Treatment of acetabular fractures in older patients-introduction of a new implant for primary total hip arthroplasty.

BACKGROUND: Fractures of the acetabulum in younger patients are commonly treated by open reduction and internal fixation. For elderly patients, stable primary total hip arthroplasty with the advantage of immediate postoperative mobilization might be the adequate treatment. For this purpose, a sufficiently stable fixation of the acetabular component is required. MATERIALS AND METHODS: Between August 2009 and 2014, 30 cases were reported in which all patients underwent total hip arthroplasty additionally to a customized implant designed as an antiprotrusion cage. Inclusion criteria were an acetabular fracture with or without a previous hemiarthroplasty, age above 65 years, and pre-injury mobility dependent on a walking frame at the most. The median age was 79.9 years (65-92), and of 30 fractures, 25 were primary acetabular fractures (83%), four periprosthetic acetabular fractures (14%), and one non-union after a failed ORIF (3%). RESULTS: The average time from injury to surgery was 9.4 days (3-23) and 295 days for the non-union case. Mean time of surgery was 154.4 min (range 100 to 303). In 21 cases (70%), mobilization with full weight bearing was possible within the first 10 days. Six patients died before the follow-up examination 3 and 6 months after surgery, while 24 patients underwent radiologic examination showing consolidated fractures in bi-plane radiographs. In 9 patients, additional CT scan was performed which confirmed the radiographical results. 13 had regained their pre-injury level of mobility including the non-union case. Only one patient did not regain independent mobility. Four complications were recognized with necessary surgical revision (one prosthetic head dislocation, one pelvic cement leakage, one femoral shaft fracture, and one infected hematoma). CONCLUSION: The presented cage provides the possibility of early mobilization with full weight bearing which represents a valuable addition to the treatment spectrum in this challenging patient group.

The impact of coagulopathy on the outcome of traumatic epidural hematoma.

PURPOSE: To evaluate the impact of trauma-associated coagulation disorders on the neurological outcome in patients with traumatic epidural hematoma undergoing surgical or non-surgical treatment. A retrospective analysis was performed using prospectively collected data in a consecutive patient series from a level 1 trauma center. METHODS: Eighty-five patients with traumatic epidural hematoma were identified out of 1,633 patients admitted to our emergency room with traumatic head injuries between October 2004 and December 2008. The following prospectively assessed parameters were analyzed: Glasgow Coma Scale, coagulopathy, presence of skull fractures, additional injuries, the Injury Severity Score, hematoma volume and thickness at admission, hematoma volume progression over time and neurologic symptoms. Furthermore, patients were grouped based on whether they had undergone surgical or non-surgical treatment of the epidural hematoma. Clinical outcome was determined according to the Glasgow Outcome Score (GOS) at hospital discharge. RESULTS: Patients with coagulopathy showed significantly lower GOS values compared to patients with intact blood coagulation. Initial and progressive hematoma volumes did not influence neurological outcome. Patients with multiple injuries did not show a worse outcome compared to those with isolated epidural hematoma. There was no difference in patient's outcome after surgical or non-surgical treatment. CONCLUSIONS: Poor outcome after traumatic epidural hematoma was associated with coagulopathy. Progression of epidural hematoma volume was not associated with coagulopathy or with poor neurological outcome. Prospective studies are needed to confirm these results.

Arthritis predicting factors in distal intraarticular radius fractures.

