed to analyse accuracy of screw placement. Results Mean cadaver age was 70.4 ± 11.7. Successful screw placement was accomplished in 22 out of 24 (91.7%) cases. The overall mean time for all 3 acetabular screws was 576.6 ± 75.9s. All 3 complications occurred during the placement of the IAS due to an impassable narrow bony corridor. QSS mean length was 50 ± 5mm, IAS mean length was 85 ± 10mm and PCS mean length was 120 ± 5mm. Conclusion In this cadaver study the novel electromagnetic navigation system was feasible to allow accurate screw placement without fluoroscopy in defined narrow peri-acetabular bony corridors.

Wirbelkorperkompressionsfrakturen sind die haufigsten osteoporoseassoziierten Frakturtypen. Seit Einfuhrung der Zementaugmentation durch Vertebroplastie und der Augmentation von Schrauben hat sich die Versorgung osteoporotischer Frakturen wesentlich geandert. Es werden biomechanische Aspekte des Risikos von Anschlussfrakturen sowie bei der Versorgung osteoporotischer Wirbelkorperfrakturen bei der reinen Zementaugmentation durch Vertebroplastie und bei der Zementaugmentation von Schrauben bei dorsalen Instrumentationen dargestellt. In einer servohydraulischen Maschine wurden 18 humane osteoporotische Lendenwirbelsaulen (L1–5) angrenzend an zementaugmentierte Wirbelkorper getestet. Dabei wurden ein Standardzement und ein speziell fur die Versuche modifizierter Zement mit einer geringeren Festigkeit verwendet. Weiterhin wurden unterschiedliche Verankerungsformen von Pedikelschrauben mit und ohne Zementaugmentation an weiteren humanen Praparaten mit einem einfachen Pull-out-Test und einem Fatique-Test, der die physiologischen Bedingungen besser widerspiegelt, gepruft. Die Zementaugmentation an der Wirbelsaule fuhrt bei osteoporotischem Knochen zu einer hoheren biomechanischen Stabilitat. Die damit verbundene veranderte Steifigkeit fuhrt jedoch zu biomechanischen Veranderungen mit dem Risiko von Anschlussfrakturen. Die Verwendung eines weniger festen Zements reduziert das Risko fur Anschlussfrakturen signifikant. Beide Schraubenaugmentationstechniken zeigten eine signifikante Erhohung der Auszugskraft gegenuber der Gruppe ohne Zement. Die Augmentation durch die Schraubenperforation ergab im Fatique-Test die hochste Stabilitat. Die Zementaugmentation fuhrt zu einer deutlichen Veranderung der biomechanischen Eigenschaften. Grose Stabilitatsunterschiede zwischen den angrenzenden Wirbelkorpern erhohen das Risiko fur Anschlussfrakturen, das durch modifizierten Zement mit reduzierter Festigkeit gemindert werden kann. Spezielle, fur die Zementapplikation konzipierte Schrauben zeigen im Fatique-Test die hochste Stabilitat.

Acute ankle sprains are frequently accompanied by syndesmotic injuries. These injuries are often overlooked in clinical examinations. The aim of this study was (1) to evaluate the incidence of syndesmotic injuries in acute ankle sprains using MRI, (2) to determine the accuracy of common clinical diagnostic tests, (3) to analyse their inter-rater reliability, and (4) to evaluate the role of clinical symptoms in the diagnosis of syndesmotic injuries. A total of 100 patients with acute ankle sprain injury without associated fractures in plane radiographs were enrolled. The clinical assessment was performed by two independent examiners. Local findings, ankle ligament palpation, squeeze test, external rotation test, Drawer test, Cotton test, and the crossed-leg test (two examiners) were compared with MRI results (read by two blinded radiologists) as a reference standard. Ninety-six participants (57 % male) met the inclusion criteria. MRI detected a ruptured anterior inferior tibiofibular ligament (AITFL) in 14 patients (15 %); 9 partial tears and 5 complete tears were evident. Evidence of pain at rest was found to predict syndesmotic injuries most accurately (p = 0.039). The palpation test over the proximal fibula produced the highest inter-rater correlation (κ = 0.65), but the lowest sensitivity for syndesmotic injuries of 8 %. All other clinical tests demonstrated moderate to fair inter-rater reliabilities (κ = 0.37–0.52). Low sensitivity values were found with all clinical tests (13.9–55.6 %). In this study, clinical examination was insufficient to detect syndesmotic injuries in acute ankle sprains. MRI scanning revealed a syndesmotic lesion in 15 % of patients. MRI scanning should be recommended in patients with ongoing pain at rest following ankle sprains. I.

