Next step trauma and orthopaedic surgery: integration of augmented reality for reduction and nail implantation of tibial fractures.

INTRODUCTION: There is a tremendous scope of hardware and software development going on in augmented reality (AR), also in trauma and orthopaedic surgery. However, there are only a few systems available for intra-operative 3D imaging and guidance, most of them rely on peri- and intra-operative X-ray imaging. Especially in complex situations such as pelvic surgery or multifragmentary multilevel fractures, intra-operative 3D imaging and implant tracking systems have proven to be of great advantage for the outcome of the surgery and can help reduce X-ray exposure, at least for the surgical team (Ochs et al. in Injury 41:1297 1305, 2010). Yet, the current systems do not provide the ability to have a dynamic live view from the perspective of the surgeon. Our study describes a prototype AR-based system for live tracking which does not rely on X-rays. MATERIALS AND METHODS: A protype live-view intra-operative guidance system using an AR head-mounted device (HMD) was developed and tested on the implantation of a medullary nail in a tibia fracture model. Software algorithms that allow live view and tracking of the implant, fracture fragments and soft tissue without the intra-operative use of X-rays were derived. RESULTS: The implantation of a medullar tibia nail is possible while only relying on AR-guidance and live view without the intra-operative use of X-rays. CONCLUSIONS: The current paper describes a feasibility study with a prototype of an intra-operative dynamic live tracking and imaging system that does not require intra-operative use of X-rays and dynamically adjust to the perspective of the surgeons due to an AR HMD. To our knowledge, the current literature does not describe any similar systems. This could be the next step in surgical imaging and education and a promising way to improve patient care.

Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion.

PURPOSE: Aim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion. METHODS: In a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018. RESULTS: One year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55). CONCLUSION: This study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients' age. Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).

[Anterolateral approach to femoral neck fractures in children]. / Anterolateraler Zugang zur Fixation von Schenkelhalsfrakturen im Kindesalter.

OBJECTIVE: Anatomic reduction and stable fixation of pediatric femoral neck fractures. INDICATIONS: All unstable and displaced femoral neck fractures (AO classification 31-E/1.1, 31-E/1.2, 31-M/2.1 I-III, 31-M/3.1 I-III, 31-M/3.2 II-III). CONTRAINDICATIONS: Relative: Stable and nondisplaced femoral neck fractures. SURGICAL TECHNIQUE: The anterolateral approach uses the muscle interval between the gluteus medius and minimus muscles and the tensor fascia lata. It provides access to the anterior part of the hip joint for open reduction and allows the retention and osteosynthesis from the lateral aspect of the femur. By incision of the anterior capsule the blood supply of the femoral head is preserved and the fracture can be visualized. An anatomic reduction should be achieved and a stable osteosynthesis according to the age of child and fracture type and location should be performed. POSTOPERATIVE MANAGEMENT: After stable fixation additional immobilization is not required. Young children are mobilized in a wheel chair with no weight bearing; older children are mobilized with partial weight bearing with crutches. According to the age of the child and fracture type full weight bearing can be allowed after 4-8 weeks after radiographic follow-up. RESULTS: Fractures of the femoral neck in children are rare and often associated with high-energy traumata. Complication rates are high such as avascular necrosis (AVN) of the femoral head, premature epiphyseal closure, nonunion, secondary displacement, coxa vara or infection. Different factors influence the outcome, including initial displacement, fracture classification, timing of reduction, stability of fixation or quality of reduction. However, especially in the lateral fractures the femoral head necrosis can be avoided by protecting the vascular supply. The reader of the article should be enabled to reduce the rate of AVNs by knowledge of the controllable risk factors and no longer accept AVN as predestined. There is a controversial discussion on the benefit of hematoma evacuation of the hip joint capsule and its influence on the rate of femoral head necrosis.

Pediatric aseptic lower leg fracture nonunion.

