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Despite the increase in clinical use of navigation systems in total knee arthroplasty, few studies have focused on the reproducibility of these systems. The aim of the present study was to assess the influence of knee position and observer experience on intra- and inter-observer agreement in limb alignment assessment with the OrthoPilot system. Limb alignment in the coronal plane and extension range of the knee were assessed in four embalmed cadaveric specimens by five independent observers and measurements were repeated four times to determine intra- and inter-observer agreement, expressed as intraclass correlation coefficients (ICCs). Additionally, navigation results were compared against figures from conventional measurement of leg alignment (ground truth). Intra- and inter-observer agreements were excellent for assessing the extension range (ICC, 0.97 and 0.95) and the coronal femuro-tibial axis in knee extension (ICC, 0.92 and 0.88) but were generally worse in knee flexion (ICC, 0.62 and 0.55). There was an increased tendency of intraobserver errors in observers with less clinical experience. Mean correlation with conventional measurements was fair (Spearman's rho 0.61). The OrthoPilot system showed excellent reproducibility for assessment of extension range and coronal limb alignment. However, assessments of coronal limb alignment in flexion were prone to error and caution should be taken when relying on these measurements. [ABSTRACT FROM AUTHOR]

Background: The treatment of displaced Colles-type fractures of the distal part of the radius remains a challenge. Two procedures for closed reduction and Kirschner wire osteosynthesis of these fractures were compared in a prospective randomized study.Methods: One hundred consecutive patients with a Colles fracture of the distal part of the radius (AO classification 23-A2, 23-A3, or 23-C1) were treated over an eighteen-month period. One group was managed with the conventional method, described by Willenegger and Guggenbuhl in 1959, in which two Kirschner wires are introduced into the styloid process of the radius. The other group was treated with the Kapandji method, as modified by Fritz et al., in which two Kirschner wires are inserted into the fracture gap and a third is placed through the styloid process. Postoperative care was standardized for both groups and carried out according to a strict procedure. Forty patients who had been operated on according to the modified Kapandji method and forty-one treated with the Willenegger technique were available for follow-up, for a follow-up rate of 81%. The follow-up assessment was performed with a modified version of the Martini score.Results: The median time to follow-up was ten months (range, six to twenty months). The results as assessed with the Martini score were, on the average, good to very good for the patients treated with the Kapandji method and satisfactory to good for the patients treated with the conventional Kirschner wire fixation. The duration of radiographic exposure was significantly shorter with the Kapandji method than with the Willenegger technique.Conclusions: Conventional Kirschner wire fixation remains a good method of osteosynthesis for the treatment of displaced fractures of the distal part of the radius. We found both the functional and radiographic outcomes of the Kapandji method to be significantly better than those of the Willenegger technique.Level Of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Fractures of the knee extensor complex are relatively rare injuries in children. We distinguish between a pure tendon rupture and ruptures with bony avulsions. A mid-substance tear in children is a relatively rare injury, whereas bony avulsions due to skeletal immaturity are seen more often. Sole bony fractures of the patella also only account for a low number of paediatric related fractures. Sleeve fractures are characterized by an avulsion of cartilage and, usually, bone pulled off from the distal patella pole. Avulsion fractures of the tibia tubercle are found in the group of sportive adolescents., Treatment: Especially dislocated fractures should be conveyed to surgical therapy to avoid excessive bone callus. Timely diagnostics and an efficient and consistent treatment are recommended. Deformities and dislocated avulsions will regularly not remodel spontaneously during further growth. Therefore, it is mandatory to reconstruct the articular surface and the knee extensor complex to avoid future complications such as osteoarthritis or elongation of the knee extensors., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature., Methodology: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this., Results: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks)., Conclusion: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases., (© 2024. The Author(s).)

Background: Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality., Methods: Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined., Results: For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment., Conclusions: Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies., Level of Evidence: III., (© 2024. The Author(s).)

