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Verletzungen der Oberschenkelmuskulatur gehoren zu den haufigsten Sportverletzungen. Beispielsweise beim Fusball machen sie nahezu 30 % aller Verletzungen aus. Insbesondere der M. rectus femoris ist aufgrund seiner anatomischen Besonderheiten exponiert. Wahrend die distalen Rupturen die Quadrizepssehne betreffen und nicht nur im Sport zu den haufigeren Verletzungen gehoren, stellen die proximalen Rupturen eine Seltenheit dar. Aufgrund der meist indifferenten klinischen Zeichen werden diese oft verspatet diagnostiziert. Klassifikationen zur Einteilung von Muskelverletzungen sind in verschiedenen Versionen in der Literatur beschrieben. In Bezug auf den M. rectus femoris existiert bisher keine Einteilung, aus der ein Therapieentscheid oder ein Algorithmus abgeleitet werden kann. Problematisch ist nicht nur die unklare Einteilung der Verletzung, sondern auch die daraus resultierende Variabilitat der Therapie. Selektive Literaturrecherche zur Erstellung einer Ubersichtsarbeit. Es gibt bisher keine standardisierte Nachbehandlung nach operativem Eingriff oder ein etabliertes Schema fur die konservative Therapie. Der Vergleich der einzelnen Studien untereinander ist aufgrund geringer Fallzahl und uneinheitlicher Klassifikation erschwert. Ein valider Behandlungsalgorithmus kann auf der Basis der aktuellen Datenlage nur schwer abgeleitet werden.

Injuries of the thigh muscles are among the most frequent sports injuries. For example, in soccer they represent nearly 30% of all injuries. The rectus femoris muscle is particularly exposed to injury due to its anatomical features. While distal ruptures involve the quadriceps tendon and are among the more frequent injuries not only in sports, proximal ruptures represent a rarity. Because of the mostly indifferent clinical signs, the diagnosis is often delayed. In the literature various versions of classifications on the grading of muscle injuries have been described.With respect to the rectus femoris muscle, there is no classification system from which a treatment decision or an algorithm can be derived. The problem is not only the unclear classification of the injury but also the variability of treatment options resulting from this.A selective search of the literature was carried out to construct a review article.No standardized follow-up treatment after surgical interventions or an established procedure for conservative treatment is currently available.The comparison of the individual studies is made difficult due to the low case numbers and nonuniform classification systems. A valid treatment algorithm can only be derived with difficulty based on the currently available data.HINTERGRUND: Verletzungen der Oberschenkelmuskulatur gehören zu den häufigsten Sportverletzungen. Beispielsweise beim Fußball machen sie nahezu 30 % aller Verletzungen aus. Insbesondere der M. rectus femoris ist aufgrund seiner anatomischen Besonderheiten exponiert. Während die distalen Rupturen die Quadrizepssehne betreffen und nicht nur im Sport zu den häufigeren Verletzungen gehören, stellen die proximalen Rupturen eine Seltenheit dar. Aufgrund der meist indifferenten klinischen Zeichen werden diese oft verspätet diagnostiziert. Klassifikationen zur Einteilung von Muskelverletzungen sind in verschiedenen Versionen in der Literatur beschrieben.In Bezug auf den M. rectus femoris existiert bisher keine Einteilung, aus der ein Therapieentscheid oder ein Algorithmus abgeleitet werden kann. Problematisch ist nicht nur die unklare Einteilung der Verletzung, sondern auch die daraus resultierende Variabilität der Therapie.Selektive Literaturrecherche zur Erstellung einer Übersichtsarbeit.Es gibt bisher keine standardisierte Nachbehandlung nach operativem Eingriff oder ein etabliertes Schema für die konservative Therapie.Der Vergleich der einzelnen Studien untereinander ist aufgrund geringer Fallzahl und uneinheitlicher Klassifikation erschwert. Ein valider Behandlungsalgorithmus kann auf der Basis der aktuellen Datenlage nur schwer abgeleitet werden.

Frakturen der oberen Extremitat zahlen zu den haufigsten im Wachstumsalter – eine Vielzahl davon findet sich um das Ellenbogengelenk. Die Fugen um den kindlichen Ellenbogen sind nur zu 20% am Langenwachstum beteiligt, wachsen sehr langsam und verfugen daher nur uber ein geringes Korrekturpotenzial. Die Moglichkeit der Spontankorrektur ist bereits mit dem 7. Lebensjahr ausgeschopft. Die Konsequenzen einer unzureichend versorgten, ellenbogennahen Fraktur konnen den Patienten somit ein Leben lang begleiten. Posttraumatische Fehlstellungen am Ellenbogen sind meist Folge einer unzureichenden Primartherapie und selten auf Wachstumsstorungen zuruckzufuhren. Sie stellen fur den behandelnden Chirurgen eine Herausforderung dar. Aus einer ungenugend behandelten suprakondylaren Humerusfraktur, einer Condylus-radialis-Fraktur oder einer ubersehenen Luxation des Radiuskopfchens konnen ein Cubitus varus oder valgus resultieren. Dieser Beitrag gibt eine Ubersicht uber die Korrekturmoglichkeiten ellenbogengelenknaher Fehlstellungen und beschreibt jeweils die von den Autoren bevorzugte Methode.

INTRODUCTION: The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS). METHODS: 62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases. RESULTS: Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis. DISCUSSION: There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

Im Rahmen moderner Versorgungsstrategien von huftgelenknahen Oberschenkelbruchen erfolgt meist im Anschluss an die belastungsstabile Versorgung der Fraktur im Akutkrankenhaus eine stationare interdisziplinar-geriatrische Fruhrehabilitation. Ob diese Versorgungssysteme einen effektiven Beitrag zur nachhaltigen Versorgungsqualitat darstellen oder lediglich zu einer Kostenverschiebung mit Verkurzung der Verweildauer im operierenden Krankenhaus fuhren, wird kontrovers diskutiert. Im Rahmen einer prospektiven Studie wurden 282 Patienten mit einer huftgelenknahen Fraktur und einem Lebensalter von durchschnittlich 86±7,9 Jahren (Range 65–110) eingeschlossen. Alle Patienten wurden operativ versorgt und anschliesend nach durchschnittlich 12±9 Tagen (4–103) in eine stationare geriatrische Rehabilitation verlegt. Die mittlere Rehabilitationsdauer dort betrug 27±13 Tage. Zielparameter der Studie waren die Alltagsaktivitat gemessen am Barthel-Index (BI) und die Wohnsituation der Patienten zum Zeitpunkt der Entlassung aus dem Akutkrankenhaus, unmittelbar nach der Rehabilitation und 1 Jahr nach dem Unfallereignis. Des Weiteren wurde der Einfluss definierter patientenbezogener Variablen auf das langfristige Aktivitatsniveau untersucht. Bei Entlassung aus dem Akutkrankenhaus lag der BI bei 42±20 Punkten und erhohte sich auf 65±26 Punkte nach Abschluss der Rehabilitation. Ein Jahr spater lag er bei 67±28 Punkten. Wahrend der Rehabilitation verbesserten sich 90% aller Patienten im BI. Innerhalb eines Jahres kam es bei 40% der Patienten wieder zu einer Verschlechterung der Alltagsaktivitat. 51% der Patienten konnten in ihr gewohntes Umfeld reintegriert werden. Ein Jahr nach dem Unfallereignis war der BI von Patienten, die nach der Rehabilitation in ihr hausliches Umfeld reintegriert wurden (BI 75±24) signifikant hoher als bei Patienten, die bereits vor dem Unfall institutionalisiert waren (BI 52±27). Die Parameter Alter, kognitive Leistungsfahigkeit und Verletzungsart hatten keinen Einfluss auf das langfristige Aktivitatsniveau. Die geriatrische Fruhrehabilitation nach einer huftgelenknahen Fraktur fuhrt kurzfristig bei nahezu allen Patienten zu einer Verbesserung der Versorgungsqualitat. Langfristig profitieren vor allem Patienten, die vor dem Unfall zu Hause lebten und auch im Anschluss an die Rehabilitation auf Dauer in ihr hausliches Umfeld reintegriert werden konnen. Ob jedoch die soziofunktionelle Effektivitat stationarer Rehabilitationen die mit steigender Gesamtverweildauer erhohten Gesamtkosten rechtfertigen, bleibt Gegenstand weiterer gesundheitsokonomischer Untersuchungen.