Ballsportarten sind die fuhrende Ursache fur Sportverletzungen. An der Hand kommt es in den meisten Fallen – 60 % aller Handverletzungen – zu Verletzungen der Finger. Dabei ist die haufigste Lasion die geschlossene Ruptur der Strecksehne uber dem Endgelenk („Mallet-Finger“). Zur Ruptur der tiefen Beugesehne („Jersey-Finger“) kommt es v. a. bei Ballkontaktsportarten wie Rugby. Zusatzlich treten Traumata des Mittel- und des Grundgelenks auf. Diese Verletzungen stellen haufig komplexe Lasionen mit besonderen Anforderungen an Diagnostik und Therapie dar. Fehldiagnosen oder insuffiziente Behandlungen konnen folgenschwer zu Fehlstellungen und zu einem Funktionsverlust an der Hand fuhren. Diese Arbeit liefert einen Uberblick uber die aktuellen Therapiestrategien und gibt Empfehlungen zur Behandlung von Profisportlern.

Die operative Stabilisierung geschlossener Tibiaschaftfrakturen ist eine Domane der Marknagelung. Waren kleine distale Fragmente fruher ein mogliches Problem in Bezug auf die axiale Ausrichtung und deren sichere anatomische Fixierung, ist dieses Problem heute durch die neuen Nageldesigns und -technologien nahezu vollstandig gelost. Noch nicht im selben Ausmas gelost bzw. unter Kontrolle sind das Problem der distalen Verriegelung, die muhselig sein und zu einer hohen Strahlenexposition fuhren kann, sowie die Kontrolle kleinerer, proximal gelegener Frakturfragmente, d. h. also isolierter Fakturen in der proximalen Tibiametaphyse oder segmentaler Frakturen der Tibia, bei denen der proximale Frakturverlauf des entstandenen Segments ebenfalls metaphysar verlauft. Der suprapatellare Zugang ermoglicht das Einbringen des Nagels bei nahezu gestrecktem Kniegelenk. Durch die Verwendung eines suprapatellaren Zugangs kann die Dislokation kurzer, metaphysarer Tibiafragmente verhindert und das Risiko fur die Entwicklung eines Anterior-knee-pain-Syndroms reduziert werden. Drei Hauptindikationen haben sich fur den suprapatellaren Zugang bewahrt: Frakturen mit einem kurzen proximalen Fragment, proximale lokalisierte Segmentfrakturen und unklare infrapatellare Weichteilverhaltnisse. Fur die distale Verriegelung von Unterschenkelmarknageln bietet das magnetfeldgefuhrte distale Verriegelungssystem SureShot® eine sichere Alternative mit reproduzierbar guter Ergebnisqualitat, Operationszeitreduktion und reduzierter Komplikationsrate gegenuber der fluoroskopischen Freihandmethode.

Wir berichten uber den seltenen Fall einer Kniegelenkinfektion, verursacht durch Neisseria meningitidis, Kapseltyp C. In der internistischen Notaufnahme stellte sich eine 19-jahrige Patientin mit seit 2 Tagen bestehender schmerzfreier Kniegelenkschwellung und Fieber von 38°C vor. Drei Tage zuvor sei es zu plotzlichem Unwohlsein und Auftreten eines Hautausschlags gekommen. Es erfolgten die stationare Aufnahme und der Beginn einer Breitspektrumantibiotikatherapie mit Ampicillin/Sulbactam. Zunachst gelingt aus der Synovialflussigkeit fur 3 Tage kein Erregernachweis und es wird von einer reaktiven Arthritis ausgegangen, bis der Nachweis von Neisseria meningitidis in den mit Kniepunktat beimpften Blutkulturflaschen gelingt. Die Patientin kann daraufhin erfolgreich mit Ceftriaxon behandelt und nach einmaliger Kniegelenkarthroskopie nach 14 Tagen aus dem stationaren Aufenthalt entlassen werden. Dieser Fall zeigt die erschwerte klinische und mikrobiologische Diagnose der primaren septischen Meningokokkengelenkinfektion auf, die jedoch im Vergleich zu anderen bakteriellen Gelenkinfektionen eine einfache und zumeist erfolgreiche Behandlung hat.

Background. The influence of increasing lateral plateau widening on the frequency of meniscal and ligamentous lesions in lateral tibial plateau fractures has been examined in very few studies using plain radiographs. Because the amount of this parameter cannot be measured accurately on plain radiographs, the purpose of this survey was to look for a possible correlation between the extent of lateral plateau widening, as measured on multidetector CT (MDCT) scans, and different soft-tissue injuries determined from magnetic resonance imaging (MRI). Materials and Methods. 55 patients with a lateral tibial plateau fracture were included in this retrospective case series. Patient age averaged 52.6 years (SD = 18.0). The degree of lateral plateau widening was measured on CT images. MRIs were screened for meniscal and ligamentous injuries. Results. We found a significant effect of increasing lateral plateau widening on the incidence of lateral meniscus lesions (P = 0.021), lateral collateral ligament tears (P = 0.047), and the overall quantity of meniscal and ligamentous lesions (P = 0.001). Discussion. MRIs are not widely used as a diagnostic tool in lateral plateau fractures of the tibia. Reasons might be the costs and the fact that it is a time-consuming examination. The results of this study may help to estimate the probability of specific soft-tissue lesions in lateral tibial plateau fractures based on measurements of lateral plateau widening on MDCT scans, and they may guide the decision for additional MRI and/or arthroscopically assisted repair.

