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In the Department of Traumatology at the University of Ulm, 26 elderly patients with displaced acetabular fractures were treated with primary implantation of a hip joint endoprosthesis between 1986 and 1996. The principles of operative therapy are stabilization of the acetabular ring, grafting of acetabular defects with autogenous corticocancellous bone and cranial buttressing with a reinforcing ring. This concept permits immediate mobilization of elderly patients and full weight-bearing and thus results in favorable early postoperative results. Secondary complications typically caused by immobilization can therefore be avoided.

Lebensqualitat wird nur derjenige Unfallchirurg in seinem dritten Lebensabschnitt finden, der Suchender bleibt und sich nicht von Vorgaben leiten lasst, sondern selbstbestimmend Entfaltungswillen und Kreativitat entwickelt.

AIM OF STUDY To determine the prevalence of joint specific risk factors in patients with different patterns of advanced hip and knee osteoarthritis (OA). METHODS We performed a cross-sectional multicenter study in four orthopaedic hospitals in the southwest of Germany. A detailed medical history (date and nature of trauma, conservative and surgical treatment of congenital or acquired joint disorders known as secondary causes of OA) and radiographic evaluation (sequelae of hip dysplasia, slipped capital femoral epiphysis or other malformations) was obtained in 809 patients with advanced hip (n = 420) or knee (n = 389) osteoarthritis, which required unilateral total joint replacement. According to the presence or absence of joint specific risk factors, patients were classified as having secondary or primary (idiopathic) OA. RESULTS In 41.7% (25.5%) of patients with hip OA and 33.4% (11.1%) of patients with knee OA some predisposing abnormality of the operated (or contralateral) joint could be observed. In hip OA the underlying pathological conditions were mainly hip dysplasia (25.0% in the operated joint and 14.8% in the non-operated joint) and slipped capital femoral epiphysis (7.1% and 14.8%), while knee OA was most often associated with a history of severe trauma (28.6% and 8.3%) CONCLUSION While there is a lack of comparable investigations in patients with advanced knee OA, the presented data is somewhat contradictory to earlier reports of the prevalence of identified underlying risk factors in patients with hip OA. The reported differences, however, might be attributed to different methodological approaches and could also resemble recent changes in the multifactorial ethiopathologic concept of OA.

Proximal tibial epiphyseal injury is a rare finding in adolescents. We report the case of a 13-year-old boy with simultaneous epiphyseal fractures of both proximal tibiae to illustrate appropriate diagnosis and treatment of this condition. The injury occurred while performing a long jump: a Salter-Harris type II fracture of the right proximal tibia was sustained at take-off and a Salter-Harris type III avulsion fracture of the left tibial tuberosity upon landing. Closed reduction and internal fixation using K-wires were performed on the right side, whereas open reduction and internal fixation were done on the left side, using a lag screw and additional McLaughlin wiring.

Pathological fractures are dreaded complications due to skeletal metastasis. Modern oncological therapies and more sophisticated new radiological techniques such as MRI and positron emission tomography have improved multimodal treatment concepts. Surgical intervention is determined by the primary disease, general condition and life expectancy of the patient. The goals of surgical treatment are improvement of life quality, pain relief and maintenance of mobility.

Current treatment regimens that are designed to prevent deep venous thrombosis in patients undergoing orthopaedic procedures rely predominantly on drug prophylaxis alone. The purpose of this randomized clinical study was to evaluate the effectiveness of a mechanical adjunct to chemoprophylaxis that involves intermittent compression of the legs.During a twenty-two month period, 1803 patients undergoing a variety of orthopaedic procedures were prospectively randomized to receive either chemoprophylaxis alone or a combination of chemoprophylaxis and mechanical prophylaxis. Nine hundred and two patients were managed with low-molecular-weight heparin alone, and 901 were managed with low-molecular-weight heparin and intermittent pneumatic compression of the calves for varying time periods. Twenty-four percent of the patients underwent total hip or knee joint replacement. Screening for deep venous thrombosis was performed on the day of discharge with duplex-color-coded ultrasound.In the chemoprophylaxis-only group, fifteen patients (1.7%) were diagnosed with a deep venous thrombosis; three thromboses were symptomatic. In the chemoprophylaxis plus intermittent pneumatic compression group, four patients (0.4%) were diagnosed with deep venous thrombosis; one thrombosis was symptomatic. The difference between the groups with regard to the prevalence of deep venous thrombosis was significant (p = 0.007). In the chemoprophylaxis plus intermittent pneumatic compression group, no deep venous thromboses were found in patients who received more than six hours of intermittent pneumatic compression daily.Venous thrombosis prophylaxis with low-molecular-weight heparin augmented with a device that delivers rapid-inflation intermittent pneumatic compression to the calves was found to be significantly more effective for preventing deep venous thrombosis when compared with a treatment regimen that involved low-molecular-weight heparin alone.