INTRODUCTION: Intra-articular malunion with step off and gap formation is claimed to be crucial for radiocarpal degeneration. In addition to well-defined intraarticular malunion, the shape of the distal radius is important for unaffected wrist function. In typical intra-articular fracture patterns with a dorsoulnar and palmar ulnar fragment, alterations of the shape of the articular surface, in a kind of a cavity, without obvious step off can be observed. The aim of the present study is to determine the residual articular deformity following intra-articular radius fractures and to analyze their impact on the final clinical and radiological outcome. MATERIALS AND METHODS: Eighty one patients with dorsally displaced distal intraarticular radius fractures were followed up for a mean period of 9 years. Surgical treatment of all patients included open reduction, plate fixation and corticocancellous bone grafting. Radiological measurements included palmar tilt, radial inclination and radial shortening as defined by ulnar variance, intra-articular Stepps and the measurement of the anteroposterior distance of the radial joint surface. Clinical assessment included active range of motion (ARM) of the wrist, pain according to a visual analogue scale (VAS), grip power, working ability, Disability of Arm, Shoulder and Hand Score (DASH Score). RESULTS: Articular malunion in the form of a cavity in the sagittal plane measured 4.8 mm, 1.3 mm more than on the non-injured side. Anteroposterior distance measured 20.6 mm, 2.1 mm more than on the non-injured side. Articular step-off and gap was noticed in 11 patients. At the final follow-up examination, there was a significant difference in articular cavity depth and the anteroposterior distance between arthritis stage I and II. Arthritis stage was associated with the range of motion (ROM) in the sagittal plane, but had no significant influence on the DASH, pain level, grip strength and ROM in the frontal plane. CONCLUSION: ORIF leads to predictable results in the restoration of length and form of the distal radius. Increasing the articular cavity depth should be avoided to prevent degenerative arthritis at the radiocarpal joint at long-term follow-up visits.

Ortho-geriatric service--a literature review comparing different models.

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

Accuracy of minimally invasive navigated acetabular and iliosacral fracture stabilization using a targeting and noninvasive registration device.

BACKGROUND: To assess the feasibility and accuracy of guide pin (GP) placement using a combined noninvasive patient immobilization and stereotactic targeting system in computer-assisted percutaneous pelvic fracture stabilization. METHODS: A total of 12 patients with negligible dislocated unstable pelvic fractures were enrolled in this study, performed between February 2002 and October 2005. Our original plans included 13 GP placements in the iliosacral area (SF) and 8 in the acetabular (AF) area. Patients were bedded on a noninvasive dual-vacuum immobilization device. Interventions were planned on a navigation system using intraoperatively acquired CT data. Radiodense markers glued to the skin and the immobilization device provided synchronization between virtual data set and real anatomical situation. A stereotactic targeting device was used for stabilization of GP tracking. GP positions were verified intraoperatively by CT, followed by fracture stabilization with cannulated screws. RESULTS: Mean GP placement accuracy according to plan: (1) SF-cohort: 2.8 mm (SD 2.0 mm, range 0.5-9.0 mm) at the bony entry point and 3.8 mm (SD 2.3 mm, range 0.6-9.5 mm) at the target point. (2) AF-cohort: 3.0 mm (SD 0.9 mm, range 1.6-4.9 mm) at the bony entry point and 3.9 mm (SD 1.9 mm, range 1.6-7.5 mm) at the target point. GP placement succeeded optimally in 11 out of 13 cases in the SF-cohort, and 6 out of 8 cases in the AF-cohort. The individual average dose-length product (DLP) per successful finished procedure was 1,576 mGy x cm (SD 812 mGy x cm, range 561-2,739 mGy x cm). CONCLUSION: Our findings substantiate application of the noninvasive patient immobilization and stereotactic targeting system as effective in computer-assited percutaneous stabilization of sacral bone fractures/SI joint disruptions and coronally oriented acetabular dome fractures. We recommend according to the ALARA (as low as reasonable achievable) principle: first, the kV and mAs values have to be reduced. Second, the scanned volume has to be strictly limited to the area of interest. Third, the number of control CTs have to be minimized. Also, the IsoC might be a better choice for implant tracking below 12 cm to reduce the radiation dose to the minimum. We believe that for all high-precise GP placements in the acetabular column area, further improvements in GP guidance (inhibiting pin tip slipping and detecting intraosseous GP deflection) are necessary.

A new distractable implant for vertebral body replacement: biomechanical testing of four implants for the thoracolumbar spine.