Dieser Artikel soll einen Uberblick uber die Moglichkeiten navigierter Operationsverfahren bei der Versorgung von Beckenring- und Azetabulumfrakturen anhand unserer experimentellen und klinischen Erfahrungen geben. Initial wurden zunachst verschiedene Navigationsverfahren zur Verschraubung des Sakroiliakalgelenks (SI) im Vergleich zur konventionellen Technik an Spenderleichen (80 Schrauben) untersucht. Danach wurde die 2D-fluoroskopische Navigation in der Klinik (35 Schrauben) mit der konventionellen Technik (n=23) verglichen und retrospektiv alle SI-Schrauben aus einem 7-Jahres-Intervall (n=139) analysiert. An Azetabula wurde experimentell die 3D-fluoroskopisch navigierte supraazetabulare Verschraubung am Leichenpraparat (10 Schrauben) durchgefuhrt und mit klinischen Fallbeispielen verglichen. In der Zusammenschau lasst sich fur die navigierte SI-Fugen-Verschraubung eine signifikante Eingriffsverlangerung gegenuber der konventionellen Technik konstatieren. Allerdings wurde die intraoperative Durchleuchtungszeit um 50% reduziert. Weiterhin wies die konventionelle Verschraubung gegenuber der Navigation eine etwa 4-mal hohere Fehlplatzierungsrate auf, die bei Operateuren mit groser Vorerfahrung signifikant niedriger war. Am Azetabulum ist die Nutzung der Navigation im 2D-Modus hilfreich, der Einsatz der Navigation im 3D-Modus ist mit einer hohen Lernkurve verbunden. Zusammenfassend stellen wir fest, dass die navigierte SI-Fugen-Verschraubung weitgehend etabliert ist. In der Azetabulumchirurgie wird die Anwendung der Navigation dagegen (vorerst) auf wenige Einzelfalle beschrankt bleiben.

INTRODUCTION: Incidence of ankle fractures in the elderly population increased for the last years. Osteoporosis, compromised soft tissue conditions, vascular supply, and systemic diseases enhance the high demands on fracture management. Here, early results of ankle fracture fixation with transtibiocalcaneal arthrodesis in elderly patients are reported. PATIENT AND METHODS: Five patients with an unstable ankle fracture were included into this prospective study. All of them underwent closed reduction and transtibiocalcaneal arthrodesis by intramedullary nailing (Hindfoot Fusion Nail, Trigen, smith & nephew). Cartilage of tibiotalar and subtalar joint was left intact. Postoperatively early mobilisation with full weight bearing in a Vacoped® boot was allowed. RESULTS: The mean age of patients was 76 ± 11 years (range: 74-87). There were no intraoperative complications. One patient showed postoperatively a heel ulcer with subsequent superficial infection at a screw entry point, which requires screw removal. Postoperative radiographics before and after mobilisation revealed satisfactory reduction results and sufficient arthrodesis without secondary dislocation for all patients. CONCLUSION: Arthrodesis of unstable ankle fractures with transtibiocalcaneal intramedullary nailing allows immediate return to full weight bearing and has a low risk of complications. Therefore Hindfoot nail arthrodesis of ankle fractures might be appropriate particularly for patients with severe comorbidities, poor bone stock, and reduced tissue conditions.

Objectives/Design: To assess the functional outcome after treatment of proximal humeral fractures with a new antegrade nail that provides angular and sliding stability. Intervention/Patients: Ninety-seven patients were treated during a 4-year period between April 2000 and March 2004. All patients were followed for 6 months, 51 patients (53%) for 12 months, and 31 patients (32%) for 24 months. This study focuses mainly on the patients with a follow up of 1 year. Their mean age was 68 years (range: 33 to 90); 22% were more than 80 years of age. Main Outcome Measurements: All fractures were radiologically graded by the Neer and AO/ASIF classifications. Clinical assessment was performed at all follow-up visits using the Constant-Murley and Neer scores, and complications were recorded. Results: There were 26.8% 2-part, 66% 3-part, and 7.2% 4-part fractures. The relative Constant-Murley score improved significantly (P < 0.001) from 72% at 6 months to 82% at 12 months after operation. No further improvement regarding functional outcome was observed after 24 months. Patients younger than 60 years of age had better results. No significant functional differences were found among 2-, 3- or 4-part fractures. Complications included backing out of the proximal screws (9.8%), secondary dislocation (1.9%), complete osteonecrosis (1.9%), and partial osteonecrosis (5.8%). Conclusion: Treatment with this nail provides sufficient fixation of the fragments to allow early mobilization. The good functional results in the majority of the patients indicate that this nail can be used, even in complex fractures and elderly patients.

Computerassistierte Verfahren sind in der Traumatologie von zunehmender Bedeutung. Als eine sinnvolle Indikation hat sich die iliosakrale Schraubeninsertion erwiesen, wobei bislang keine systematischen Untersuchungen dazu vorliegen, mit welchem Navigationsverfahren die besten Ergebnisse erzielt werden konnen. In einer experimentellen Untersuchung sollte die Praktikabilitat eines fur die Beckenchirurgie zugelassenen 3D-Bildwandlers fur diese Indikation gepruft und mit bereits etablierten Navigationsverfahren verglichen werden. Die Versuche wurden an 20 fixierten Humankadavern vorgenommen. Zur Durchfuhrung der navigierten Prozedur wurde ein aktives optoelektronisches System verwendet. Die Verschraubung erfolgte perkutan in Ruckenlage mit durchbohrten Spongiosaschrauben, wobei 4 Behandlungsgruppen gebildet wurden. Die postoperative Schnittbildgebung erfolgte mittels fluoroskopischem 3D-Scan und MSCT. Zielparameter der Untersuchung waren neben der Praktikabilitat und Prazision der Verfahren die durchschnittliche Operations- und Durchleuchtungszeit pro instrumentierter Schraube. Alle navigierten Verfahren fuhrten im Vergleich zur konventionellen Technik zu einer Verlangerung der Operationszeit (2D: p 0,05, CT: p 0,05). Die CT-Navigation erwies sich fur die untersuchte Indikation aufgrund des storanfalligen Registrierungsvorgangs und der haufig unzureichenden Matchingprazision allerdings nur als bedingt geeignet. Unsere Daten zeigen, dass die fluoroskopisch navigierte Verschraubung des hinteren Beckenrings gegenuber der CT-Navigation hinsichtlich Praktikabilitat und logistischem Aufwand eindeutige Vorteile aufweist. Beide bildwandlergestutzten Navigationsverfahren senken daruber hinaus die intraoperative Strahlenbelastung im Vergleich zur konventionellen Technik. Eine verbesserte Prazision der Schraubenplatzierung kann eher durch Verwendung eines 3D-Bildwandlers erreicht werden, mit dem daruber hinaus die Schraubenplatzierung noch intraoperativ zuverlassig beurteilt werden kann.