PURPOSE: Lower leg nonunion in pediatric patients is a rarity. Therefore, eight European pediatric trauma units retrospectively analyzed all patients younger than 18 years suffering lower leg fractures resulting in aseptic nonunion. METHODS: Thirteen children and adolescents less than 18 years old (2 girls and 11 boys) diagnosed with aseptic nonunion of the tibia and/or fibula were evaluated. In all patients, epidemiological data, mechanism of injury, fracture configuration, and the initial treatment concept were assessed, and the entire medical case documentation was observed. Furthermore, potential causes of nonunion development were evaluated. RESULTS: The mean age of patients was 12.3 years with the youngest patient being seven and the oldest being 17 years old. Open fractures were found in six out of thirteen patients (46%). Nonunion was hypertrophic in ten and oligotrophic in three patients. Mean range of time to nonunion occurrence was 7.3 ± 4.6 months. Nonunion healing resulting in complete metal removal was found in 12 out of 13 patients (92%), only in one case of a misinterpreted CPT type II osseous consolidation could not be found during the observation period. Mean range of time between surgical nonunion revision and osseous healing was 7.3 months as well. CONCLUSION: If treatment principles of the growing skeleton are followed consistently, aseptic nonunion of the lower leg remains a rare complication in children and adolescents. Factors influencing the risk of fracture nonunion development include patient's age, extended soft tissue damage, relevant bone loss, and inadequate initial treatment.

[Ankle fractures in children and adolescents]. / Sprunggelenkfrakturen im Kindes- und Jugendalter.

In children and adolescents, injuries of the ankle are seen frequently in routine practice. The fracture pattern is less dependent on the mechanism of injury than on the maturity of the growth plate. Therefore, a differentiation is made between fractures with open epiphyses and fractures with a closing growth plate in adolescents. The potential for growth-related spontaneous deformity correction is limited, so axial alignment especially in the frontal plane has to be achieved during initial treatment. In displaced articular fractures an anatomical reconstruction of the articular surface and stable osteosynthesis have to be achieved to minimize the risk of early osteoarthritis. Growth arrest is not always avoidable despite an ideal reconstruction and can occur in all fracture types; however, with optimal conservative or surgical treatment, iatrogenic damage of the epiphysis can be avoided thereby reducing the incidence of growth disorders as a complication of ankle fractures in children and growing adolescents.

Severe pressure ulcers requiring surgery impair the functional outcome after acute spinal cord injury.

STUDY DESIGN: Retrospective matched cohort study. OBJECTIVES: Assessing the influence of surgically managed grade 3 and 4 pressure ulcers (PU) in the acute phase after spinal cord injury (SCI) on the neurological and functional outcome after 1 year. SETTING: Specialized SCI-unit within a level 1 trauma center in Murnau, Germany. METHODS: We performed a retrospective matched cohort study. For every patient with acute SCI and a PU requiring surgery, we identified matched controls within our database in a 1:3 ratio. Matching criteria were: AIS-grade (American Spinal Injury Association Impairment Scale), neurological level and age. The scores of the SCIM-III (Spinal Cord Independence Measure) and the ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury) as well as the total length of stay (LOS) at the hospital were used as outcome parameters. We applied a stratified analysis using a conditional logistic regression to test for group differences in each outcome parameter of the study. RESULTS: In a 6-year period (2010-2015) 28 patients required flap surgery due to 3-4° PU in the acute phase after SCI. Of these patients, 15 had complete data sets according to the EMSCI (European Multicenter Study about Spinal Cord Injury) protocol. Patients with severe PUs during the acute SCI phase had a significantly impaired functional outcome. After 1 year the improvement of the SCIM score was significantly lower in the PU group compared to the control group (17.4 versus 30.5; p < 0.006). However, the change in AIS grade after 1 year was not significantly affected. The LOS was prolonged by a mean of 48 days in the PU group (p < 0.006). CONCLUSIONS: Severe PUs requiring surgery in the acute phase after SCI impair the functional outcome and increase LOS. Preventive measures should be applied to all acute SCI patients. Patients should be transferred to specialized SCI-centers as soon as possible.