INTRODUCTION: Expandable titanium implants for vertebral body replacement in the thoracolumbar spine have been well established in the reconstruction of the anterior spinal column. Load transfer at the bone-implant interface remains a point of concern. The purpose of the study was to compare the performance in axial load transfer from the implant to the vertebral body in four different implants, all of them in clinical use to date. MATERIALS AND METHODS: We tested a second generation implant (Synex II) in comparison to three different expandable titanium cages: Synex I, Obelisc and X-Tenz. Twenty-four intact fresh frozen human lumbar vertebrae (L1-L4) were distributed into four identical groups according to bone mineral density (BMD). The BMD was determined by quantitative computed tomography (qCT). Specimens were loaded in craniocaudal direction with a material testing machine (Mini Bionix II) at a constant speed of 5 mm/min. Load displacement curves were continuously recorded for each specimen until failure (diminishment of compressive force (F) and/or obvious implant migration through the vertebral body end plate). One-way analysis of variance (ANOVA) and post-hoc tests (Bonferroni) were applied to detect differences at 1, 2, 3, and 4 mm displacement (F (1-4 mm)) between implant groups. RESULT: No significant differences were observed with regard to maximum compression force (F (max)) and displacement (d (max)) until failure: Synex II (1,782.3 N/4.67 mm); Synex I (1,645.3 N/4.72 mm); Obelisc (1,314.0 N/4.24 mm); X-Tenz (1470.3 N/6.92 mm). However, the mean compression force at 1-4 mm displacement (F (1-4 mm): 300-1,600 N) was highest for Synex II. The difference at 2 mm displacement was significant (p = 0.028) between Synex II (F (2 mm) = 879 N) and X-Tenz (F (2 mm) = 339 N). CONCLUSION: The modified end plate design of Synex II was found to perform comparably at least with regard to the compressive performance at the implant-bone interface. The risk of the new implant for collapse into the vertebral body might be reduced when compared to the competitors.

[Limits of palmar locking-plate osteosynthesis of unstable distal radius fractures]. / Grenzen der palmaren winkelstabilen Plattenosteosynthese bei instabilen distalen Radiusfrakturen.

PURPOSE: The use of locking plate systems in the treatment of distal radius fractures has increased during the last years. In the presented study our experience and results after palmar plating of dorsal dislocated distal radius fractures are analysed and presented. Besides the functional and radiological results, the potential surgical risks and the observed complications are discussed. PATIENTS AND METHODS: Over a mean 15-month period, 112 consecutive patients (24 men, 88 women) with an average age of 57 years who were treated for an unstable dorsal dislocated distal radius fracture using the palmar locking-plate system could be assessed. The functional results were compared with the uninjured contralateral side. The subjective pain level was assessed using the visual analogue scale (VAS) and the subjective results were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) Score. Radiographic assessment included palmar tilt, radial inclination, and ulnar variance. The objective and subjective functional results were evaluated using the modified Mayo-Wrist Score. RESULTS: Functional results: extension slashed circle 53.1 degrees (84 % as compared with the uninjured side); flexion slashed circle 45.8 degrees (81 % as compared with the uninjured side); pronation slashed circle 78.7 degrees (95 % as compared with the uninjured side); supination 81.9 degrees (95 % as compared with the uninjured side); grip strength slashed circle 56 Kp (73 % as compared with the uninjured side). Radiological results: postoperative reduction/mean postoperative loss of reduction: radial inclination: slashed circle 20.4 degrees /slashed circle 0.2 degrees ; palmar tilt: slashed circle 0.2 degrees /slashed circle 3.1 degrees ; ulnar variance: 0.08 mm/slashed circle 0.42 mm. Pain values: slashed circle 2.7 points; DASH score: slashed circle 14.8 points; complications: breakage of plates 1 %, screw loosening 3 %, intraarticular screw position 2 %, delayed bone union 4 %, rupture M. extensor pollicis longus 2 %/M. flexor pollicis longus 3 %, peritendinitis extensor tendons 5 %, synovialitis flexor tendons 8 %, CTS 3 %, complex regional pain syndrome 6 %. CONCLUSION: Favourable indications for palmar locking plate osteosynthesis are A2, A3, C1 and C2 fractures with big distal fracture fragments. In these cases, additional bone grafting is not needed. In very distal fractures, multidirectional plate-systems are advantageous. Multifragmental C3 fractures show a high complication rate. Additional bone grafting for the metaphyseal defect should be considered.

[Acceptance of patient-related evaluation of wrist function following distal radius fracture (DRF)]. / Zur Akzeptanz der patientenbezogenen Bewertung der Handgelenkfunktion nach distaler Radiusfraktur (DRF).