Introduction For optimal treatment of femoral fractures, it is essential to understand the anatomical antecurvation of the human femur. Recent clinical studies have highlighted the problem of distal anterior encroachment or even perforation of the nail tip. The aim of this study was to accurately describe the femoral antecurvation in a large cohort. Another objective was to identify the most important influences on femoral antecurvation, such as age, femur length, gender and ethnicity. Methods A three dimensional modelling and analytical technology was applied for the analysis of 1,232 femurs. Individual femoral antecurvation was precisely computed to determine whether gender, femur length, age, ethnicity or body mass index influence the radius of curvature (ROC). Results The calculated mean ROC for all femurs was 943 mm. The lowest ROC of 826 mm was found in female Asian femurs. A regression analysis demonstrated that age and femur length could predict the variability of the curvature, with femoral length as most powerful predictor. A matched pair subgroup analysis between Asians and Caucasians could not show any significant differences of ROC values. Conclusions The mean radius of the femoral antecurvation may be smaller than previously reported revealing a significant mismatch between the actual individual anatomy and existing implants. In opposite to existing literature, this study suggests, that antecurvation differences between various ethnicities may exclusively be attributed to differences in femoral length and age. The findings of this study may be found helpful in the development of novel designs for intra- and extramedullary implants.

Osteochondritis dissecans (OCD) represents an important clinical entity in orthopedic sports medicine. Once surgical intervention is required, retrograde drilling for OCD lesions remains technically challenging. A novel electromagnetic navigation system was developed to be a radiation-free navigation tool providing spatiotemporal real-time information to the surgeon without the need for a stationary patient tracker and without relevant setup and calibration times. The novel system was tested for arthroscopically assisted retrograde drilling of cadaveric OCD lesions of the knee and talus and compared with the gold standard fluoroscopy-guided retrograde drilling procedure in a controlled laboratory study setup. The novel method considerably improves on the standard operating procedure in terms of safety, operation time, and radiation exposure and will be available for further surgical indications.

Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking.The purpose of this study was to determine (1) the proportion of patients who develop nerve injuries after acetabular fracture; (2) which fracture type(s) are associated with increased nerve injury risk; and (3) which surgical approach was associated with the highest proportion of patients developing nerve injuries using data from the German Pelvic Trauma Registry. Two secondary aims were (4) to assess hospital volume-nerve-injury relationship; and (5) internal data validity.Between March 2001 and June 2012, 2236 patients with acetabular fractures were entered into a prospectively maintained registry from 29 hospitals; of those, 2073 (92.7%) had complete records on the endpoints of interest in this retrospective study and were analyzed. The neurological status in these patients was captured at their admission and at the discharge. A total of 1395 of 2073 (67%) patients underwent surgery, and the proportions of intervention-related and other hospital-acquired nerve injuries were obtained. Overall proportions of patients developing nerve injuries, risk based on fracture type, and risk of surgical approach type were analyzed.The proportion of patients being diagnosed with nerve injuries at hospital admission was 4% (76 of 2073) and at discharge 7% (134 or 2073). Patients with fractures of the "posterior wall" (relative risk [RR], 2.0; 95% confidence interval [CI], 1.4-2.8; p=0.001), "posterior column and posterior wall" (RR, 2.9; CI, 1.6-5.0; p=0.002), and "transverse+posterior wall" fracture (RR, 2.1; CI, 1.3-3.5; p=0.010) were more likely to have nerve injuries at hospital discharge. The proportion of patients with intervention-related nerve injuries and that of patients with other hospital-acquired nerve injuries was 2% (24 of 1395 and 46 of 2073, respectively). They both were associated with the Kocher-Langenbeck approach (RR, 3.0; CI, 1.4-6.2; p=0.006; and RR, 2.4; CI, 1.4-4.3; p=0.004, respectively).Acetabular fractures with the involvement of posterior wall were most commonly accompanied with nerve injuries. The data suggest also that Kocher-Langenbeck approach to the pelvic ring is associated with a higher risk of perioperative nerve injuries. Trauma surgeons should be aware of common nerve injuries, particularly in posterior wall fractures. The results of the study should help provide patients with more exact information on the risk of perioperative nerve injuries in acetabular fractures.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Die distale Radiusfraktur zahlt zu den haufigsten knochernen Verletzungen des Menschen. Es existieren 2 Gipfel der Pravalenz: im jugendlichen Alter um das 10. Lebensjahr sowie im mittleren Alter um das 60. Lebensjahr. Die Behandlung der Radiusfraktur ist hinsichtlich Diagnostik, Klassifikation und der zahlreichen Therapieoptionen komplex. Behandlungsziele sind die Wiederherstellung einer schmerzfreien uneingeschrankten dauerhaften Funktion des Handgelenks und die Vermeidung frakturtypischer Komplikationen. Stabile Frakturen werden in der Regel konservativ behandelt. Instabile Frakturen mit Trummerzonen intra- und extraartikular werden zunachst geschlossen reponiert und anschliesend osteosynthetisch versorgt. Die winkelstabile palmare Plattenosteosynthese hat sich in den letzten Jahren als Standardversorgung der distalen Radiusfraktur etabliert. Komplexe intraartikulare Mehrfragmentfrakturen vom Typ C3 gemas der Klassifikation der Arbeitsgemeinschaft Osteosynthese (AO) bedurfen einer umfassenden Diagnostik, um typische Begleitverletzungen praoperativ zu diagnostizieren und intraoperativ mitzubehandeln.