Das Skelettsystem stellt nach Leber und Lunge den dritthaufigsten Manifestationsort von Metastasen dar. 30± 50 % aller Patienten, die an einem Malignom erkranken, entwickeln ossare Metastasen. Viele dieser Metastasen zeigen keine Symptome, konnen jedoch im Sektionsgut nachgewiesen werden. Knochenmetastasen treten am haufigsten in der Wirbelsaule auf (bis zu 60± 80%). Weitere Pradilek− tionsstellen sind Becken, Femur, Rippen und Humerus. Die Inzidenz von Knochenmetastasen ist abhangig vom Primartumor. Sie treten gehauft beim Mamma− karzinom (50 ± 85 %), beim Prostatakarzinom (60 ± 80%), beim Nierenzellkarzinom (20 ± 50%), beim Schildrusen− karzinom (20± 60 %) sowie beim Bronchialkarzinom (20± 60 %) auf.

Bei der klinischen Untersuchung kann die absolute Beinlangendifferenz mit der Brettchen- oder schneller der PALM-Methode bestimmt werden (Genauigkeit ±1,5 cm). Die Bestimmung der Beinlangendifferenzen mit dem Masband ist noch ungenauer. Wesentlich exakter ist die Bestimmung der relativen Beinlange mit radiologischen Methoden. Bei der Orthorontgenographie und der CT betragen die Richtigkeit ±3 mm und die Wiederholbarkeit ±2 mm. Somit sind auch hier Abweichungen von bis zu 5mm bei der Einzelmessung moglich. Die Genauigkeit der navigierten Ultraschallmessung (2.5D-Sonographie) liegt in der gleichen Grosenordnung. Auch bei standardisierter Durchfuhrung der Telerontgenographie betragen die Richtigkeit und Wiederholbarkeit bei der Bestimmung der Beinachse ±3°. Die Bestimmung der anatomischen Beinachse an langen Kniegelenksaufnahmen sollte wegen einer noch groseren Ungenauigkeit nicht durchgefuhrt werden. Torsionswinkeldifferenzen konnen klinisch nur im Bereich der Unterschenkel mit einer ausreichenden Genauigkeit (95% Fehler

Grosschadensereignisse stellen stets besondere Anforderungen an die rettungsdienstliche Logistik. Als geradezu „klassisches“ Beispiel fur den Massenanfall von Verletzten gilt das Eisenbahnungluck. Im deutschsprachigen Raum sind aufgrund hoher Sicherheitsstandards derartige Ereignisse selten, wiewohl im Ablauf gut untersucht (Eschede). Auffallend, wenn auch aus der Abfolge logisch, sind sehr geringe Daten in der Literatur uber den Ablauf solcher Massenunglucke vom Unfallzeitpunkt bis zum Beginn der professionellen Hilfe, also die Phase der sog. Laienhilfe oder „Chaosphase“. Der Autor erlebte als Fahrgast die frontale Kollision zweier Zuge der Zugspitzbahn am 10.06.2000 mit. Durch die direkte Verfolgung des Unfallgeschehens als Betroffener und leicht Verletzter, aus der zunachst geleisteten „ersten arztlichen Hilfe ohne Mittel“ sowie der dann folgenden eigenen notarztlichen Mithilfe ergaben sich interessante Erkenntnisse uber die unmittelbar nach einem Grosschadensereignis ablaufenden Vorgange. Zusammengefasst konnte aus der gemachten Erfahrung die grose Bedeutung der Unfall(fremd)anamnese in Bezug auf den Aufenthaltsort einzelner Patienten zum Zeitpunkt des Unglucks als entscheidender Erkenntnisgewinn fur die Einschatzung der Verletzungsschwere, zur Erleichterung der Triage und zur raschen Versorgung gewonnen werden.