Die Versorgung instabiler Verletzungen der oberen Halswirbelsaule (HWS) mit dem Halofixateur stellt aufgrund seiner einfachen Applikation eines der etablierten Standardverfahren in der Unfallchirurgie dar. Bislang liegen keine Untersuchungen zur Beeinflussung der Lebensqualitat durch die Applikation des Halofixateurs vor. Da im eigenen Krankengut altere Patienten uberproportional haufig reprasentiert sind, sollte bei der Durchfuhrung der Untersuchung besonderes Augenmerk auf diese Patientengruppe gelegt werden. Im Rahmen einer retrospektiven Studie wurden 41 Patienten (Durchschnittsalter 51,8±23,5 Jahre) mit einer instabilen Verletzung der oberen HWS, die im Zeitraum von 1988–2003 in unserer Klinik mit einem Halofixateur behandelt wurden, erfasst und die allgemeine gesundheitsbezogene Lebensqualitat im Mittel 8,0 Jahre nach dem Trauma mit dem SF-36-Fragebogen untersucht. Zielparameter der Untersuchung waren neben der Lebensqualitat die Komplikationsrate und die Beurteilung der Frakturheilung im zeitlichen Verlauf. Gegenuber der altersreferenzierten Normpopulation fuhlten sich die Patienten zum Zeitpunkt der Untersuchung in ihrer Lebensqualitat eingeschrankt. Dies traf insbesondere auf die Patienten mit einem Alter von >60 Jahren zu. Die Frakturen gelangten im Halofixateur teilweise verzogert zur Ausheilung und waren in 17% der Falle nach 12 Wochen noch nicht durchbaut. In dieser Gruppe waren ausschlieslich Patienten >60 Jahre vertreten. Lokale Komplikationen im Bereich der Kopfschrauben traten altersunabhangig in 43% der Falle auf. Bei Patienten hoheren Alters muss bei Applikation des Halofixateurs zur Versorgung instabiler Frakturen der oberen HWS eine verzogerte Frakturheilung in Kauf genommen werden. Weiterhin beeintrachtigt die Methode die subjektive Lebensqualitat der Patienten. Bei geeigneter Indikation sollten daher auch bei alteren Patienten interne Osteosyntheseverfahren zur Stabilisierung von Verletzungen der oberen HWS in Erwagung gezogen werden.

Hintergrund Die MRT stellt ein sensitives, nicht strahlenbelastendes bildgebendes Verfahren dar und bietet sich daher fur die Diagnostik kindlicher Wirbelsaulenverletzungen an. Als ein indirektes Verletzungszeichen lasst sich hierbei u. U. ein sog. „bone bruise“ nachweisen, ohne dass weitere Verletzungen sichtbar werden. Ziel der vorliegenden Arbeit war es, die klinische Bedeutung dieser Diagnose bei kindlichen Wirbelsaulenverletzungen zu untersuchen.

Currently there are few data available regarding the application and efficacy of computer-assisted procedures in the sacral spine. In order to optimize and standardize this procedure, a controlled experimental investigation has been performed. The aim of the study is to systematically assess the efficacy of a novel three-dimensional image intensifier used for navigated transiliac screw insertion into the first sacral vertebra. Screws were inserted iliosacrally into the first sacral vertebra of preserved human cadaver specimens. The instrument navigated procedure was performed with the "Siremobil Iso-C(3D) " (Siemens Medical Solutions) and the "Navigation System" by Stryker. The accuracy and quality of the imaging procedure as well as the fluoroscopic exposure times were measured. These results were compared to three control groups (CT-based navigation, C-arm navigation, and fluoroscopic guidance). In each group a total amount of 20 screws was implanted. Screw position was postoperatively assessed by Iso-C(3D) or CT-scan. The navigated procedure using the Iso-C(3D) provided good feasibility characteristics without requiring a specific matching process. It revealed the shortest procedure time of all navigated procedures and significantly decreased fluoroscopic time compared to C-arm navigation and fluoroscopic guidance. Furthermore, Iso-C(3D) navigation showed no screw malposition and was in this regard superior to C-arm navigated and fluoroscopic guided procedures. The quality of imaging was sufficient for accurate placement, but did not share the high-resolution level of CT-based navigation. These findings indicate that application of the Iso-C(3D) for navigated transiliac screw insertion into S1 can be recommended as a feasible and safe technique, enabling the surgeon to reduce procedure and fluoroscopic time. Further progress in improving the quality of the Iso-C(3D) image should be attempted.

Knochenersatzmaterialien haben in den letzten Jahren einen festen Platz im klinischen Alltag des Orthopaden und Unfallchirurgen eingenommen. Fur die knocherne Defektbehandlung vor allem bei alteren osteoporotischen Patienten sind die verfugbaren Substanzen sehr hilfreich. Das langfristig groste Entwicklungspotential wird augenblicklich den resorbierbaren Materialien zugeschrieben. Hier sind es vor allem die resorbierbaren Kalziumphosphatzemente, die im derzeitigen Mittelpunkt des klinisch/experimentellen Interesses stehen. Durch ihre Viskositat konnen mit den Zementen Defekte unterschiedlicher Form und Grose vollstandig aufgefullt werden. Die minimal invasive Applikation uber Stichinzisionen unter radiologischer Kontrolle ist moglich, wodurch die Zugangsmorbiditat in vielen Fallen in denen die Behandlung eines knochernen Defektes notwendig ist reduziert werden kann. Die Kombination mit einer stabilen Osteosynthese ist jedoch haufig erforderlich. Die Substanzen werden vollstandig in das biologische Konstrukt Knochen integriert und sind dem physiologischen Remodelingprozes unterworfen, d. h. die Materialien werden durch Osteoklasten resorbiert und durch neuen Knochen ersetzt. Diese Eigenschaft der Kalziumphosphatzemente ermoglicht es, das eigentliche Knochenersatzmaterial mit Medikamenten und/oder Wachstumsfaktoren zu vermischen und eine kontrollierte Freisetzung der Substanzen aus dem System zu erreichen. Zu berucksichtigen ist hierbei, dass die Resorption der kalziumhaltigen Zemente abhangig ist von ihrem Implantationsort (anatomische Lokalisation) und praktisch nie vollstandig geschieht. In wie weit auch diaphysare Defekt mit Hilfe von Kalziumphosphatzementen sicher uberbruckt werden konnen mussen weitere experimentelle Untersuchungen belegen. Die biologische Wertigkeit im Vergleich zu autogenem Knochen kann nur durch—noch immer fehlende—kontrollierte klinische Studien bestimmt werden.