Functional outcome after traumatic cervical spinal cord injury is superior in adolescents compared to adults.

OBJECTIVE: Determining differences in neurological and functional outcome between adolescents and adults after acute traumatic spinal cord injury (SCI). DESIGN: Retrospective, multi-center case-control study. METHODS: 100 cases of patients under 18 years at accident with acute traumatic cervical SCI admitted to SCI centers participating in the European Multi-center study about SCI (EMSCI) between January 2005 and April 2016 were reviewed. According to their age at accident, age 13 to 17, patients were selected for the adolescent group. After applying in- and exclusion criteria 32 adolescents were included. Each adolescent patient was matched with two adult SCI patients for analysis. OUTCOME MEASURES: ASIA Impairment scale (AIS) grade, neurological, sensory, motor level, total motor score, and Spinal Cord Independence Measure (SCIM III) total score. RESULTS: Mean AIS conversion, neurological, motor and sensory levels as well as total motor score showed no significantly statistical difference in adolescents compared to the adult control group after follow up of 6 months. Significantly higher final SCIM scores (p < 0.05) in the adolescent group compared to adults as well as a strong trend for a higher gain in SCIM score (p < 0.061) between first and last follow up was found. CONCLUSIONS: Neurological outcome after traumatic cervical SCI is not superior in adolescents compared to adults in this cohort. Significantly higher SCIM scores indicate more functional gain for the adolescent patients after traumatic cervical SCI. Juvenile age appears to be an independent predictor for a better functional outcome.

[Relevance of MRI After Closed Reduction of Traumatic Hip Dislocation in Children]. / Die Bedeutung des MRT nach geschlossener Reposition der traumatischen Hüftgelenkluxation im Kindes- und Jugendalter.

BACKGROUND: Traumatic hip dislocation in children and adolescents is a rare entity that typically results from high-energy trauma. After closed joint reduction, further treatment depends on the specific pattern of the lesion as identified using cross sectional imaging. The aim of this retrospective analysis was to evaluate relevant side effects after traumatic hip dislocation in children and adolescents in order to examine the need for focused diagnostics. PATIENTS/MATERIAL AND METHODS: This retrospective analysis covered 8 adolescents under 18 years suffering isolated traumatic hip joint dislocation between 2001 and 2017. In all patients, closed joint reduction was performed immediately after admission to the emergency room. In order to evaluate the complete extent of the injury, 5 patients received an MRI and 3 patients a CT scan following closed joint reduction. RESULTS: Two female and 6 male patients with a median age of 11 (range 5 - 16) years were included. In 2 cases, a free joint body was detected in the posterior joint gap in the posttraumatic CT scan after closed joint reduction. Interposition of the labrum into the joint gap was detected intraoperatively in both cases. In one patient who received posttraumatic MRI, labral interposition into the joint gap was observed after closed reduction. These findings were confirmed intraoperatively. In 4 other patients, no posttraumatic labral lesion was detected in the MRI after closed reduction. The reported side effects included ruptured anterior inferior iliac spine and ruptured femoral head ligament. CONCLUSION: MRI is gaining increasing importance following traumatic hip dislocation in children and adolescents. A missing chondral or osteochondral fragment in the CT scan does not exclude a labral lesion or interposition. Therefore, MRI following closed reduction is mandatory in any case.

[Thoracic injuries in severely injured children : Association with increased injury severity and a higher number of complications]. / Thorakale Verletzungen beim schwer verletzten Kind : Assoziation mit erhöhter Verletzungsschwere und vermehrten Komplikationen.