We studied the effect of full and partial weight-bearing on venous peak velocity in the legs of 73 subjects. We used colourflow Duplex ultrasound to determine the minimal amount of weight-bearing required to produce the same venous peak velocity as full weight-bearing. We found that the venous peak velocity remains the same in the femoral vein during partial weight-bearing (196 N and above). This is important for postoperative physiotherapy and thrombo-prophylaxis. The median peak velocity was 30 cm/s. This corresponds to an amplification factor of four in relation to the individual resting level (peak velocity). In addition, we found that partial weight-bearing at 196 N can reliably be reproduced. The median value of partial weight-bearing after a three-day training programme was 206 N.

Die Autoren berichten uber eine prospektive multizentrische Studie zur operativen Behandlung frischer Verletzungen des thorakolumbalen Ubergangs (Th10 bis L2). Die Studie soll die derzeitigen Behandlungsmethoden und ihre Ergebnisse an einem grosen Kollektiv reprasentativ analysieren und wird von der Arbeitsgemeinschaft “Wirbelsaule” der Deutschen Gesellschaft fur Unfallchirurgie (DGU) erarbeitet. An 18 unfallchirurgischen Kliniken in Deutschland und Osterreich wurden von September 1994 bis Dezember 1996 insgesamt 682 Patienten prospektiv erfasst. Die Nachuntersuchung der Patienten ist z. Z. noch nicht abgeschlossen. Im Teil 1 (Epidemiologie) wurden Studiendesign und epidemiologische Daten des Kollektivs dargestellt. Der vorliegende Teil 2 schildert die Details der Operationen sowie Messdaten der konventionellen Rontgenuntersuchungen und Computertomographien (CT); 448 (65,7%) Patienten wurden von dorsal, 197 (28,9%) kombiniert dorsoventral und 37 (5,4%) isoliert von ventral operiert; 72% der 448 von dorsal stabilisierten Patienten erhielten eine transpedikulare Spongiosaplastik. Die kombinierten dorsoventralen Eingriffe wurden bei 75 (38,1%) Verletzten einzeitig und bei 122 (61,9%) zweizeitig durchgefuhrt. Die durchschnittliche Operationszeit war bei kombiniertem Eingriff mit 4:14 h signifikant langer als bei dorsalem (p

The knowledge gained in anatomical studies on the sensory innervation of the ankle joint was applied to 11 patients suffering from post-traumatic arthrosis of the ankle joint who underwent denervation operations following successful test blocks. In order to achieve an ankle joint denervation as complete as possible while maintaining the sensitivity of the sole and dorsum of the foot, neurotomies away from the joint were performed in the saphenous, sural, and deep peroneal nerves as well as the interosseous branch, whereas the tibal nerve and the superficial peroneal nerve were skeletized by neurotomy of the branches to the ankle joint only. Good results were obtained in seven out of 10 patients examined in the follow-up.

120 Patienten nach Ersatz des vorderen Kreuzbandes (VKB) mit La-Fil-Kohlefaserprothese wurden retrospektiv mittels Fragebogen und 80 Patienten klinisch nach im Mittel 10 ± 2 Jahren untersucht. Die subjektive Beurteilung ergab 60 % zufriedene Patienten bei deutlich vermindertem Aktivitatsniveau. Als objektive Komplikationen waren bei 72,5 % der Patienten die C-Faser rupturiert und bei 68 % der Patienten synoviale Reaktionen zu beobachten. Rontgenologisch zeigten sich in bis zu 59 % der Falle arthrotische Veranderungen. Die mit C-Faser rekonstruierten Collateralbander (85 % medial, 5,8 % lateral) waren zu 75 % stabil. Fur das Versagen der Kohlefaserprothesen scheinen weniger die Aktivitat oder die Zeit als vielmehr das Einwachsverhalten der Prothesen eine Rolle zu spielen. Im Langzeitverlauf fuhrt die reaktive Synovitis uber katabole Enzymreaktionen zur Gelenkdestruktion. Klinische Zeichen sind rezidivierende Gelenkergusse und Schmerzen. Zur Unterbrechung des Circulus vitiosus ist die (arthroskopische) Synovektomie indiziert.