Hintergrund Ein neues elektromagnetisches Navigationssystem wurde entwickelt und im Rahmen einer Kadaverversuchsstudie hinsichtlich seiner Machbarkeit und Prazision zur minimal-invasiven anatomischen Rekonstruktion des korakoklavikularen Bandapparats evaluiert.

It is becoming increasingly common for a patient to have ipsilateral hip and knee replacements. The inter-prosthetic (IP) distance, the distance between the tips of hip and knee prostheses, has been thought to be associated with an increased risk of IP fracture. Small gap distances are generally assumed to act as stress risers, although there is no real biomechanical evidence to support this. The purpose of this study was to evaluate the influence of IP distance, cortical thickness and bone mineral density on the likelihood of an IP femoral fracture. A total of 18 human femur specimens were randomised into three groups by bone density and cortical thickness. For each group, a defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing the appropriate lengths of component. The maximum fracture strength was determined using a four-point bending test. The fracture force of all three groups was similar (p = 0.498). There was a highly significant correlation between the cortical area and the fracture strength (r = 0.804, p < 0.001), whereas bone density showed no influence. This study suggests that the IP distance has little influence on fracture strength in IP femoral fractures: the thickness of the cortex seems to be the decisive factor. Cite this article: Bone Joint J 2014;96-B:1378–84.

Purpose The aim of this cadaveric study was to evaluate the accuracy, feasibility, and operation time of a novel electromagnetic navigation system (ENS) and procedure for transclavicular-transcoracoid tunnel placement compared with a standard minimally invasive (SMI) reconstruction method for minimally invasive arthroscopically assisted anatomic acromioclavicular joint reconstruction. Methods Ten arthroscopically assisted electromagnetic-navigated transclavicular-transcoracoid drilling procedures and 10 SMI procedures were performed on 10 human cadavers using 2 TightRope reconstructions (Arthrex, Naples, FL) for each site. Postoperative computed tomography scans were acquired to determine tunnel placement accuracy. Optimal coracoid tunnel placement was defined according to the anatomic insertions of the trapezoid and conoid ligaments with the oblong button placed in a center-base position at the coracoid undersurface without cortical breach or fracture. Both reconstruction procedures were performed without fluoroscopy. Results Successful tunnel placement was accomplished in 98.8% using the ENS method and in 83.8% using the SMI procedure ( P = .087). The mean overall operation time was 28.5 ± 6.6 minutes for the ENS method and 35.2 ± 3.9 minutes for the SMI method ( P = .012). The ENS procedure required no directional readjustments or restarts. Drill misguidance with subsequent cortical breach occurred twice in the SMI group. In both groups no fractures were documented. Conclusions In this descriptive laboratory study, both the ENS and the SMI techniques achieved the desired anatomic reconstruction. Compared with the SMI method, the ENS procedure showed higher accuracy, required a shorter operation time, and was associated with no complications. Clinical Relevance Length of surgery, drilling accuracy, and reduction of radiation exposure in acromioclavicular joint reconstruction procedures affect the safety of both patients and surgeons.

During the one-stage exchange procedure for periprosthetic joint infection (PJI) after total hip arthroplasty (THA), acetabular defects challenge reconstructive options. Porous tantalum augments are an established tool for addressing acetabular destruction in aseptic cases, but their utility in septic exchange is unknown. This retrospective case-control study presents the initial results of tantalum augmentation during one-stage exchange for PJI. Primary endpoints were rates of re-infection and short-term complications associated with this technique. Study patients had no higher risk of re-infection with equivalent durability at early follow-up with a re-infection rate in both groups of 4%. In conclusion, tantalum augments are a viable option for addressing acetabular defects in one-stage exchange for septic THA. Further study is necessary to assess long-term durability when compared to traditional techniques for acetabular reconstruction.