INTRODUCTION: Outcome evaluation after distal radius fractures is mainly based on wrist function and radiological parameters, while measuring patient satisfaction seems to be more difficult. The purpose of this study was to assess different subjective features with regard to patient satisfaction for wrist healing, activity and participation. MATERIALS AND METHODS: A questionnaire combining items from the established PRWE (Patient related wrist evaluation), wrist-specific items from the DASH (Disability of Arm, Shoulder and Hand) as well as the ICF questionnaire (international classification of function, health and disease) was created, and then distributed to patients without wrist injuries (group 1) and patients following a distal radius fracture (group 2). Analysis of answered questions was performed with regard to response rate, valid content, mean differences between the two groups, correlation with radiology features in the patient group and age. RESULTS: Of 510 individuals with non-relevant wrist injuries, 96.7 % of the questions were answered, while of 133 distal radius fracture patients, 92.2 % of the questions were answered, rendering a total response rate of 95.5 %. Frequency of not responding to questions varied between 1.4 % to 14.4 %, and remained < 5 % for 17 questions. Internal consistency of the questionnaire with regard to wrist function was high in both groups (Cronbach alpha index for patients with non-relevant wrist injuries 0.9836, for distal radius fracture patients 0.9881). All questions were deemed specific for wrist function (discriminatory power > 0.7), and highly significant (p < 0.01) for ascertainment of subjective comfort after distal radius fracture in comparison with non-relevant wrist injuries. Fourteen of 25 questions (56 %) were correlated significantly (p < 0.05) with radiological features of malunion. For ages 30 to 49, and > 70 years, wrist function was deemed worse in the distal radius fracture patients vs. the non-injured wrist group. For ages 50 to 69, a significant difference was found only for 5 of 25 (20 %) questions. CONCLUSION: All questions were of a high validity and significance to determine subjective outcome after distal radius fractures. Patient acceptance was significantly different for questions, and subjective wrist comfort depended on age. For ages 50 to 69, additional questions in terms of employment situation and recreational function could be incorporated. Only about half of the questions correlated with radiological parameters of distal radius malunion. Eight questions showed both high acceptance and high correlation with radiology. Standardised measurements of range of motion and power, as well as radiology features and subjective questions of high acceptance and radiology relevance are essential for a wrist-specific questionnaire.

[Distal radius fractures--aetiology, treatment and outcome]. / Distale Radiusfrakturen--Atiologie, Behandlungsmethoden und Ergebnisse.

INTRODUCTION: Distal radius fractures were investigated in a retrospective open multicenter cohort study to assess aetiology, fracture pattern and treatment modalities and their influence on subjective and objective outcome. PATIENTS AND METHOD: Demographic data, fracture history, course of fracture healing, functional and radiological parameters and the DASH-questionnaire were collected from 18 Austrian hospitals and analysed statistically. PATIENTS: n = 707, 465 (65.8 %) female, 242 (34.2 %) male. Mean age: 52 (19 - 86) years; age group 1 (19 - 39 years) 26 %, age group 2 (40 - 59 years) 41 %, age group 3 (60 years and elder) 33 %. FOLLOW-UP: mean 5.8 (3.9 - 17) years; HISTORY: fall 65.1 %, sports 17.4 %, traffic accidents 8.9 %, fall from great height 7.5 %; others 1.1 %. Most frequent fracture patterns according to AO: A2 (26.6 %), C2 (22.2 %), A3 (16.1 %), C1 (12.7 %); according to PE: I-2 (44.8 %), I-1 (40.0 %), III-2 (4.4 %), II-2B (4 %). There was no significant correlation between fracture pattern and age groups for both fracture classifications. TREATMENT: 57.9 % surgical, 42.1 % conservative. Radiological results: Depending on treatment, there were significant differences between the radial tilt and the palmar radial inclination, the dorsal and palmar ulnar variance and the width of the DRU-joint. DASH-questionnaire: Median 6.03 (90 - 0). There was a significant, minor positive correlation of bad results in the elderly and a minor positive correlation of bad results correlated to the palmar radial inclination as well as a minor negative correlation to the palmar DRUJ-value and the ulnar variance. CONCLUSION: The incidence of distal radius fractures was increased in females and in patients with the age between 40 - 59 years. The most frequent cause to sustain a distal radius fracture was a simple fall. 85 % of the fractures were dislocated dorsally. The most frequent fracture type was the dorsal intraarticular. There was no specific fracture type observed to be typical for one of the age groups and surgical treatment was almost as frequent as conservative. Surgical treatment improved reconstruction of the radial tilt, palmar inclination and the DRU-joint. Subjective outcome was worse in elderly patients. The radiological changes in the DRU-joint correlated to minor DASH values.