Navigationsgestutzte Operationsverfahren beruhen auf der Interaktion von Kamera und chirurgischem Instrument, was eine geometrische Positionsbestimmung von Letzterem erlaubt. Das Rechnersystem, an welches die Daten weitergeleitet werden, setzt die raumliche Lage des Instruments in Bezug zur Knochenanatomie des Patienten. Im vorliegenden Beitrag wird insbesondere auf CT-basierte Navigation, C-Arm-Navigation und ihre Einsatzmoglichkeiten eingegangen.

Die offene operative Versorgung intraarticularer verschobener Fersenbeinbruche setzt sich immer mehr durch. Uberwiegend werden diese Bruche heute uber einen erweiterten lateralen Zugang versorgt. Zur Stabilisierung der verschiedenen z. T. komplexen Frakturformen kommen unterschiedlichste Implantate zum Einsatz. Die von uns entwickelte „Low-contact-Platte“ ist auf die speziellen Erfordernisse bei Fersenbeinfrakturen ausgerichtet. Es konnen damit alle Frakturformen versorgt werden, da die Implantatform der Anatomie des Fersenbeins nachempfunden wurde und die Vielzahl der Schraubenlocher einen variablen Einsatz der Schrauben gestattet. Die Ergebnisse in 36 Fallen bestatigen, das die neue Platte den Anforderungen gerecht wird.

After the active working life is completed it is not passive relaxation which will bestow enduring endorphin levels but the exact opposite: enduring tension! Quality of life and happiness in the third phase of life will only be found by trauma surgeons who remain seeking, not led by guidelines but self-determined and developing creativity and willingness to unfold.

Das spezialisierte Traumazentrum vermag unter Ausnutzung aller fachbezogenen Kapazitaten optimale Uberlebenschancen fur Schwerstverletzte zu bieten. Diese Leistung ist jedoch nur moglich, wenn Kooperationsfahigkeit unter den beteiligten Spezialisten besteht und die Koordination durch einen kompetenten Traumaleader, der auf dem Boden interdisziplinar erarbeiteter und akzeptierter Behandlungsrichtlinien agiert, gewahrleistet wird.

Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB(R)-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model.For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded.Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing.The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.

Proximal tibial epiphyseal injury is a rare finding in adolescents. We report the case of a 13-year-old boy with simultaneous epiphyseal fractures of both proximal tibiae to illustrate appropriate diagnosis and treatment of this condition. The injury occurred while performing a long jump: a Salter-Harris type II fracture of the right proximal tibia was sustained at take-off and a Salter-Harris type III avulsion fracture of the left tibial tuberosity upon landing. Closed reduction and internal fixation using K-wires were performed on the right side, whereas open reduction and internal fixation were done on the left side, using a lag screw and additional McLaughlin wiring.

Irreversible destruction of the forefoot and midfoot generally leads to amputation. So-called limited surgical procedures such as transmetatarsal or Chopart/Syme amputations often result in poor clinical outcomes. Prostheses for these stumps are difficult to fit, a fact that reduces mobility for these patients, so reamputations are not rare. The very old method of tibiocalcaneal arthrodesis introduced by Pirogoff in 1854 can be an interesting surgical alternative in these cases, and the use of an Ilizarov external ring fixator may solve the stabilisation problem.From 1 January 1990 to 1 January 2007, six patients underwent surgery for tibiocalcaneal Pirogoff arthrodesis with an external Ilizarov ring fixator.All patients could be evaluated postoperatively, with a medium follow-up time of 45.8 months. Outcome was measured with a modified ankle disarticulation score. In four cases, the outcome was good or excellent. Two cases (33%) with initially successful arthrodeses required transtibial reamputations because of secondary infection. All other cases healed very well. There was no delayed union or nonunion of the arthrodeses in our series.Tibiocalcaneal Pirogoff arthrodesis can be a surgical alternative in forefoot and midfoot destructions to achieve a well-covered, comfortable stump with a minimum of leg-length shortening that is easy to fit with a prosthesis and even allows some limited barefoot mobility. Bony fixation and healing of the arthrodesis are the challenges, but these difficulties can be avoided by using an external ring fixator system. Despite a failure rate of up to one-third, this method can be an effective solution due to the good functional outcome.

Pathological fractures are dreaded complications due to skeletal metastasis. Modern oncological therapies and more sophisticated new radiological techniques such as MRI and positron emission tomography have improved multimodal treatment concepts. Surgical intervention is determined by the primary disease, general condition and life expectancy of the patient. The goals of surgical treatment are improvement of life quality, pain relief and maintenance of mobility.