The application of autogenous bone grafts represents the golden standard for reconstruction of the load-bearing anterior column in the thoracolumbar spine. However, the osseous integration of the implanted grafts is demanding and delayed union or pseudarthrosis may occur. There are no standardized data available yet indicating the further course in such cases. The aim of this study was to evaluate the incorporation of endoscopically applied grafts and to develop therapeutic strategies for delayed or non-fusions. Twenty patients suffering from unstable injuries of the thoracolumbar spine were studied in a prospective clinical trial. After primary dorsal stabilization, the anterior column was thoracoscopically reconstructed with an autogenous iliac crest graft and a fixed-angle implant (MACS). The osseous integration of the bone grafts was detected by MSCT 1 year postoperatively. Complete integration of the transplanted bone grafts was observed in only 65% of the cases. In 25% partial integration was detected and in two cases a fracture of the transplanted iliac crest graft occurred. Despite the incomplete integration of the bone grafts, the further course without surgical intervention revealed no clinical or radiological evidence of a concomitant implant loosening or a relevant secondary loss of correction. Similar to the open technique, endoscopic reconstruction of the anterior column with autogenous bone grafts may lead to disadvantageous results concerning the integration and healing of the applied bone grafts. Decision making in such cases depends on the individual clinical and radiological findings (i.e., evidence of implant loosening and concomitant loss of correction).

Third generation biomaterials are being designed with the aim that once implanted they will help the body to heal itself. One desirable characteristic of these materials in bone is their ability to be remodeled, i.e. that osteoclasts resorb the material and it is subsequently replaced by newly formed bone through osteoblastic activity. So far the only way to test this biological property of bone substitutes are animal experiments with all their limitations like ethics, costs and limited transferability to man. The present study was designed, to develop a human in vitro assay, allowing to generate human osteoclasts directly on the biomaterial. The assay was validated using calcium phosphate cement and PMMA as biomaterials. Quantification was performed by raster electron microscopy and computer assisted image analysis. Dentin was used as internal standard. Our assay shows iso-bone resorbability of calcium phosphate cement in comparison to unresorbable PMMA cement. Both current clinical orthopedic practice and future skeletal engineering may profit from the availability and use of a test system for the assessment of resorption quality. The assay presented here allows to address this question of resorbability and to select the best materials for the use as bone substitutes in specific patients.

Osteosynthesis with the proximal femoral nail (PFN) features the advantages of high rotational stability of the head–neck fragment, an unreamed implantation technique and the possibility of static or dynamic distal locking. However, the use of the nail is technically ambitious and is accompanied by some risks of error, which can lead to failure of the osteosynthesis. In this paper we present the results of a critical analysis of mistakes that were made in our hospital during the introduction period of this implant. We carried out a prospective analysis of the data of 121 consecutive patients who were suffering from trochanteric or subtrochanteric fracture between December 1997 and December 2000 and who had been treated with a PFN. We identified intraoperative technical difficulties in 23 patients (19.1%). Seven cases showed postoperative local complications that required operative revision on six patients (4.9%). The main reasons for the failure of the operations involved were poor reduction and wrong choice of screws. Following our critical analysis, we were able to avoid those problems. When 31A fractures are to be stabilised with a PFN, the precise technical performance of the implantation represents the basic surgical requirement. Already present minor deviations will subsequently cause loosening of the implants and failure of the operation.

Synthetically manufactured bone substitute materials are widely used to fill cancellous bone defects in fracture treatment. By using these materials, complications occurring with the harvesting of autologous bone such as inflammation, hemorrhage and pain are prevented. Ideally, after osteointegration, the bone substitute resorbs, and complete restoration of bone architecture is achieved. Until now, clinical experience is limited to non-fully resorbable calcium phosphates, e. g., hydroxyapatite. Previous studies have revealed a fully resorbable pure calcium phosphate, which is applied in a paste form as a bone implant and results in complete resorption and biocompatibility. The purpose of this prospective, uncontrolled clinical study was to investigate the safety and performance of this new resorbable bone substitute material. In 107 patients, bone defects were filled with 1.0–27.5 g (median 5.45 g) of the bone substitute material. From 15 patients, biopsy samples for histological examination could be taken during secondary surgery, mostly when implants for osteosynthesis had to be removed. On clinical, radiologic and histological examination, the bone substitute material studied appeared safe and efficient for filling bone defects in fracture treatment, showing resorption and osseous integration during remodeling of bone. No clinical signs of allergic reactions or inflammation did occur. When using calcium phosphate bone cement, a second surgical procedure to harvest autologous bone is not necessary and complications at the donor site are avoided.

The treatment of osseous defects is widely established in the elderly. The number of positive reports on the successful application of bovine as well as coralline hydroxyapatite ceramics has continuously increased during the last few years. In trauma surgery hydroxyapatite ceramics are most commonly applied in metaphyseal defects evoked by traumatic fractures of the long bones. The bovine and coralline materials applied are biocompatible and exhibit an interconnecting porous system. Good osteoconductive properties of such materials have repeatedly been demonstrated. Due to possible harmful effects caused by abrasion of the material, intra-articular application should be strictly avoided. Biological degradation of the materials does not occur even during long-term follow-up. The application of hydroxyapatite ceramics was introduced at our institution in 1992. Since then, no adverse events have been observed and only a few relevant complications were described in the literature. We report on a patient revealing a mechanical failure of a bovine hydroxyapatite (Endobon) 7.5 years after implantation into a metaphyseal defect of the proximal tibia caused by a traumatic fracture.

The scapho-capitate syndrome (Fenton syndrome) is so rare that diagnosing is a real challenge to every clinician. Therefore, its primary treatment is not always possible. In this case we are reporting about a delayed open treatment of a Fenton syndrome ten days after the original injury. Open reduction was performed via a dorsal approach and the capitate fracture was stabilized with K-wires and the scaphoid fracture with screw fixation. After postoperative immobilization of the wrist using an external fixator for six weeks the patient was already able to work again only twelve weeks after surgery.

Aufgrund der hoheren mechanischen Stabilitat hat die kombinierte dorsoventrale Stabilisierung von Frakturen des thorakolumbalen Ubergangs in den letzten Jahren zunehmend an Bedeutung gewonnen. Bislang liegen nur wenige Daten zum postoperativen Verlauf nach einer dorsoventralen Instrumentierung vor. Unklar ist insbesondere, welche Auswirkungen sich auf die Lebensqualitat ergeben.Zielsetzung dieser Untersuchung war es,die allgemeine gesundheitsbezogene Lebensqualitat nach einer dorsoventralen Stabilisierung des thorakolumbalen Ubergangs zu erfassen. Dabei sollte eruiert werden, ob bestimmte Faktoren die Entwicklung chronischer Beschwerden bei diesem Krankengut begunstigen. 30 Patienten einer konsekutiven Serie mit traumatischen Frakturen des thorakolumbalen Ubergangs wurden in eine prospektive klinische Studie eingeschlossen. Nach dorsaler Stabilisierung mit einem Fixateur interne (USS,Synthes®) wurde der verletzte Wirbelsaulenabschnitt von ventral mit einem autogenen Beckenkammspan und einem winkelstabilen Implantat (MACS, Aesculap®; VentroFix, Synthes®) instrumentiert. Die Lebensqualitat wurde mit dem SF- 36-Fragebogen 2 Jahre postoperativ untersucht. Der Grund-Deckplatten-Winkel (GDW) wurde praoperativ,unmittelbar postoperativ und 2 Jahre postoperativ erfasst. Die Auswertung der Daten ergab eine deutliche Beeintrachtigung der Lebensqualitat, hauptsachlich in den Dimensionen "Korperliche Rollenfunktion", "Korperlichen Schmerzen" und "Emotionale Rollenfunktion". Bei 42% der Patienten bestanden 2 Jahre postoperativ noch masige oder starke Schmerzsymptome. Radiologisch zeigte sich zu diesem Zeitpunkt ein geringfugiger Korrekturverlust, in den meisten Fallen ohne Anzeichen einer relevanten kyphotischen Deformitat. Die statistische Auswertung der Daten ergab keinen Zusammenhang zwischen den Parametern der Lebensqualitat und den klinisch-radiologischen Ergebnissen.Insbesondere fand sich keine Korrelation zwischen "Korperlichen Schmerzen" und dem GDW (r=0,112, Korrelationskoeffizient nach Spearman). Die hier vorgestellten Patienten wiesen 2 Jahre nach einer dorsoventralen Stabilisierung der thorakolumbalen Wirbelsaule eine eingeschrankte Lebensqualitat auf.Im Vordergrund stand dabei die anhaltende Schmerzsymptomatik. Diese ging uberwiegend nicht mit einer relevanten radiologischen Fehlstellung einher. Neben der eigentlichen Verletzung kommt als Schmerzursache der ausgedehnte operative Eingriff in Frage, wobei keine Unterschiede zwischen dem offenen und dem minimal-invasiven Verfahren zur ventralen Stabilisierung gesehen wurden. Insgesamt kann festgestellt werden, dass der SF-36 ein geeignetes Messinstrument darstellt, um die postoperative Lebensqualitat bei wirbelsaulenverletzten Patienten mit einer dorsoventralen Stabilisierung des thorakolumbalen Ubergangs zu erfassen.