[Long-term results following ORIF of dorsal dislocated distal intraarticular radius fractures]. / Langzeitergebnisse operativ versorgter distal intraartikulärer Speichenfrakturen.

PURPOSE: To evaluate the sequelae of distal intraarticular radius fracture with regard to the development of arthritis and clinical symptoms. PATIENTS AND METHOD: In a retrospective follow-up examination, 72 patients with a distal intraarticular radius fracture could be included for clinical and radiological investigation 9 years following the trauma. All fractures were treated by ORIF and cortico-cancellous bone grafting. RESULTS: Radiological evaluation revealed 5.1 degrees palmar tilt, 19.1 degrees radial tilt and the ulnar variance amounted to -0.5 mm. The articular cavity depth in the sagittal plane measured with 4.6 mm, 1.2 mm more than the non-involved side. Articular step-off was noticed in 6 patients. According to the Knirk and Jupiter classification system, two patients healed without arthritis, 43 patients presented arthritis stage 1, and 27 stage 2. Evaluation of the data showed a significant correlation between arthritis and articular cavity depth. But arthritis had neither influence on the DASH, nor the pain level. On the other hand, arthritis led to decreased sagittal wrist motion. CONCLUSION: ORIF of distal intraarticular radius fractures led to predictable results concerning restoration of length and form of the distal radius. Arthritis had a minor influence on the clinical end result.

Treatment of periprosthetic acetabular fractures after previous hemi- or total hip arthroplasty: Introduction of a new implant.

OBJECTIVE: Treatment of displaced periprosthetic acetabular fractures in elderly patients. The goal is to stabilize an acetabular fracture independent of the fracture pattern, by inserting the custom-made roof-reinforcement plate and starting early postoperative full weight-bearing mobilization. INDICATIONS: Acetabular fracture with or without previous hemi- or total hip arthroplasty. CONTRAINDICATIONS: Non-displaced acetabular fractures. SURGICAL TECHNIQUE: Watson-Jones approach to provide accessibility to the anterior and supraacetabular part of the iliac bone. Angle-stable positioning of the roof-reinforcement plate without any fracture reduction. Cementing a polyethylene cup into the metal plate and restoring prosthetic femoral components. POSTOPERATIVE MANAGEMENT: Full weight-bearing mobilization within the first 10 days after surgery. In cases of two column fractures, partial weight-bearing is recommended. RESULTS: Of 7 patients with periprosthetic acetabular fracture, 5 were available for follow-up at 3, 6, 6, 15, and 24 months postoperatively. No complications were recognized and all fractures showed bony consolidation. Early postoperative mobilization was started within the first 10 days. All patients except one reached their preinjury mobility level. This individual and novel implant is custom made for displaced acetabular and periprosthetic fractures in patients with osteopenic bone. It provides a hopeful benefit due to early full weight-bearing mobilization within the first 10 days after surgery. LIMITATIONS: In case of largely destroyed supraacetabular bone or two-column fractures according to Letournel additional synthesis via an anterior approach might be necessary. In these cases partial weight bearing is recommended.

[Masquelet technique for the treatment of large dia- and metaphyseal bone defects]. / Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte.