BACKGROUND: Severely injured children and adolescents in clinical practice are rare. For adequate treatment of these patients, detailed knowledge of anatomical and physiological peculiarities, as well as abundant injury patterns, are indispensable. Traumatic brain injuries are known to lead to an unfavorable outcome. In addition, thoracic trauma is regarded as prognostically unfavorable. OBJECTIVES: This study depicts epidemiology and injury patterns of severely injured children and adolescents focusing on peculiarities in the severely injured with associated thoracic injuries. MATERIALS AND METHODS: A retrospective analysis of underaged patients with suspicion of severe injuries who obtained emergency-room treatment in our level-one trauma center during a four-year time period was performed. The data was collected prospectively using the TraumaRegister® of the German Trauma Society as well as an extended house-internal dataset including data of daily clinical routine. The patients were divided into subgroups with (TT) and without (KT) thoracic trauma based on whether a thoracic injury was present or not. For further analysis, four age groups were established. RESULTS: In all, 256 patients younger than 18 years were eligible. Of these, 46 patients revealed thoracic injuries. The mean age of patients with thoracic trauma (12.4 ± 4.9 years) was significantly higher than for patients without thoracic trauma (8.0 ± 5.2 years). In both subgroups, most patients were male (TT: 69.9%, KT: 64.8%). Patients with concomitant thoracic trauma showed a significantly higher injury severity score (ISS) than patients without thoracic trauma (ISS: TT: 26.7 ± 15.8 vs. KT: 8.1 ± 6.8 points). Mortality was higher for TT as well (TT: 6.9% vs. KT: 1.9%). For both groups, traffic accidents were the most common cause of injury. Of patients with thoracic injuries, 52.2% developed at least one complication during their hospital stay (KT: 12.9%). CONCLUSIONS: Thoracic trauma is a relevant factor in children with regard to the severity of total injury and complications. Particular attention should therefore be paid to early diagnosis and treatment.

[Surgical treatment of fractures of the distal tibia in adolescents]. / Die operative Behandlung von Ubergangsfrakturen der distalen Tibia.

OBJECTIVE: Injury to the epiphyseal cartilage during the period of growth plate closure in adolescence results in specific stereotyped injury patterns due to the change in biomechanics. According to the number of fragments, fractures of the distal tibia can be categorized into so-called two-plane and triplane I and II fractures. Since these fractures are involving the joint, the most important aspect for further therapy is the reconstruction of the joint surface. As the growth plate has already begun to close at this stage, relevant growth disturbances are unlikely. INDICATIONS: Fracture dislocation > 2 mm. CONTRAINDICATIONS: Undislocated fractures. Usual surgical and anesthetic risks. SURGICAL TECHNIQUE: Closed bone reduction is suitable for most minimally displaced fractures but in uncertain cases with advanced displacement, operative reduction may be necessary. The osteosynthesis can be achieved preferably by cannulated screws which, depending on the localization, can be placed intersecting the growth plate. POSTOPERATIVE MANAGEMENT: Basically, plaster immobilization is not necessary in case of stable osteosynthesis. Depending on the patient's cooperation and the fracture stability, a lower-leg cast may additionally be applied. Non-weight bearing for 6 weeks. RESULTS: While short-term results are generally good, data on long-term outcome and possible development of arthrosis is still insufficient.

Surgical treatment of overgrowth of the greater trochanter in children and adolescents.

After developmental dislocation of the hip, Perthes disease, bacterial coxitis, and other pediatric hip conditions, the femoral neck may develop short, with an overgrowth of the greater trochanter. Forty-four patients with trochanter overgrowth (47 hips) ages 6 to 17 years underwent surgery. Trochanteric epiphysiodesis was performed in 13 patients (group A), distal transfer of the greater trochanter in 24 patients (26 hips; group B), and femoral neck lengthening osteotomy in 7 patients (8 hips; group C). The mean follow-up time was 8.3 years. Clinical results were evaluated by the hip score according to Merle d'Aubigné. Radiological parameters were evaluated by 2 of the authors. Each operative method led to an improvement of clinical symptoms. In group A, no significant changes in the radiological parameters could be found. Groups B and C showed significant improvements in the radiological parameters. However, no difference was found between these 2 groups.