BACKGROUND The requirements for treatment of femoral fractures are increasing with the rising age of the patients. The aim of this study was to evaluate femoral stiffness and the fracture risk after inserting different implants and implant combinations. METHODS A total of 48 cadaveric femors were harvested and 8 groups were randomized on the basis of the bone mineral density (BMD). Different osteosyntheses following prosthetic stem implantation (hip and knee prostheses) were performed and compared with native femurs. All specimens were biomechanically tested in a four-point bending until fracture. RESULTS The insertion of a femoral stem decreases the stiffness by approximately 33%. Ipsilateral retrograde nailing reduces the force to failure even more. This instable situation can be stabilized by a lateral locking compression plate. The most stable situation occurred in the presence of two cemented stems. CONCLUSION Taken together these results clearly indicate that a hip prosthesis significantly weakens the femur, whereas two stems produce the most stable situation at all. The situation of a hip prosthesis and an retrograde nail should be avoided or covered by a bridging-osteosynthesis. In clinical practice an extramedullary fixation technique for distal femoral fractures should be preferred.

The aim of this investigation was to perform a biomechanical comparison between 1- and 2-screw systems used for the treatment of intertrochanteric fractures for centralized and decentralized placement of femoral neck screws of failure loads, stiffness, survival rates, tip apex distance (TAD), and failure mode.As fracture model, an AO 31A2.3 fracture was used. Twelve pairs of human cadaver femora were tested. Femoral neck screws were implanted in the femoral head in center/center, posterior/central, and anterior/superior position in axial/frontal plane. A single-screw system (Gamma 3 Locking Nail; Stryker GmbHCo. KG) and a 2-screw system (Trigen-Intertan; SmithNephew GmbH) were used. To simulate the load in situ, a cyclic load was carried for 10,000 cycles in a material testing machine. If no cyclic failure occurred, femora were loaded until the failure. The systems were compared according to the stiffness, survivability through 10 k cycles, TAD, and load to failure.None of the tested bones failed at center/center location in the decentralized positions 3 Gamma Nail and 2 Intertan specimens failed during cyclic testing. The 2-screw system resisted higher forces in all positions (Gamma: 5370N ± 1924, Intertan: 7650N ± 2043; P = 0.014).Based on these data, it is clear that both the nail systems showed a higher biomechanical stability with a lower TAD. The 2 specimens that failed with the Intertan in the cyclic tests had a TAD ≥49 mm. The cutout failures that we detected during cyclic testing in the Gamma system had a TAD ≥30 mm. Thus, it is clear that the TAD affects failure independent of the implant used. With a less than ideal lag screw placement, however, the Intertan system with 2 integrated screws was able to withstand higher loads in this study.

Fungal peri-prosthetic infections of the knee and hip are rare but likely to result in devastating complications. In this study we evaluated the results of their management using a single-stage exchange technique. Between 2001 and 2011, 14 patients (ten hips, four knees) were treated for a peri-prosthetic fungal infection. One patient was excluded because revision surgery was not possible owing to a large acetabular defect. One patient developed a further infection two months post-operatively and was excluded from the analysis. Two patients died of unrelated causes. After a mean of seven years (3 to 11) a total of ten patients were available for follow-up. One patient, undergoing revision replacement of the hip, had a post-operative dislocation. Another patient, undergoing revision replacement of the knee, developed a wound infection and required revision 29 months post-operatively following a peri-prosthetic femoral fracture. The mean Harris hip score increased to 74 points (63 to 84; p < 0.02) in those undergoing revision replacement of the hip, and the mean Hospital for Special Surgery knee score increased to 75 points (70 to 80; p < 0.01) in those undergoing revision replacement of the knee. A single-stage revision following fungal peri-prosthetic infection is feasible, with an acceptable rate of a satisfactory outcome. Cite this article: Bone Joint J 2014;96-B:492–6.