Der Kalziumphosphatzement BIOBON® steht seit 1998 fur den klinischen Einsatz zur Behandlung knocherner Substanzdefekte zur Verfugung. Hinsichtlich des Einsatzes von BIOBON® als Knochenersatzmaterial sind in der Literatur gegenwartig keine Daten zu den klinischen Resultaten verfugbar. Um die mittelfristigen klinischen Ergebnisse bei der Therapie metaphysarer Defekte nach distaler Radiusfraktur mit BIOBON ® zu evaluieren,wurden im Rahmen einer retrospektiven Studie 29 Patienten erfasst, die aufgrund einer instabilen distalen Radiusfraktur mit BIOBON® und additiver Osteosynthese von 1998 bis 2001 behandelt wurden. Von den 29 Patienten konnten 20 (69,0%) zur klinisch-radiologischen Nachuntersuchung nach durchschnittlich 18,35 Monaten (9—40 Monate) einbestellt werden. Bei allen Patienten waren radiologisch noch Anteile des Ersatzmaterials im Knochen nachweisbar. Im Gartland-und-Werley-Score wurden im Durchschnitt 7,5 Punkte (2—21 Punkte) und damit ein gutes Ergebnis erzielt. Kalziumphosphatzemente stellen eine gute Alternative zur autogenen Knochentransplantation dar,von der vor allem altere Patienten profitieren konnen.

Fragestellung. In der operativen Versorgung instabiler Frakturen des thorakolumbalen Uberganges besteht Unklarheit daruber,mit welchem Verfahren die besten Ergebnisse erzielt werden konnen.Aufgrund der hoheren mechanischen Stabilitat scheint sich gegenwartig die kombinierte dorsoventrale Stabilisierung durchzusetzen.Fur das kombinierte Verfahren sind bislang trotz erster Langzeituntersuchungen keine aussagekraftigen Daten zur Einheilung autogener Transplantate verfugbar.Zielsetzung dieser Untersuchung war es, die Integration autogener Transplantate und die lokalen Komplikationen an der Entnahmestelle zu evaluieren. Methodik. Um die knocherne Fusionsrate zu untersuchen,wurden aus einer konsekutiven Serie 30 Patienten mit traumatischen Frakturen des thorakolumbalen Uberganges selektiert und in eine prospektive klinische Verlaufsstudie eingeschlossen. Nach dorsaler Stabilisierung mit einem Fixateur interne (USS, Synthes) erfolgte die Instrumentierung der ventralen Saule durch Verwendung eines autogenen trikortikalen Beckenkammspans und zusatzliche Osteosynthese (MACS,Aesculap; VentroFix, Synthes). Die knocherne Fusion wurde computertomographisch vor der Entfernung des dorsalen Implantates (t=12±2,4 Monate) untersucht. Ergebnisse. Die Analyse der ca.1 Jahr postoperativ durchgefuhrten Computertomographien erbrachte den Nachweis einer vollstandigen knochernen Integration der Transplantate in 77% (23/30). Klinisch mussten lokale Beschwerden an der Entnahmestelle in 37% (11/30) der Falle hingenommen werden. Schlussfolgerungen. Diese Daten verdeutlichen, dass eine vollstandige Fusion der vorderen Saule unter Verwendung autogener Beckenkammspane keineswegs in allen Fallen erwartet werden kann und mit einer relativ hohen Rate lokaler Komplikationen an der Entnahmestelle gerechnet werden muss. Vor diesem Hintergrund werden alternative Verfahren wie der Einsatz von Cages zunehmend an Bedeutung gewinnen.

Wahrend bei Erwachsenen vorwiegend die untere HWS von einem Trauma betroffen ist, uberwiegen bei jungeren Kindern Verletzungen im Bereich C1/C2. Dabei kann es in seltenen Fallen auch zu Bandverletzungen in diesem Bereich kommen. Die diagnostische Abklarung solcher Verletzungen erweist sich in der Praxis als auserst schwierig. Ebenso existieren in der Literatur kaum Daten hinsichtlich Behandlungsregime und Prognose. Wir berichten uber 2 Kinder mit einer isolierten Ruptur der Ligg. alaria. Die Diagnose wurde in beiden Fallen durch MRT gesichert, welche wir zum Ausschluss von ligamentaren Verletzungen der oberen HWS bei Kindern als Mittel der Wahl empfehlen. Trotz widerspruchlicher Datenlage zur biomechanischen Bedeutung der Ligg. alaria halten wir ein konservatives Vorgehen fur vertretbar. Masgeblich bleibt jedoch die umgehende Abklarung, um eine mogliche Gefahrdung des Patienten zu vermeiden.

Endobon, eine porose Hydroxylapatitkeramik bovinen Ursprungs, ist seit 1989 als Knochenersatzmittel zur Therapie von Knochendefekten zugelassen. In der Literatur sind gegenwartig keine Langzeitdaten zur klinischen Anwendung von Endobon verfugbar. Um die Langzeiteffekte von Endobon zu evaluieren, wurden im Rahmen einer retrospektiven Studie 35 Patienten mit Tibiakopffrakturen untersucht, die von 1992–1997 in unserer Klinik behandelt wurden. Nach Anhebung und Rekonstruktion der Gelenkflache wurden die metaphysaren Defekte mit Endobon gefullt und die Frakturen durch Plattenosteosynthese stabilisiert. Von den eingeschlossenen Patienten konnten im Januar 2000 insgesamt 26 zu einer Nachuntersuchung einbestellt werden. Ein mechanisches Versagen der implantierten Keramiken mit sekundarem Korrekturverlust wurde nicht beobachtet. Einzelne Biopsate zeigten, dass das eingebrachte Material nach 18 Monaten vollstandig ossar integriert wurde. Radiologische Anzeichen fur eine Auslockerung, Dislokation, Sinterung oder Fraktur der Keramiken wurden auch nach Entfernung des Osteosynthesematerials nicht gesehen. Diese Daten zeigen, dass Endobon im Langzeitverlauf mechanisch stabil ist und bei entsprechender Indikation eine gute Alternative zur autogenen Spongiosaplastik darstellt.