Fractures of the proximal humerus are common in elderly patients, especially in osteoporotic bone. Requirements for surgical treatment are high primary stability to allow early functional physiotherapy. The Non-Contact Bridging (NCB) Plate for the proximal humerus (PH) is a new head locking system for treating fractures of the proximal humerus which allows minimally invasive surgery (MIS).In this contribution, the implant and technique are described, as well as the analysis of the first clinical results after 61 procedures.In a mainly elderly patient population (mean: 73 years, range: 50-91 years) 61 minimally-invasive procedures were performed. The placement of screws led to a high primary stability. Primary implant failure occurred in one case (1.69%). The average constant score after 6 months was 62 points (age related mean 72).Using the MIS-technique, the NCB-PH plate provides high primary stability, allowing functional treatment without postoperative limitations. The first clinical results show a good functional outcome in a mainly elderly patient population.

Infections of the locomotive system appear in many different forms such as acute inflammation of joints or bone following injury or surgical or chronic processes, often lasting for years. They demand an exact treatment plan not only to remove necrotic tissue but also for reconstruction of defects. A special problem is infection following alloplastic reconstruction of joints or spine. Multiple surgical procedures are required to hinder reinfection, restore function, and assure acceptable patient quality of life.

Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy.Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system).Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay.A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.

Vacuum therapy is a routine and successful method for wound treatment and for the temporary covering of soft-tissue defects. It is an occlusive method that can be used for treating acute, chronic and infected wounds. To date, no data are available regarding secretion transit times and pressure conditions in lesions treated with vacuum therapy. The present study had as its objectives to examine the mechanisms of vacuum therapy and determine the effects of physical forces on the wound surface with the purpose of formulating recommendations for pressure settings using the various available vacuum pumps.Using an appropriate model, we measured secretion transit times and pressures using two different vacuum therapy pads. We then conducted pressure measurements during dressing change in eight patients with wound surfaces greater than 20 cm(2).The secretion transit times remained unchanged with the polyvinyl alcohol (PVA) pad and a negative pressure of 40 kPa, but decreased by about 50 % when the black polyurethane (PU) pad was used. Pressure measurements showed that, at this negative pressure, there was only a slight positive external pressure of 31 mmHg on the wound surface.When the PVA pad is used, negative pressures greater than 40 kPa should be applied in order to effect a maximum transit of wound secretion and prolongation of the use of the vacuum dressing. When the PU pad is used, the applied negative pressure can be lower due to the pad's larger pores, as recommended by Argenta and Morykwas. An excessive external pressure on the wound surface does not occur.

In a prospective study 104 patientsor=65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination. A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients. PHF patients showed a high incidence in "fear of falling" throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping. One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Arthrodesis of the sacroiliac joint (SI) usually requires a large surgical exposure using the lateral approach. Computer-assisted surgery based on intraoperative 3D fluoroscopy imaging can reduce the approach to stab incisions. The clinical example shows the insertion of two screws and a cylindrical bone graft to achieve an arthrodesis of the SI joint. The intraoperatively navigated placement of implants and bone graft was performed only by stab incisions.

The differentiation between degenerative syndromes of the cervical spine and post-traumatic symptoms requires accident analysis. Experiments with human subjects yield data only in the low-energy range, and there are still no accident analyses of structural traumas of the cervical spine. From 1 January 2000 to 30 April 2002, 15 patients with structural injuries to the cervical spine due to car accidents were treated in the Department of Trauma Surgery of the University of Ulm. In 11 of these cases, the DEKRA Ulm completed an appraisal of the accident process.With lateral impacts, structural injuries to the cervical spine can occur even at speeds of only ca 10 km/h. Injuries to the alar ligaments are produced by frontal collisions with substantial differences in speed. Data from accident analysis of structural injuries to the cervical spine must be taken into consideration in causality examinations of distortions of the cervical spine.