OBJECTIVE: Treatment of large dia- and metaphyseal bone defects (> 3 cm) with two surgical interventions with an interval of 4-8 weeks. INDICATIONS: Dia- and metaphyseal bone defects predominantly of the lower extremity. CONTRAINDICATIONS: Intraarticular bone defects, persisting bone infection or osteomyelitis, insufficient soft tissue coverage in the region of the bone defect, osteoporosis. SURGICAL TECHNIQUE: First surgical intervention: thorough bone debridement and soft tissue coverage, implantation of a cement spacer into the bone defect for the induction of a synovial foreign-body membrane, internal or external fixation. Second surgical intervention: removal of the cement spacer and filling of the bone defect with autologous cancellous bone graft, optionally internal fixation after initial external fixation. POSTOPERATIVE MANAGEMENT: Partial to full weight-bearing after the first surgical intervention depending on pain. Partial weight-bearing (max. 15 kg) after the second surgical intervention, until radiological signs of a remodeling of the regenerate bone occur. Usually no implant removal. RESULTS: A total of 6 patients (4 men, 2 women) aged 15-66 years with average bone defects of 7 cm (range 4-10 cm) were treated using the Masquelet technique. There were 2 aseptic femoral nonunions and 4 tibial nonunions (2 septic and 2 aseptic nonunions). One case was a periprosthetic tibial bone defect. Bone stabilization after debridement was performed using ring fixators on the tibia and an intramedullary nail and a locking plate on the femur, respectively. The second surgical intervention was performed after 6-9 weeks. In 3 of the 4 tibial cases, internal fixation was performed during this intervention. The iliac crest and the RIA (reamer-irrigator-aspirator) technique were used for cancellous bone grafting. Amputation after breakage of the plate was necessary in the patient with the periprosthetic bone defect. Nonunion at the docking site required cancellous bone grafting in 1 patient. All 5 patients were able to perform full weight-bearing without pain after 6 months. The Ilizarov fixator was removed 5 months after the second surgical intervention in a 15-year-old patient. None of the other implants were removed.

[Correction of posttraumatic lower leg deformities using the Taylor Spatial Frame]. / Die Korrektur posttraumatischer Deformitäten am Unterschenkel mit dem "Taylor Spatial Frame"

OBJECTIVE: Correction of posttraumatic lower leg deformities using percutaneous osteotomy, external fixation with a ring fixator, and computer-assisted gradual correction with the Taylor Spatial Frame (TSF). INDICATIONS: Posttraumatic lower leg deformities not suitable for acute correction and internal fixation or deformities that are suitable but have a significantly increased risk for complications: deformities with poor soft tissue coverage, rigid deformities that require gradual correction, complex mulitplanar deformities, deformities with shortening, and periarticular juvenile deformities. CONTRAINDICATIONS: Posttraumatic lower leg deformities which are suitable for acute correction and internal fixation are also suitable for deformity correction using the TSF. In these cases, however, we recommend acute correction and internal fixation in order to improve the patient comfort. Lack of patient compliance for self-contained correction and pin care. SURGICAL TECHNIQUE: Percutaneous fixation of the TSF rings to the main fragments using transosseous K-wires and half pins (hybrid fixation). Percutaneous osteotomy of the tibia either by drilling across both cortices and completion of the osteotomy using an osteotome (DeBastiani method) or by using the Gigli saw with preservation of the periostal envelope. Connection of both rings with six oblique telescopic struts via universal joints (hexapod platform). Computer-assisted planning of the correction. POSTOPERATIVE MANAGEMENT: Gradual postoperative correction of the deformity by changing the strut lengths according to the correction plan. Strut changes, if required. Osseous consolidation of the osteotomy site with the TSF or revision to internal fixation. RESULTS: The correction of posttraumatic lower leg deformities using the TSF was performed in 6 cases. The mean deformity was 15° (12-22°) in the frontal plane and 6° (4-8°) in the sagittal plane. The correction time was 19 days (14-22 days). The deviation between planned and achieved correction was 0-3° in the frontal plane and 0-2° in the sagittal plane. The osseous consolidation of the osteotomy site was carried out in the TSF in 5 cases with a mean external fixation time of 112 days (94-134 days). In one case, the TSF was removed after the correction and the osteotomy site was fixed using an intramedullary nail. Pin site infections were observed in 3 cases. There were no further complications. The treatment goal was achieved in all cases. The examination at final follow-up was performed after 1 year. All patients were able to walk without walking aids and with no pain at that time. They were able to perform all of their activities of the daily life and their leisure activities without limitations.

[Augmented posterior instrumentation for the treatment of osteoporotic vertebral body fractures]. / Die Behandlung osteoporotischer Wirbelkörperfrakturen mit augmentierter Instrumentation.