Patienten mit Trisomie 21 weisen haufig eine atlantoaxiale Instabilitat auf. Obwohl neurologische Symptome selten auftreten, wurden nach Bagatelltraumen der HWS vereinzelt todliche Zwischenfalle durch Kompromittierung der Medulla beschrieben. Anhand eines Fallbeispiels wird demonstriert, dass Patienten mit Trisomie 21 bei einem Trauma der HWS als Hochrisikogruppe aufzufassen und zwingend einer diagnostischen Abklarung von C1/C2 zuzufuhren sind. Ist eine adaquate Diagnostik nicht durchfuhrbar, sollte grundsatzlich die primare Stabilisierung erwogen werden, um einer atlantoaxialen Instabilitat mit vitaler Bedrohung des Patienten vorzubeugen. Die dorsale Spondylodese stellt dabei das Verfahren der Wahl dar. Neben den klassischen Fusionstechniken nach Gallie oder Brook/Jenkins kommen die transartikulare Verschraubung nach Magerl sowie die Stabilisierung mit dem CerviFix®-System in Betracht.

Seit der Definition der Grundsatze „Ambulantes Operieren“ durch die Gesetzliche Unfallversicherung am 01.01.2005 besteht in einigen Fallen nicht nur die Moglichkeit, sondern die Verpflichtung fur alle am Heilverfahren beteiligten Arzte, bestimmte Operationen ambulant durchzufuhren. Die unter dem 3. Hauptthema der 33. Unfallmedizinischen Tagung in Baden-Baden gehaltenen Vortrage sowie die sich anschliesende Diskussion zeigten, dass hier noch erhebliche Diskrepanzen zwischen Anspruch und Realitat bestehen. Politik und Kostentrager mussen einen akzeptablen Rahmen schaffen, der ambulantes Operieren betriebswirtschaftlich attraktiver abbilden lasst, als dies aktuell der Fall ist. Daruber hinaus muss das Problem der adaquaten Aus- und Weiterbildung unter den geanderten Rahmenbedingungen gelost werden. Um die Entscheidungstrager entsprechend zu sensibilisieren, mussen Krankenhauser und niedergelassene Arzte als gleichgesinnte Partner auftreten.

Producción Científica, Pertrochanteric fractures are increasing and their operative treatment remains under discussion. Failures needing reoperations such as a cut-out are reported to be high and are associated with multiple factors including poor bone quality, poor fracture reduction and improper implant placement. The PFNA® with perforated blade offers an option for standardized cement augmentation with a PMMA cement to provide more stability to the fracture fixation. It remains unclear if the augmentation of this implant does any harm in a longer time span. This prospective multicenter study shows clinical and radiological results with this implant with a mean follow-up time of 15 months.

Most fractures during growth affect the upper extremities. Severe fractures with an increased number of complications are mainly localized beyond the elbow joint. Displaced fractures of the elbow joint have limited potential for spontaneous correction as the bones near the elbow joint account for only 20% of growth in length and the possibility of spontaneous correction is already exhausted at the age of 7. The consequences of inadequately reduced elbow fractures, therefore, may adversely affect a patient for his lifetime. Cubitus varus and valgus are the most common deformities following insufficiently treated supracondylar humerus fractures, fractures of the radial or dislocations of the radial head. Posttraumatic deformities of the elbow are usually the result of an insufficient primary therapy and rarely the result of growth disturbances. For the attending surgeon, posttraumatic deformities on a child's elbow are challenging.

Producción Científica, Pertrochanteric fractures are a rising major health-care problem in the elderly and their operative stabilisation techniques are still under discussion. Furthermore, complications like cut-out are reported to be high and implant failure often is associated with poor bone quality. The PFNA1 with perforated blade offers a possibility for standardised cement augmentation using a polymethylmethacrylate (PMMA) cement which is injected through the perforated blade to enlarge the load-bearing surface and to diminish the stresses on the trabecular bone. The current prospective multicentre study was undertaken to evaluate the technical performance and the early clinical results of this new device. In nine European clinics, 59 patients (45 female, mean age 84.5 years) suffering from an osteoporotic pertrochanteric fracture (Arbeitsgemeinschaft fu¨ r Osteosynthesefragen, AO-31) were treated with the augmented PFNA1. Primary objectives were assessment of operative and postoperative complications, whereas activities of daily living, pain, mobility and radiologic parameters, such as cement distribution around the blade and the cortical thickness index, were secondary objectives. The mean follow-up time was 4 months where we observed callus healing in all cases. The surgical complication rate was 3.4% with no complication related to the cement augmentation. More than onehalf of the patients reached their prefracture mobility level within the study period. A mean volume of 4.2 ml of cement was injected. We did not find any cut-out, cut through, unexpected blade migration, implant loosening or implant breakage within the study period. Our findings lead us to conclude that the standardised cement augmentation using the perforated blade for pertrochanteric fracture fixation enhances the implant anchorage within the head–neck fragment and leads to good functional results.

In addition to a stabile osteosynthesis autologous cancellous bone graft remains an essential therapy option in persistent non-union. Despite this therapy regimen persistent non-union can occasionally occur. The aim of this study was to evaluate the treatment of persistent non-union with a combination of platelet-rich plasma (PRP) and autologous cancellous bone.In this prospective study 17 patients with persistent non-union of long bones were treated by a combination of PRP and autologous iliac crest bone. Inclusion criteria were a minimum of one previously failed cancellous bone transplantation and an atrophic non-union persisting for 6-14 months (mean 9 months). The patients were examined clinically and radiologically at intervals of 3, 6 and 9 months postoperatively.After an average time of 17 months (range 15-23 months) the patients were treated by a combination of PRP and autologous cancellous bone. In all cases the non-union was successfully treated and osseous bridging was found radiologically after an average of 5 months (range 4-7 months) without any complications.The combination of PRP and autologous cancellous bone appears to be a safe and effective method for treatment of persistent non-union. The use of PRP does not result in substantial additional costs. Allergies and graft versus host reactions are not expected because of the autologous origin.

The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS).62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases.Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis.There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

Modern strategies for postoperative care of patients with hip fractures include early discharge from the acute care hospital to inpatient interdisciplinary rehabilitation facilities. Whether these programs are effective for the patients and improve their long-term outcomes or if they simply transfer costs, with a reduction of the inpatient days in the acute care hospital, is currently under discussion.This prospective study included 282 patients with hip fracture admitted to our trauma center were included into the prospective study. The mean patient age was 86+/-8 (65-110) years. All patients were treated operatively. After a mean of 12+/-9 days, the patients underwent inpatient interdisciplinary geriatric rehabilitation for a mean of 27+/-13 (4-103) days. The primary outcome measure was their activities of daily living (Barthel index) before, at the end of rehabilitation, and 1 year after trauma. In addition, patient-related variables were correlated with the Barthel index.With discharge from the acute care hospital, the Barthel index was 42+/-20 points and it increased during rehabilitation to 65+/-26 points. One year later the Barthel index was 67+/-28 points. Ninety percent of patients improved their Barthel index during rehabilitation. Within 1 year, 40% of patients deteriorated in their activities of daily living. Fifty one percent of patients were reintegrated back to their homes. Patients who lived at home before trauma and were reintegrated back to their homes had a significant higher Barthel index (75+/-24) 1 year after trauma than patients who were living in a nursing care facility before the trauma (Barthel index 52+/-27). The variables of age, level of cognition, and type of fracture had no influence on the long-term outcome. An extension of rehabilitation above the mean time period did not improve the sustainable clinical outcome.Postoperative inpatient rehabilitation programs enhance short-term activities of daily living. In particular, patients who lived at home before the trauma and were reintegrated back home benefited in perpetuity from geriatric rehabilitation. A policy for early discharge to geriatric rehabilitation is associated with extension of overall hospital stay. This association along with the related increased health care costs should be weighed against the sociofunctional effectiveness of these programs.