Posteriore Schulterluxationen stellen ein seltenes Verletzungsbild dar, gehen jedoch haufig mit weichteiligen und/oder ossaren Begleitverletzungen wie der reversen Hill-Sachs-Lasion oder einem dorsalen Labrumschaden einher. Fur die Kombination dieser Lasionen existieren bisher keine evidenzgesicherten Therapieempfehlungen. Anhand von zwei Fallberichten und einer Literaturanalyse sollen Losungsmoglichkeiten zur operativen Versorgung kombinierter knocherner und weichteiliger Verletzungen bei hinterer Schulterluxation aufgezeigt werden. Wir berichten uber 2 Patienten mit einer frischen traumatischen dorsalen Erstluxation, die zunachst arthroskopisch exploriert, dann in offener Technik versorgt wurden. Im ersten Fall erfolgte zunachst die arthroskopische Refixation des hinteren Labrums, anschliesend die offene Versorgung der reversen Hill-Sachs-Lasion mittels Osteosynthese und alloplastischem Knochenersatzmaterial. Im zweiten Fall erfolgte die diagnostische Arthroskopie sowie nach frustranem Versuch der arthroskopisch gestutzen retrograden Anhebung des Defekts die offene Rekonstruktion des Humeruskopfes mittels allogenem Knochen. In beiden Fallen wurde zum Abschluss des Follow-up nach 16 bzw. 12 Monaten ein gutes klinisches Ergebnis mit einem Constant-Score von 79 bzw. 86 Punkten beobachtet. Radiologisch wurde eine abgeschlossene knocherne Heilung ohne Zeichen einer posttraumatischen Osteoarthrose gesehen. Zusammenfassend zeigen beide Falle, dass es sich bei der operativen Versorgung der frischen, traumatischen hinteren Schulterluxation anbietet, zunachst das Gelenk arthroskopisch zu explorieren, um Begleitverletzungen des Labrums erkennen und ggf. mitversorgen zu konnen. Die knocherne Pathologie des Humeruskopfes kann anschliesend in offener Technik angegangen werden, wobei die Therapiewahl in Abhangigkeit der Defektgrose zu treffen ist.

Background Central screw positioning in the scaphoid provides biomechanical advantages. Methods A prospective randomized study of six fluoroscopically guided and six electromagnetically navigated screw (ENS) placements was performed on human cadavers. Accuracy of screw position was determined. Intraoperative fluoroscopy exposure times, readjustments of drilling directions, complete restarts and complications were documented. Results The ENS method provided a mean time benefit of 7.34 min compared with the standard method and the mean screw length ratio (SLR coronar: ENS 0.96 ± 0.04 mm, SFF: 0.92 ± 0.04 mm, P = 0.065; SLR sagittal: ENS 0.98 ± 0.02 mm, SFF: 0.91 ± 0.04 mm, P = 0.009) and the screw axis deviation angle (AD coronar: ENS 3.33 ± 2.34°, SFF: 10.33 ± 2.58°, P = 0.002; AD sagittal: ENS 2.83 ± 0.98°, SFF: 11.00 ± 6.16°, P = 0.002) were lower. Using the electromagnetic navigation procedure no drilling readjustments or restarts were required, no cortical breach occurred. Conclusions Compared with the standard fluoroscopic technique, the ENS method used in this study showed higher accuracy, less complications, required less operation and radiation exposure time. Copyright © 2014 John Wiley & Sons, Ltd.

Intramedullary fixation of intertrochanteric fractures has become the standard method of fixation especially in unstable fracture types. Even though there have been developments on implant design and technology, the surgical technique of reduction and implant positioning remains the mandatory factor in treating these fractures successfully. The advantages of nailing in the mainly elderly patients sustaining intertrochanteric femur fractures are a short lever arm and a lateral support in the trochanter supplied by the nail. The disadvantages are that it is often harder to achieve a closed reduction of a displaced fracture and to maintain the reduction with the intramedullary implant. To obtain and maintain anatomic reduction and a secure fracture fixation, the surgical approach and fixation technique is of great importance. It starts with correct patient positioning, fracture reduction (accounting for varus dislocation and dislocation of flexed fragments), choosing the correct nail entry point and perfect lag screw positioning within the head-neck fragment and distal locking. To maintain the reduction achieved intraoperatively, the decision has to be made to use a cerclage wiring or to tolerate fracture gaps in the metaphyseal area. Intraoperative controlled compression of the neck or the subtrochanteric area is of great importance to reduce delayed unions or nonunions. Intramedullary fixation of unstable per-, inter- or subtrochanteric fractures shows biomechanical advantages compared to extramedullry fixation techniques. Even though there have been several amendments and developments of implants, a better implant does not compensate for an inadequate surgical approach or deficient surgical techniques which are paramount for successful treatment. When fixing fractures with intramedullary nailing systems, the surgeon should always try to achieve anatomic reduction and a perfect implant positioning to allow immediate full weight bearing without an increased risk of cut-out, non-union and implant failure.