OBJECTIVE: Reduction and stabilization of osteoporotic vertebral body fractures using posterior short-segment instrumentation. Cement augmentation of the pedicle screws in order to improve the screw's holding power in osteoporotic bone and to reduce postoperative loss of reduction. Quick and painless postoperative mobilization without further bracing. INDICATIONS: Burst fractures (type A3 according to Magerl). Posttraumatic kyphosis following osteoporotic vertebral body fractures. Revision surgery after screw loosening. Type B and C fractures according to Magerl. CONTRAINDICATIONS: Osteoporotic fractures which are suitable for nonoperative treatment or percutaneous cement augmentation techniques (vertebroplasty, kyphoplasty). Vertebral body fractures in patients with good bone quality. SURGICAL TECHNIQUE: Insertion of pedicle screws in a typical manner. If perforated screws are used, cement application under fluoroscopic control via the central perforation of the screws. If pedicle screws without perforation are used, application of the cement using a Kyphoplasty technique and insertion of the screws. After hardening of the cement, completion of the instrumentation. POSTOPERATIVE MANAGEMENT: Mobilization starting on the first day after surgery. Avoidance of heavy lifting and manual labor for 3 months. Implant removal only if it is necessary due to complications. RESULTS: Between July 2008 and December 2009, 10 patients with osteoporotic vertebral body fractures of the thoracic and lumbar spine were treated with cement-augmented posterior instrumentation. The mean age was 65.8 years (range 35­94 years). There were six type A (2 A1 and 4 A3 lesions) and four type B lesions (1 B1, 1 B2, and 2 B3 lesions) according to Magerl. Indications for cement augmentation of the pedicle screws were the patients' age (4 patients), osteoporosis with t scores < − 2.5 (2 patients), poor intraoperative screw hold (2 patients), and revision surgery after loosening of pedicle screws (2 patients). Cement leakage was observed in 5 patients with no further clinical relevance. Loosening of cement augmented pedicle screws occurred in 1 patient with a consecutive loss of reduction of 10°. There was no need to remove any of the cement-augmented screws in the first 24 months.

[Elastic stable intramedullary nailing after corrective osteotomy of symptomatic malunited midshaft clavicular fractures]. / Elastisch stabile intramedulläre Nagelung nach Korrekturosteotomie von symptomatisch fehlverheilten Klavikulafrakturen.

OBJECTIVE: To restore alignment and length of the clavicle, to relieve typical symptoms of malunion, and to improve functional outcome and aesthetic results. INDICATIONS: Symptomatic malunion after clavicular fractures, including local pain and tenderness, weakness and rapid fatigability of the shoulder girdle muscles, impairment of overhead mobility, numbness, parasthesia, and pain of the arm and fingers during overhead movements due to brachial plexus irritation (thoracic outlet syndrome), and dissatisfaction with the appearance of the shoulder girdle. CONTRAINDICATIONS: Atrophic nonunions, osteoporosis, asymptomatic malunion. SURGICAL TECHNIQUE: A 5-cm skin incision is made above the deformity of the malunited clavicle. The osteotomy plane is determined under fluoroscopic guidance, within the callus separating the two original main fracture fragments. Under fluoroscopic guidance, the medullary canal is reopened on both sides with a 2.7 mm drill bit. Afterwards a 1.5 cm skin incision is made just above the sternal end of the clavicle. The anterior cortex is drilled and a titanium nail (diameter 2.5 mm) is introduced. Under rotational movement, the nail is advanced to the osteotomy site. The nail is inserted into the lateral fragment. Then the inserted nail is cut back as far as possible on the medial entry point. Wound closure. POSTOPERATIVE MANAGEMENT: No immobilization, movement not restricted. Patients are encouraged to use the arm in daily activities. Heavy weight bearing is not allowed until osseus consolidation. RESULTS: In 5 patients (3 men, 2 women) with a mean age of 34 years (range, 23-44 years) with symptomatic malunion after clavicular fractures, a corrective osteotomy and elastic stable intramedullary nailing (ESIN) was performed. After 6 months (mean 4.4 months), all osteotomies were healed and the nails were removed. There were no complications. At final follow-up (12 months), the DASH and Constant scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with the appearance of the shoulder girdle and overall outcome.