Computer-assisted procedures have recently been introduced for navigated iliosacral screw placement. Currently there are only few data available reflecting results and outcome of the different navigated procedures which may be used for this indication. We therefore evaluated the features of a new 3D image intensifier used for navigated iliosacral screw placement compared to 2D fluoroscopic and CT navigation.Twenty fixed human cadavers were used in this trial. Cannulated cancellous screws were percutaneously implanted in the supine position in four treatment groups. An optoelectronic system was used for the navigated procedures. Screw placement was postoperatively assessed by fluoroscopic 3D scan and CT. The target parameters of this investigation were practicability, precision as well as procedure and fluoroscopic time per screw.All navigated procedures revealed a significant loss of time compared to non-navigated screw placement (2D: p0.001, 3D: p0.05, CT: p0.001). Simultaneously a significant decrease of radiation exposure time was observed in the navigated groups (p0.001 each). The misplacement rate was 20% in the non-navigated and the 2D fluoroscopic navigated group each. Procedures providing 3D imaging of the posterior pelvis did not produce any screw misplacement (p0.05). However, the CT procedure was associated with time-consuming registration and high rates of failed matching procedures.Our data show a clear benefit of using C-arm navigation for iliosacral screw placement compared with the CT-based procedure. While both fluoroscopy-based navigation procedures decrease intraoperative radiation exposure times, only 3D fluoroscopic navigation seems to improve the precision compared to non-navigated screw placement.

The treatment of unstable cervical spine injuries with the halo vest represents an established procedure. So far no data reflecting the quality of life of patients following a halo vest treatment are available. Elderly people make up a large part of the inpatients in our hospital. Therefore special attention is payed to this group of patients in this study.In this study 41 patients (average age of 51.8 +/- 23.5 years) with an unstable injury of the upper cervical spine were investigated. All of them underwent a halo vest therapy in our hospital during 1988-2003. The health-related quality of life was assessed in the mean 8.0 years after the trauma by using the SF-36 Health Survey. Additionally, the incidence of complications and the union rate over time were observed.The evaluation of the data obtained from the SF-36 revealed a reduced quality of life in the patient group in comparison to the reference population. This was particularly apparent in patients older than 60 years. The fracture healing under halo vest treatment was comparably slow. In 17% of the cases no fracture union was obtained after 12 weeks. This was only seen for patients older than 60 years. The complication rate associated to the halo vest amounted to 43% and was independent of age.The treatment of unstable fractures of the upper cervical spine with a halo vest results in a prolongated fracture healing for elderly people. Furthermore a halo vest therapy reduces the health related quality of life. Therefore, even for elderly patients an internal osteosynthetic stabilization of an unstable injury of the upper cervical spine should be considered if indicated.

Composites of amorphous carbonated apatite and poly-(R)-3-hydroxybutyrate (PHB) and poly-(R)-3-hydroxybutyrate-co-(R)-3-hydroxyvalerate (PHBHV), respectively, were studied by pH monitoring upon immersion in water and by long-term osteoblast culture. For comparison, α-tricalcium phosphate (α-TCP), one glass ceramic (GB 9N), and one bioglass (Mg 5) were subjected to the same experiments. Excellent cell proliferation was found on the composite of calcium phosphate with PHB and on the reference materials (α-TCP, glass ceramic, bioglass). In contrast, cell death was observed repeatedly on the composite with PHBHV. A composite of amorphous calcium phosphate and PHB appears to be well suited as slowly biodegradable bone substitution material.

Classical anatomic atlases cannot provide the spectrum of views and the detail required in modern diagnostic and surgical techniques. Computer modeling opens the possibility to choose any view from one single model. A computerized model of the hand is presented, which has been obtained by segmentation and graphic modeling of the Visible Human dataset. In addition to being able to choose arbitrary viewpoints, it allows interrogation of the chosen views by mouse click. We believe the functions of these new kinds of atlases are superior to the classical ones.

Biomaterials are designed to support orthopedic surgeons and once implanted they will help the body to heal itself. In this way one of the most attractive substances are biomaterials that allow gluing of bone fragments and implant fixation. Although no bone adhesive is established for practical use in clinical practice yet, there is evidence in vitro and in vivo that a new class of bone adhesives based on alkylene bis(dilactoyl)-methacrylates may meet the requirements to bridge the gap between bench and bedside. The purpose of this experimental study was to investigate the long-term biocompatibility as well as the integration in the remodeling process of a new polymer of this group of substances that was used for both fragment adaptation and implant fixation in a large-scale animal model. In 24 sheep the lateral tibial condyle was osteotomized and refixed by three cortical screws. In 12 of them overdrilling the bone thread of one screw was performed to simulate the poor mechanical properties of osteoporotic bone and the polymer was used in this setting for screw augmentation, furthermore the osteotomy surface was covered with polymer before osteosynthesis to analyze the influence of the material on bone healing. In the other 12 sheep that served as controls osteosynthesis was performed without a polymer. All animals were permitted to walk immediately after surgery under full weight bearing conditions. Six animals of the polymer group and six animals of the control group were analyzed after 6 weeks and 6 months, respectively. Bone healing and implant integration was evaluated by contact X-rays, histology and histomorphometric quantification. After 6 weeks integrity of the healing bone in the polymer group was preserved as compared to the controls, albeit signs of prolonged aseptic inflammation were observed in the polymer group, which is in line with previous reports. In sharp contrast after 6 months, extensive tissue destruction was observed in all animals of the polymer group that was attributed to a massive foreign body reaction at the histological level. These long-term results suggest that (i) short-term observation not always allow valid conclusions regarding the biocompatibility of biomaterials, (ii) that biocompatibility might vary between species, and (iii) that the polymer used in this setting, although previously attributed to be a good candidate for clinical use in patients, does not meet the necessary criteria and tremendously interferes with the physiology of skeletal repair.

MRI is a sensitive diagnostic tool, which is especially suited for the diagnosis of vertebral injuries in children since no radiation has to be applied to gonads or blood-producing organs. An indirect sign of vertebral injury is the presence of "bone bruise," an edema of the vertebral body without other bony lesions. The purpose of this study was to elucidate the clinical significance of "bone bruise" following vertebral trauma in children.Between 1998 and 2003 a total of 66 children with vertebral injuries were treated at our institution; 34 of these patients initially underwent MRI. In this retrospective study 20 of these children who were diagnosed with a vertebral injury based on the presence of a "bone bruise" in an MRI on admission were examined clinically as well as by follow-up MRI.All 20 patients stated they felt no limitations in daily activities. On examination there were no significant pathologic findings. We did not note persistence of a "bone bruise" or a collapse of the affected bone in the follow-up MRI.If a "bone bruise" is detected in the MRI after vertebral trauma in children, it usually has a good prognosis. With adequate therapy, which in our regimen consists of bedrest and early mobilization, we did not note any secondary collapse of the affected vertebrae.