Previous studies have compared the functional outcome and torsional differences following closed intramedullary nailing of femoral fractures. Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Until now studies were designed to evaluate the correct torsional differences by examining every patient following antegrade or retrograde femoral nailing. The series included 13 women and 28 men, average age 44.5 years, who suffered a fracture of the distal femoral diaphysis. Postoperatively we established the diagnosis by three-dimensional determination of the torsion and length of the lower extremities by ultrasound measurement. Furthermore, we performed the clinical examination according to the Tegner and Lysholm score and the Merle d'Aubigne score. There were no significant differences in torsional deformity and length found. The functional outcome showed no significant differences between the two groups. The functional examination exhibited a reduction of flexion in knee motion in the retrograde group. In the antegrade group the motion of the hip was decreased. A correlation between the functional outcome and the torsional deformity was not found. The possible advantage of positioning by using the retrograde femoral nail was not verified.

Advances in the treatment of tumors have improved the life expectancy of cancer patients appreciably. As a consequence the incidence of bone metastases has also increased. Surgical interventions must achieve a maximal palliative effect with minimal morbidity and mortality. Major objectives are reduction of pain while preserving stability and function. Surgical treatment of primary and secondary bone tumors is complicated and thus also burdened with complications. However, interdisciplinary therapy comprising surgical resection and stabilization, radiotherapy and/or chemotherapy improves life expectancy and the quality of life of the cancer patient.

Today the most common application in the field of computer-assisted surgery is navigated total knee arthroplasty. During the last 5 years the imageless kinematic navigation systems have gained wide acceptance. As several prospective randomized studies could show, the standard deviation of the mechanical axis is reduced significantly by these techniques. However, the direction of the mechanical axis is only one factor which influences the long-term results of total knee arthroplasty. Further important factors are ligament balancing and position of the femoral and tibial components in all three planes. Up to now no studies have been able to show a significantly better functional result, a more rapid recovery, or a decreased complication rate. Drawbacks of the navigation systems are the additional costs and the additional operation time between 15 and 20 min. Therefore, navigated total knee arthroplasty is not yet a standard procedure, but this technique is well on the way to becoming the gold standard in the future.

Calcaneus fractures are a major cause of accident- related invalidity. Long-term results are unsatisfactory with various therapy concepts as reported in the literature. Objective of this study is the long-term clinical and radiological outcome of a patient group treated with a low contact plate. Subjective assessment of function by the patient was an important evaluation criterion. From 01/92 to 12/98 a total of 182 patients with 209 calcaneus fractures were treated. Out of them 95 patients with 109 calcaneus fractures had a follow-up over a period ranging from 6 to 88 months (average 37.9 months). Severe impairment of walking was reported by 34.7 % of the patients. Severe impairment for work was declared by 68.4 % of the patients. 74.7 % of the patients complained middle or severe burden-pain. 64.3 % of the patients felt their quality of life impaired. After the injury 75.8 % of the patients were still employed. Arthrosis of the inferior ankle joint was found in 91.5 % of the cases. Within this collective three patient groups were formed with different follow-up periods to evaluate the temporal course, showing no significant differences. Frequently good functional and subjective results cannot be expected even with standardized operative procedures.

Opinions vary with regard to the equipment and structural furnishings required for adequate management of the trauma patient in the dedicated shock suite. In order to assess the current situation in Germany, we conducted a survey of the 76 centers participating in the Polytrauma Registry of the DGU. Fifty-one questionnaires were returned by centers representing all levels of care. Responses revealed, for example, that not all centers possess capabilities for conventional radiography in the shock suite (7/51). Only 20 centers had a fixed table; the remaining 24 hospitals used either an image converter or a mobile X-ray unit. A dedicated ultrasound scanner was provided for the shock suite in 39 of 51 centers responding. Dedicated computed tomography scanners were provided for the shock suite in only eight centers (one dedicated trauma center, three level 3 centers, four university hospitals). All eight scanners use helical CT technology; at least three of the units are 8- or 16-slice. Of 51 shock suites, 12 are air-conditioned in compliance with sterile criteria (and are officially designated as surgical suites), while the remaining 39 are not. In acute cases, emergency surgeries can be performed in the shock suite in 37 centers, but not in the remaining 14 shock suites. According to the survey, slightly less than half of the hospitals responding are un-satisfied with the shock suite infrastructure ( n=24) and, of these, 13 centers are actively planning changes (the necessary financial resources have been guaranteed in 10 centers). Fourteen centers desire changes but do not currently have the required money. Information provided by Philips and Siemens suggests that the cost of furnishing a new shock suite ranges between 1.4 and 1.7 million euros. Responses to our survey show that a large gap remains between wishes and reality in the technical infrastructure in many shock suites in Germany.