Purpose: In childhood and adolescence, cross-sectional imaging, most commonly computed tomography (CT), is often performed for advanced diagnosis of joint injuries of the distal lower leg and upper ankle. Due to radiation exposure, the need for CT remains controversial, as these injuries follow stereotypies and usually have a similar course. Alternatively, the performance of magnetic resonance imaging (MRI) is also discussed. Since radiation sensitivity at this young age is much higher than in adults, an effort must be to minimize radiation exposure according to as low as reasonably achievable (ALARA) principles. The aim of this survey is to evaluate the current procedure in Germany in the diagnosis of pediatric injuries of the distal lower leg and upper ankle., Methods: For data collection, a survey entitled "CT in fractures of the ankle joint in childhood and adolescence: subject of the survey are injuries between 8 and 15 years of age" of the Section of Pediatric Traumatology in the German Association of Trauma Surgery was sent to all members via the distribution list of the German Society of Orthopedics and Traumatology and the distribution list of the German Society of Pediatric Surgery in a period from September 20, 2022-December 21, 2022. The survey included a total of 21 questions. Target groups were trauma and pediatric surgeons and orthopedic surgeons working in the hospital and in practice., Results: A total of 525 participants took part in the survey: ultrasound diagnostics are used by almost 25% and the Ottawa Ankle Rules by over 50% always or in most cases. A conventional x-ray is always or most often used by over 90%. CT imaging is rarely used by 88.57%, mainly for surgical planning or analysis of fracture progression. 69.9% report that their radiology department uses a pediatric protocol for CT exams; 25.71% do not know if this is the case. MRI imaging is also used infrequently by 89.33%, mostly to identify associated injuries. Overall, CT imaging is chosen by 55.62% and MRI imaging by 35.24% as the sectional imaging modality for suspected fractures; 95.05% consider sectional imaging useful for a triplane fracture, 59.24% for a two-plane fracture, 41.71% for a Salter-Harris type III/IV injury, and 8% for a Salter-Harris type I/II injury., Conclusion: The survey showed that the conventional X-ray is still the gold standard. Interestingly, more than half of the respondents regularly use the Ottawa Ankle Rules, and diagnostics using ultrasound are also used by almost a quarter. Awareness of radiation protection in children exists, although a quarter of all participants do not know the extent to which their radiology department has a specific pediatric protocol for CT imaging. Cross-sectional imaging is performed on a regular basis. Regarding the actual extent of imaging, there is a clear divergence between theory and practice., (© 2023. The Author(s).)

Introduction: Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist., Material and Methods: Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion., Results: Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment., Conclusion: In addition to X‑rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: Numerous approaches to the management of juvenile and aneurysmal bone cysts (ABC) are described in the specialist literature together with discussion of the associated healing and recurrence rates. Since there is currently no evidence-based treatment standard for these conditions, the aim of this systematic literature review with meta-analysis was to examine the different management approaches, evaluate the corresponding clinical outcomes and, as appropriate, to formulate a valid treatment recommendation., Methods: A systematic search on OVID Medline ® based on a pre-existing search strategy returned 1333 publications. Having defined inclusion and exclusion criteria and analysis of the relevant full texts, 167 publications were included in the descriptive analysis and 163 in the meta-analysis. For this purpose, different subgroups were created, based on the type of cyst and the therapeutic procedure. Those subgroups were then analysed in relation to their healing rates, the number of recurrences and complication rates., Results: For aneurysmal bone cysts, both surgical removal and Doxycycline injection lead to excellent outcomes (98% healing) and low recurrence rates (6% and 11% resp.). Curettage (91% healing), including its combination with autologous cancellous bone graft (96% healing), showed very good healing rates but higher recurrence rates (22% and 15%, resp.), which were however improved by preoperative selective arterial embolization. A critical view must be taken of radiotherapy (90% healing) and the injection of alcohol (92% healing) because of their high complication rates (0.43/cyst and 0.42/cyst, resp.). In the management of juvenile bone cysts, surgical interventions like curettage and cancellous bone graft (87% healing) are far superior to non-surgical approaches (51% healing), furthermore, the application of autologous cancellous bone graft reduced the recurrence rate (3% recurrence) compared to curettage alone (20% recurrence). In subgroup analysis, treatment by ESIN was found to produce excellent outcomes (100% healing), though the patient collectives were small., Conclusion: Surgical procedures to treat aneurysmal bone cysts appear to be the method of choice whereby Doxycycline injection may be an alternative. A surgical approach should be preferred in the treatment of juvenile bone cysts., (© 2022. The Author(s).)