Cervical spine injuries are rare in children. They tend to occur predominantly in the region of atlanto-axial articulation. Even traumatic rotatory atlanto-axial subluxation (AAD) has been described in the literature, however, there is no consistent therapeutic protocol. We report on a 4 year old girl with an acute traumatic rotatory atlanto-axial subluxation treated with closed reduction and retention in a hard-collar. Control CT scans and physical examination after 6 weeks revealed an excellent outcome without any signs of recurrence. As there is a correlation between outcome and increasing length of the dislocation-therapy interval, optimal management of acute rotatory atlanto-axial subluxation depends on early diagnosis with plain radiography and CT scans. Timely diagnosed cases may be treated successfully with closed reduction and cervical immobilisation in a hard-collar. Failure to obtain reduction and recurrence are an appropriate indication for surgical intervention.

The application of autogenous bone grafts represents the golden standard for reconstruction of the load-bearing anterior column in the thoracolumbar spine. However, the osseous integration of the implanted grafts is demanding and delayed union or pseudarthrosis may occur. There are no standardized data available yet indicating the further course in such cases. The aim of this study was to evaluate the incorporation of endoscopically applied grafts and to develop therapeutic strategies for delayed or non-fusions. Twenty patients suffering from unstable injuries of the thoracolumbar spine were studied in a prospective clinical trial. After primary dorsal stabilization, the anterior column was thoracoscopically reconstructed with an autogenous iliac crest graft and a fixed-angle implant (MACS). The osseous integration of the bone grafts was detected by MSCT 1 year postoperatively. Complete integration of the transplanted bone grafts was observed in only 65% of the cases. In 25% partial integration was detected and in two cases a fracture of the transplanted iliac crest graft occurred. Despite the incomplete integration of the bone grafts, the further course without surgical intervention revealed no clinical or radiological evidence of a concomitant implant loosening or a relevant secondary loss of correction. Similar to the open technique, endoscopic reconstruction of the anterior column with autogenous bone grafts may lead to disadvantageous results concerning the integration and healing of the applied bone grafts. Decision making in such cases depends on the individual clinical and radiological findings (i.e., evidence of implant loosening and concomitant loss of correction).

Dorsal stabilisation has represented the standard procedure for the treatment of burst fractures of the thoracolumbar spine for a long time, but in the last few years the combined dorsoventral stabilisation has gained in significance due to its higher mechanical stability. However, there are no data yet available indicating whether the patients benefit from the combined operation with regard to their postoperative quality of life and what the advantages are in comparison with the dorsal procedures. Therefore, the question was researched in the framework of a matched-pairs analysis of patients suffering from an unstable fracture of the thoracolumbar transition.From a consecutive series of patients treated in our clinic between 1995 and 2000, 10 patients with combined and 10 patients with a purely dorsal stabilisation were selected and included in the study. Their quality of life was summed up in retrospect with the SF-36 questionnaire. The X-rays were analysed, and the Cobb angle as well as the sagittal index were calculated. Only patients with burst fractures of the thoracolumbar transition without accompanying co-morbidity and neurological deficits were included in the study. Both of the treated groups were matched with regard to sex, age and radiological patterns of injury.Patients who had undergone only a dorsal stabilisation showed a significant loss of correction according to the sagittal index at the time of the examination (0.88+/-0.02 postoperative vs 0.77+/-0.03 at 4 years postoperatively, p=0.01). In the group of patients treated with the combined therapy, there was no statistically relevant loss of correction with regard to the sagittal vertebral profile. The SF-36 questionnaire showed a reduced quality of life in both groups compared with an age-referenced norm population, especially concerning the parameters of bodily health. No statistically relevant difference was observed between the two groups. Further, there was no statistically relevant association between the parameters of the SF-36 and the clinical and radiological data. After performing several regression analyses it could be shown that the patient's mental health is a strong predictor of the postoperative vitality (r=0.803, p0.01). However, none of the remaining parameters was able to predict the postoperative quality of life.The patients in this study showed a reduced quality of life, independent of the method of surgical treatment. Although better radiological results could be seen for the combined procedure, regarding the postoperative quality of life no advantage could be proved compared with the dorsally stabilized patients. Furthermore, there was no relation between the radiological results and the quality of life parameters. Therefore, it can be assumed that the injury itself seems to be the main cause of the decreased quality of life after a burst fracture of the thoracolumbar transition.

The treatment of osseous defects is widely established in the elderly. The number of positive reports on the successful application of bovine as well as coralline hydroxyapatite ceramics has continuously increased during the last few years. In trauma surgery hydroxyapatite ceramics are most commonly applied in metaphyseal defects evoked by traumatic fractures of the long bones. The bovine and coralline materials applied are biocompatible and exhibit an interconnecting porous system. Good osteoconductive properties of such materials have repeatedly been demonstrated. Due to possible harmful effects caused by abrasion of the material, intra-articular application should be strictly avoided. Biological degradation of the materials does not occur even during long-term follow-up. The application of hydroxyapatite ceramics was introduced at our institution in 1992. Since then, no adverse events have been observed and only a few relevant complications were described in the literature. We report on a patient revealing a mechanical failure of a bovine hydroxyapatite (Endobon) 7.5 years after implantation into a metaphyseal defect of the proximal tibia caused by a traumatic fracture.

The scapho-capitate syndrome (Fenton syndrome) is so rare that diagnosing is a real challenge to every clinician. Therefore, its primary treatment is not always possible. In this case we are reporting about a delayed open treatment of a Fenton syndrome ten days after the original injury. Open reduction was performed via a dorsal approach and the capitate fracture was stabilized with K-wires and the scaphoid fracture with screw fixation. After postoperative immobilization of the wrist using an external fixator for six weeks the patient was already able to work again only twelve weeks after surgery.

Combined dorsoventral stabilization provides superior mechanical stability in the operative treatment of thoracolumbar spine fractures. Currently, there are no data available reflecting the quality of life in trauma patients following the combined procedure. The aim of this investigation was to study the health-related quality of life after dorsoventral stabilization of the thoracolumbar junction using the SF-36 Health Survey.In order to assess the quality of life, 30 patients from a consecutive series with unstable fractures of the thoracolumbar junction were investigated in a clinical study. After posterior stabilization with an internal fixator (USS, Synthes),anterior arthrodesis was performed subsequently by autogenous iliac bone grafting in combination with osteosynthesis (MACS, Aesculap; VentroFix, Synthes). The quality of life was investigated 2 years after surgery. Additionally, plain X-rays were obtained and the degree of kyphotic deformation was measured.The evaluation of the data obtained from the SF-36 revealed a reduced quality of life, especially regarding the "physical functioning index", the "bodily pain index", and the "emotional functioning index". Of the patients, 42% still suffered from moderate to severe pain. Measurement of the Cobb angle showed a slight loss of correction without occurrence of a relevant kyphotic deformity. Our statistical analyses did not show any correlation between the data obtained from the SF-36 and the clinical results. Especially there was no correlation between the "bodily pain index" and the Cobb angle ( r=0.112, Spearman's rank order correlation).The patients studied here showed a reduced quality of life 2 years after dorsoventral stabilization of the thoracolumbar junction predominantly resulting in long-term pain symptoms. As these findings could not be related to the radiological results (i.e., the occurrence of a kyphotic deformation), other factors such as injury of the motion segment of the spine and the major surgical procedure have to be considered as the main reasons for the reduced quality of life. In summary, it can be concluded that the SF-36 is a suitable tool for the investigation of the postoperative outcome following dorsoventral stabilization of the thoracolumbar junction in trauma patients.