It is still unknown exactly how many persons sustain a severe injury (ISSor =16) in Germany each year. Considering the growing restrictions and the introduction of DRGs, it was necessary to acquire data about this rather resource-intensive aspect of trauma care. The aim of this study was therefore to assess the incidence of severe trauma within a defined population. In a retrospective study all surgical emergencies within a 5-year period (1996-2000) were reviewed. Data on type, pattern, severity of injury, and mortality were extracted from the patients' records. During the study period 454 persons sustained a severe injury (ISSor =16), 112 individuals died at the scene of the accident, and 64 during the hospital stay. The average ISS of the surviving patients was 27 (ISS 16-75). The calculated incidence of severe trauma was 25/100,000 inhabitants per year. Extrapolated, up to 40,000 persons sustain a severe injury each year in Germany. For the first time, this study has provided data on the incidence of major trauma in Germany. Based on the acquired data and a previous cost analysis, hospital treatment costs for severely injured patients amount to up to 2 billion Euros per year in Germany.

The presented thromboprophylactic concept includes weight bearing and ankle motion as well as breathing therapy and drug prophylaxis (antiphlogistics, analgesic drugs, heparin). Routinely performed ultrasound screening of the deep veins (legs and pelvis) before release showed a low DVT incidence of 2.5% in a prospective clinical observation of 841 inpatients. Obesity, venous insufficiency, and a history of previous thromboembolic events were associated with a significantly increased risk of thrombosis (relative risk 4.1, 4,9, and 5.8, respectively) The duration of immobilization also had a relevant influence indicating that early postoperative physiotherapy in traumatology and orthopedic surgery has a widely underestimated thromboprophylactic effect.

The effectiveness of physiotherapy in patients with whiplash injuries of the cervical spine is a subject of critical discussion. Besides the inadequate situation with regard to the medical data available and the financial cuts in drug prescription, organizational factors and structures are assumed to be factors that have an influence on the effectiveness of physiotherapy.The aim of this study was to evaluate data on training, patient population, communication, prescription activity and therapies of physiotherapists.In a survey of 213 physiotherapists in the City of Ulm, data were collected with the aid of questionnaires related to "therapy of whiplash-associated disorders".The results show deficits in the theoretical knowledge of physiotherapists, in the exchange of information and in therapy management. The survey further revealed that 22% of the patients decide themselves which therapy they will undergo. One can assume that these factors have a detrimental effect on the effectiveness of conservative therapy.An optimization of the organizational structures is thus urgently required and constitutes the only possibility, in the short to medium term, of improving the effectiveness of physiotherapy in patients with whiplash injuries of the cervical spine.

The goal of these studies was to evaluate the accuracy of in vivo and in vitro application of CT- and C-arm-based navigation at the thoracic and lumbar spine. With CT based navigation, 82 pedicle screws were consecutively inserted, 53 into the thoracic and 29 into the lumbar spine. Seven (13%) perforations were detected at the thoracic spine and two (7%) at the lumbar spine. Additionally, minor perforations below the thread depth were seen in six (11%) thoracic and in two (7%) lumbar instrumentation. With C-arm-based navigation, 74 screws were consecutively placed into 38 thoracic and 36 lumbar pedicles. Perforations were noted in ten (26%) thoracic and four (11%) lumbar implants. Minor perforations were observed in another nine (24%) thoracic and ten (28%) lumbar pedicles. The observer-independent and standardized in vitro study based on a transpedicular 3.2-mm drill hole aiming a 4-mm steel ball in a plastic bone model showed pedicle perforations of the drill canal only in thoracic vertebrae, 1 of 15 in CT-based and 3 of 15 in C-arm navigation. The quantitative calculation of the smallest distance between the central line through the drill canal and the center of the steel ball resulted in 1.4 mm (0.5-4.8 mm) for the CT-based navigation at the thoracic spine and in 1.8 mm (0.5-3 mm) at the lumbar spine. For the C-arm based navigation the distance was 2.6 mm (0.9-4.8 mm) for the thoracic spine and 2 mm (1.2-3 mm) for the lumbar spine. In our opinion, the clinical results of the comparative accuracy of CT- and C-arm-based navigation in the present study showed moderate advantages of the CT-based technique in the thoracic spine, whereas CT- and C-arm based navigation had comparable perforation rates at the lumbar pedicle. The results of the experimental study correlated with the clinical data.