The established technique for posterior C1 screw placement is via the lateral mass. Use of C1 monocortical pedicle screws is an emerging technique which utilizes the bone of the posterior arch while avoiding the paravertebral venous plexus and the C2 nerve root. This study compared the relative biomechanical fixation strengths of C1 pedicle screws with C1 lateral mass screws.Nine human C1 vertebrae were instrumented with one lateral mass screw and one pedicle screw. The specimens were subjected to sinusoidal, cyclic (0.5 Hz) fatigue loading. Peak compressive and tensile forces started from ±25 N and constantly increased by 0.05 N every cycle. Testing was stopped at 5 mm displacement. Cycles to failure, displacement, and initial and end stiffness were measured. Finally, CT scans were taken and the removal torque measured.The pedicle screw technique consistently and significantly outperformed the lateral mass technique in cycles to failure (1,083 ± 166 vs. 689 ± 240 cycles), initial stiffness (24.6 ± 3.9 vs. 19.9 ± 3.2 N/mm), end stiffness (16.6 ± 2.7 vs. 11.6 ± 3.6 N/mm) and removal torque (0.70 ± 0.78 vs. 0.13 ± 0.09 N m). Only 33 % of pedicle screws were loose after testing compared to 100 % of lateral mass screws.C1 pedicle screws were able to withstand higher toggle forces than lateral mass screws while maintaining a higher stiffness throughout and after testing. From a biomechanical point of view, the clinical use of pedicle screws in C1 is a promising alternative to lateral mass screws.

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective. We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed. Cite this article: Bone Joint J 2013;95-B:1527–32.

Prior fracture surgery in the setting of subsequent arthroplasty may confer an increased risk of infection. The current authors retrospectively reviewed 122 patients from 2006 to 2010. Joint aspirations performed preoperatively in two of 52 patients revealed bacterial growth. Preoperative CRP levels were elevated in 22.8% with a mean value of 10.4 mg/L (range 5.5 to 33.3). Intra-operative cultures were performed in 109 patients, with a single patient sample exhibiting bacterial growth (0.9%). Preoperative aspiration showed a sensitivity of 1.0 and specificity of 0.98 (P

Polytrauma mortality rates have been continuously decreasing in recent years. Due to rising prevalence of obesity, overweight patients are increasing in numbers within the polytrauma population. The body mass index (BMI) provides information about nutritional status. Varying results have been reported concerning the effect of body mass index on polytrauma outcome. Both obesity and the condition of being underweight are independent risk factors for increased polytrauma mortality. While being underweight is associated with early polytrauma mortality, the presence of obesity correlates with higher rates of multi-organ failure and sepsis and is associated with late polytrauma mortality.

Normal progression of osteoporosis or the rigid reinforcement of the fractured vertebral body with polymethyl methacrylate (PMMA) cement is being discussed as a cause for adjacent-level fractures after vertebroplasty. The purpose of this study was to investigate whether augmentation with low stiffness cement can decrease the risk of adjacent-level fractures in low-quality bone.Eighteen female osteoporotic lumbar specimens (L1-L5) were harvested and divided into three groups according to bone mineral density: (I) native; (II) PMMA; (III) modified PMMA (lower stiffness). For the PMMA and modified PMMA groups, a compression fracture was first mechanically induced in L3, and then the fracture received vertebroplasty treatment. The cement stiffness reduction of the modified PMMA group was achieved via an addition of 8 mL of serum to the typical PMMA base. All specimens were exposed to cyclic loading (4 Hz) and a stepwise increasing applied peak force. Cement stiffness was tested according to ISO 5833.A 51% decrease in cement stiffness was achieved in the modified PMMA group (954 ± 141 vs. 1,937 ± 478 MPa, p0.001). Fatigue fracture force (the force level during cyclic loading at which the deformation experienced a sudden increase; FFF) was significantly affected by bone quality (r (2) = 0.39, p = 0.006) and by the initial fracture force (the force necessary to create the initial fracture in L3 prior to augmentation; r (2) = 0.82, p0.001). Using initial fracture force as a covariate, the FFF of the modified PMMA group (1,764 ± 49 N) was significantly higher than in the PMMA group (1,544 ± 55 N; p = 0.03).A possible method to reduce adjacent-level fractures after vertebroplasty in patients with reduced bone quality could be the use of a lower modulus cement. Therefore, mixing cement with biocompatible fluids could prove useful to tailor cement properties in the operating theater.

We describe the successful reconstruction of the index finger metacarpophalangeal joint with an osteochondral autograft from the lateral femoral condyle following failed curettage and cementation of a giant cell tumour of the proximal phalanx base. At the 2-year follow-up, a good functional outcome was noted with 0-80° range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumour recurrence.

There have been only a few small studies of patients with an infected shoulder replacement treated with a single-stage exchange procedure. We retrospectively reviewed 35 patients (19 men and 16 women) with a peri-prosthetic infection of the shoulder who were treated in this way. A total of 26 were available for clinical examination; three had died, two were lost to follow-up and four patients had undergone revision surgery. The mean follow-up time was 4.7 years (1.1 to 13.25), with an infection-free survival of 94%.The organisms most commonly isolated intra-operatively were Staphylococcus epidermidis and Propionibacterium acnes; two patients developed a recurrent infection. Three different types of prosthesis were used: a hemiarthroplasty, a hemiarthroplasty with a bipolar head and reverse prosthesis. The mean Constant-Murley score at final follow-up was 43.3 (14 to 90) for patients with a hemiarthroplasty, 56 (40 to 88) for those with a hemiarthroplasty with a bipolar head and 61 (7 to 90) for those with a reverse prosthesis. The mean hospital stay was 10.6 days (5 to 29).Single-stage exchange is a successful and practical treatment for patients with peri-prosthetic infection of the shoulder.Cite this article: Bone Joint J 2013;95-B:391–5.