Osteosynthesis refers to various surgical procedures, closed or open, for the treatment of fractures of any age. To document and control the osteosynthesis and the healing process X‑ray controls of the affected skeletal segment are performed during the operation and at regular intervals. To assess the quality of an osteosynthesis or to identify a complication, a comprehensive and systematic image review is useful. This includes the assessment of the restoration of the functional anatomy, the position of the material in relation to the surrounding structures, an evaluation of the stability as far as this is possible, and a control of the bone healing in a functionally correct position., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The aim of this study was to determine whether traumatic dislocation of the patella is provoked by the presence of predisposing factors and examine the role of the mechanism of injury., Methods: Cases diagnosed with dislocation of the patella and covered by the workers' compensation program were identified and classified as traumatic based on insurance regulations. We examined predisposing factors (e.g., frontal axis, torsional deviation, trochlear dysplasia, patella alta) in case groups based on age at dislocation and trauma mechanism. Retrospective cohort study, level of evidence III., Results: Our sample size comprised 104 cases, consisting of 54 children and 50 adults. The most common mechanism of injury in children and adults was rotational trauma. Only 20% of the children and 21% of the adults exhibited no relevant predisposing factors. Group specifically, falls accounted for the highest number of cases exhibiting none of the defined anatomical predisposing factors. Children are more frequently affected by predisposition-related dislocations than adults., Conclusion: The proportion of predispositions is high. A fall, direct impact, or rotational trauma can be viewed as an adequate mechanism of trauma. For successful treatment, it is paramount to analyze the exact mechanism of the trauma and address any underlying predispositions.

Introduction: Elbow dislocation is the second most frequent joint dislocation after shoulder dislocation. They have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed.The purpose of this systematic review and meta-analysis was to review the literature and analyze the evidence of early functional rehabilitation., Methods: A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified and evaluated in a stepwise approach. Of these publications 29 met the inclusion criteria of the authors and described simple elbow dislocations in 5765 patients.Data from the studies and subgroups included were initially categorized descriptively in conservative and surgical primary therapies, in immobilizing (immobilization lasting 2 weeks or longer) and free-functional follow-up treatments, and those data were then extracted from each subgroup in absolutes. We then pooled these numbers into descriptive statistics to ensure their comparability. We determined the success rates from the numbers of excellent and good results of the specific used outcome scores., Results: The effect estimate of the conservative therapy's success rate was 84% and for surgical treatment 80% (P < .0001). The difference between the immobilizing treatment (78% success rate) and early-function therapy (83% success rate) was significant (P = .002).In a subgroup analysis the success rate of conservative and immobilizing therapy was 79%, of conservative and early-functional therapy 91%, of surgical and immobilizing groups' was 77% and of the surgical and early-functional therapies was 93%. The difference among the 4 treatment options was significant (P < .0001), as were differences between the 2 conservative groups (P < .0001) and between the 2 surgical groups (P = .044)., Discussion: Conservative therapy is the dominant therapy. Regardless of the primary therapy chosen in simple elbow dislocations: early functional follow-up care seems to be superior to immobilizing therapy with a duration more than 2 weeks., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear., Aim: This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality., Material and Methods: Retrospective cohort study, evidence level III. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18 years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma., Results: A total of 54 patellar dislocations were identified with a patient age of 14 years (range 9-18 years). A mild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% a high proportion of patella alta and a trochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was >75%. In the fall cohort the rate of children without relevant predisposition was highest., Conclusion: The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Sacral U‑shaped fractures are rare but severe injuries. Due to the resulting spinopelvic dissociation they are highly unstable. Reduction and stabilization are usually required and decompression may be necessary due to frequent concomitant neurological injuries. In the literature there is no consensus with respect to the selection of the surgical approach., Case Presentations: After a road traffic accident an 18-year-old woman suffered a U-fracture of the sacrum type II according to Roy-Camille and was treated with bilateral double sacroiliac screw osteosynthesis and sacral laminectomy. A 76-year-old man with a U‑fracture type I according to Roy-Camille after falling down the stairs was treated by lumbopelvic fixation. A 24-year-old man with U‑fracture type II according to Roy Camille after a road accident was treated with triangular vertebropelvic stabilization and sacral laminectomy. For all patients the outcome was good., Conclusion: Surgical treatment is necessary, with minimally invasive techniques offering advantages over open surgery. A distinction must be made between lumbopelvic fixation and posterior pelvic ring fixation. Multiple aspects must be taken into consideration of the indications when selecting the surgical technique.