Free vascularised iliac bone graft for recalcitrant avascular nonunion of the scaphoid.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

[An improved vertebral body replacement for the thoracolumbar spine. A biomechanical in vitro test on human lumbar vertebral bodies]. / Ein verbessertes Wirbelkörperersatzimplantat für die thorakolumbale Wirbelsäule. Biomechanischer In-vitro-Test an humanen Lendenwirbelkörpern.

BACKGROUND: In recent years, the use of expandable titanium cages for vertebral body replacement in the thoracolumbar spine has been well established for the treatment of tumors, unstable traumatic lesions, or posttraumatic deformity. Collapse of the implant into the vertebral body remains a point of concern. A biomechanical compression test was designed to assess implant subsidence for a newly developed prototype for vertebral body replacement in the thoracolumbar spine using human cadaveric lumbar vertebrae. The objective of this study was to compare the compressive performance of a new expandable cage with modified end-plate design with three commonly available expandable cages for vertebral body replacement. MATERIALS AND METHODS: The compressive strengths at the implant-vertebral body interface were measured via axial loading of the new prototype (Synex II) in comparison with three different expandable titanium cages: Synex I (Synthes), Obelisc (Ulrich Medical) and X-Tenz (DePuy Spine). Twenty-four intact, fresh frozen human lumbar vertebrae (L1-L4) were distributed into four identical groups according to BMD (determined by quantitative computed tomography) and the vertebral level. Specimens were loaded in the craniocaudal direction with a material testing machine at a constant speed of 5 mm/min. Load displacement curves were continuously recorded for each specimen until failure (diminishment of compressive force (F)/obvious implant migration through the vertebral body endplate). One-way analysis of variance and post-hoc tests (Bonferroni) were applied to detect differences at 1, 2, 3, 4 mm displacement (F1-4 mm), and Fmax between implant groups. RESULTS: The four expandable cages did not show statistically significant biomechanical differences in terms of maximum compression force (Fmax) until failure: Synex II (1,782 N/4.7 mm); Synex I (1,645 N/4.7 mm); Obelisc (1,314 N/4.2 mm); X-Tenz (1,470 N/6.9 mm). However, the mean compression force until 4 mm displacement (F1-4 mm: 300-1,600 N) was highest for Synex II. The difference at 2 mm displacement was significant (p=0.028) between Synex II (F2 mm=879 N) and X-Tenz (F2 mm=339 N). CONCLUSION: The modified endplate design of the new prototype was found to improve its compressive performance under constrained uniaxial loading conditions at the implant-bone interface. The improved compressive behaviour of the new implant might help to reduce the risk of implant subsidence and collapse into the vertebral body in vivo.

Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial.

INTRODUCTION: Nondisplaced scaphoid waist fractures treated with prolonged plaster immobilisation often lead in transient joint stiffness and to a delay in return to sport and work activity. The long time off work increases the work off compensation costs. Internal fixation of scaphoid fractures has resulted in a shorter time to union and to return to work and sports. This prospective study compares cast immobilisation with screw fixation and the direct cost with indirect cost of conservative and minimally invasive treatment of undisplaced scaphoid fractures. MATERIALS AND METHODS: Forty-seven patients with an acute nondisplaced waist fracture of the scaphoid were allocated into either cast immobilisation or internal screw fixation for this study. Cost data concerning the groups of nonoperated and operated patients were analysed. Range of wrist motion, grip strength, DASH-score, time to fracture union, return to work time and the needed physiotherapy at the final follow-up at 6 months were evaluated. RESULTS: Twenty-one patients were included in the group of screw fixation and 23 patients were included in the group of cast immobilisation. At final follow-up there was no significant difference in the range of motion of the wrist or in grip strength. The operatively treated group had a better mean DASH-score than the conservative group. Fracture union was seen in the screw fixation group at a mean of 43 days and in the cast immobilisation group at a mean of 74 days (P < 0.5). The average time of return to work was 8 days for patients who had an internal screw fixation, while those treated with a cast returned to work at a mean of 55 days (P < 0.5). In total the internal fixation of undisplaced scaphoid fractures is less expensive than conservative treatment. CONCLUSION: Internal screw fixation of nondisplaced scaphoid fractures had a shorter time to bony union and the patients returned earlier to work compared with cast immobilisation. Although it is assumed that operative treatment is more expensive, in this study the cost was not found to be higher.