Der hintere Beckenring ist entscheidend fur die Stabilitat des Beckens. Die Verletzungsformen sind vielfaltig und konnen als rein ligamentare, knocherne oder kombinierte Verletzungen auftreten. Bei gleichzeitigen ventralen und dorsalen Verletzungen muss v. a. entschieden werden, welche Seite zuerst angegangen werden muss. Dabei kommen fur den hinteren Beckenring ilioiliakale Plattenosteosynthesen, lokale Plattenosteosynthesen, iliosakrale Schraubenosteosynthesen und lumbopelvine Abstutzungen zum Einsatz. Ein wichtiges Kriterium fur die Zugangswahl ist die Weichteilsituation. Diese verbietet mitunter ausgedehnte Zugange. Gerade am hinteren Beckenring mussen die Weichteile so weit moglich geschont werden, da es sonst durch das Aufliegen der teilweise schwer verletzten Patienten zu Wundheilungsstorungen kommen kann. Ziel der vorliegenden Arbeit ist es, die am haufigsten dorsal verwendeten Zugange bei Beckenringverletzungen darzustellen.

There is a lack of studies reporting on rhBMP-2 application in pediatric orthopaedics, although few reports demonstrated promising results of the use of rhBMP-2 in children, especially for spine fusion and for the treatment of congenital pseudarthrosis of the tibia. The objectives of this study were (1) to examine clinical and radiographic healing after rhBMP-2 application for the treatment of congenital pseudarthrosis of the tibia (CPT) or persistent tibial nonunion in children and adolescents, and (2) to investigate the safety of rhBMP-2 use in these cases. Therefore we reviewed the medical records of ten patients with a mean age of 8.6 years (2.3–21) with CPT (n = 7) or persistent tibial nonunion for at least six months (n = 3) who had been treated with rhBMP-2. Nine of ten patients had union at final follow-up, after a mean of 72.9 months (25–127). In the CPT group, primary healing of the pseudarthrosis occurred in six of seven patients at a mean of 5.2 months (3–12). Repeat rhBMP-2 application was performed in three patients; two patients had one additional application each, and one patient had three additional applications. Complications that may be attributed to the use of rhBMP-2 were seen in two of fifteen applications, including a compartmemt syndrome and a hematoma. In this retrospective case series rhBMP-2 has been used successfully to treat CPT or persistent tibial nonunion in pediatric patients. However, prospective randomized controlled trials are warranted to investigate the long-term efficacy and safety of rhBMP-2 use in these cases.

Aneurysmal bone cysts (ABC) are benign bone tumors, which are highly vascularized. The main course of treatment is curettage followed by bone grafting or cement insertion. Still recurrence remains a main problem for patients. Denosumab is a monoclonal antibody, which acts as an inhibitor of the RANK/RANKL pathway, diminishing bone turnover. Recent case reports have shown that Denosumab can be a promising therapeutic agent for people suffering from therapy-resistant ABC. We report the case of a 35-year-old female patient presenting with a pronounced ABC of the pelvis. Since the tumor was inoperable, Denosumab was administered, leading to a significant shrinkage of the lesion, which allowed surgical intervention. Upon recurrence, Denosumab was restarted putting the patient once more into remission. Follow-up was four years overall with a clinical and radiological stable disease for fifteen months after final discontinuation of the monoclonal antibody. Therefore, our case further underlines the potential of Denosumab in the treatment of ABC.

Background. The aim of this study was to examine clinical and radiographic healing after rhBMP-2 application in children and adolescents presenting with nonunion of the femur and to investigate the safety of rhBMP-2 use in these cases. Materials and Methods. We reviewed the medical records of five patients with a mean age of 11 years (5.4 to 16.2) with nonunion of the femur who were treated with rhBMP-2 and internal fixation using a locking plate at a single institution. Particular attention was paid to identify all adverse events that may be due to rhBMP-2 use. Results. Union occurred in four of five patients at a mean of 12.1 months (7.9 to 18.9). The locking plates were removed after a mean of 16 months (11 to 23). One patient had nonunion due to deep infection. After a mean follow-up of 62.5 months (17 to 100), union was still evident in all four patients and they were fully weight-bearing without pain. Discussion. In this retrospective study, rhBMP-2 combined with a locking plate has been used successfully to treat children and adolescents with nonunion of the femur in four of five cases. One major complication was thought to be possibly related to its use.