Background and Purpose: Unstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate., Patients and Methods: The analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n = 957 with vs n = 4,542 without). Furthermore, the subgroups with secondary surgery (n = 713 vs n = 1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n = 24 vs n = 219). Calculated odds ratios were adjusted for potential confounders., Results: Patients treated by CC/EF were younger (45 ± 20 vs 62 ± 24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3 mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p < 0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02-1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06-20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation., Interpretation: Primary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate., Methods: Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d'Aubigne and the EQ. 5D-3 L scores., Results: Over an 11-year period (2004-14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d'Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts., Conclusion: Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients., Trial Registration: DRKS, no. 00000488 . Registered 14th July 2010 - Retrospectively registered.

Background: Simple elbow dislocations in childhood are rare. Nevertheless, they have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed., Aim: The purpose of the study was to review the literature and to derive a recommendation for the best treatment concept., Material and Methods: A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified (initially nonspecific for age) and evaluated in a stepwise approach. Of these publications four met the inclusion criteria of the authors. The analysis was carried out descriptively and in a meta-analysis., Results: The 4 publications included described simple elbow dislocations in 81 children (≤16 years). The weighted average age was 9.9 years with a gender ratio of 3.8 (boys:girls). The median follow-up was 49 months. Posterior and posterolateral dislocations were the most common with 73%. In 69 children the treatment was conservative and of these 66 were immobilized for longer than 2 weeks after closed reduction. The 12 children who had surgical treatment suffered dislocations that had not been reduced for longer than 3 weeks. The success rate of the conservatively treated immobilized group was 88%, of the conservatively treated non-immobilized group 70% and of the surgical group 42%. The differences between the success rates of the treatment methods was significant (p = 0.032)., Conclusion: Simple elbow dislocations in children are rare. They most commonly occur in posterior and posterolateral directions. The prognosis is favorable; however a timely diagnosis and correct reduction are relevant for a good outcome.

Background: Luxation of the elbow occurs around the age of 7 years instead of a supracondylar humeral fracture. The most common complication is a fracture of the medial epicondyle of the ulna in the sense of a bony avulsion of the ligament. There are only few case reports regarding collateral injuries of the brachial artery. All authors have described this complication as being very rare., Case Report and Literature Search: This article reports the case of a 10-year-old boy, who suffered a dorsal luxation of the left elbow. After reduction the left hand was noticeably pale and cold. The diagnostics showed a complete rupture of the brachial artery, associated with a dislocated fracture of the medial epicondyle of the ulna. In addition to the case report, the available literature concerning traumatic rupture of the brachial artery in pediatric elbow dislocation was evaluated., Results: Because of the results of the clinical examination and the Doppler examination with a lack of blood flow in the brachial artery of the left arm, computed tomography angiography was directly performed. The result was a complete interruption of the brachial artery at the level of the left elbow. The brachial artery rupture was treated using a local vein graft from the brachial vein. The fracture of the medial epicondyle of the ulna was treated by open reduction and an osteosynthesis with Kirschner (k) wires was performed., Discussion: The clinical suspicion of an injury of the brachial artery justifies a rapid diagnostic investigation by CT angiography and an open vascular intervention as the only possibility to recreate a sufficient blood flow.