Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: A randomised clinical trial.

OBJECTIVE: To compare the one-year postoperative outcomes of anti-gravity treadmill rehabilitation with those of standard rehabilitation in patients with ankle or tibial plateau fractures. DESIGN: An open-label prospective randomised study. SETTING: Three trauma centres. SUBJECTS: Patients were randomised into the intervention (anti-gravity treadmill) or control (standard protocol) rehabilitation group. MAIN MEASURES: The primary endpoint was changes in the Foot and Ankle Outcome Score for ankle fractures and Knee Injury and Osteoarthritis Outcome Score for tibial plateau fractures from baseline to 12 months after operation. Secondary endpoints were the subscores of these scores, muscle atrophy (leg circumference at 20 cm above and 10 cm below the knee joint) and the Dynamic Gait Index. RESULTS: Initially, 73 patients (37 vs 36) underwent randomisation. After 12 months, 29 patients in the intervention group and 24 patients in the control group could be analysed. No significant difference was noted in the Foot and Ankle Outcome Score (80.8 ± 18.4 and 78.4 ± 21.1) and Knee Injury and Osteoarthritis Outcome Score (84.8 ± 15.2 and 81.7 ± 17.0). The change in the Dynamic Gait Index from 12 weeks to 12 months differed significantly between the groups (P = 0.04). Patients with tibial plateau fractures had a 3 cm wider thigh circumference in the intervention group than those in the control group (95% confidence interval: -0.2 to 6.3 cm, P = 0.08). CONCLUSION: One year after surgery, patients who had undergone anti-gravity treadmill rehabilitation showed better gait than patients in the control group, and those with tibial plateau fractures had less muscle atrophy.

[Is polytrauma treatment in deficit in the aG-DRG system?] / Ist die Polytraumaversorgung im aG-DRG-System defizitär?

BACKGROUND: The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G­DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included. METHODS: All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings. RESULTS: A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €). CONCLUSION: Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted.

Impact of anti-gravity treadmill rehabilitation therapy on the clinical outcomes after fixation of lower limb fractures: A randomized clinical trial.

OBJECTIVE: To compare the effects of anti-gravity treadmill rehabilitation with those of standard rehabilitation on surgically treated ankle and tibial plateau fractures. DESIGN: Open-label prospective randomized multicenter study. SETTING: Three level 1 trauma centers. SUBJECTS: Patients with tibial plateau or ankle fractures who underwent postoperative partial weight-bearing were randomized into the intervention (anti-gravity treadmill use) or control (standard rehabilitation protocol) groups. MAIN MEASURES: The primary endpoint was the change in the Foot and Ankle Outcome Score for ankle fractures and total Knee injury and Osteoarthritis Outcome Score for tibial plateau fractures (0-100 points) from baseline (T1) to six weeks after operation (T4) in both groups. Leg circumference of both legs was measured to assess thigh muscle atrophy in the operated leg. RESULTS: Thirty-seven patients constituted the intervention and 36 the control group, respectively; 14 patients dropped out during the follow-up period. Among the 59 remaining patients (mean age 42 [range, 19-65] years), no difference was noted in the Foot and Ankle Outcome Score (54.2 ± 16.1 vs. 56.0 ± 16.6) or Knee injury and Osteoarthritis Outcome Score (52.8 ± 18.3 vs 47.6 ± 17.7) between the intervention and control groups 6 weeks after operation. The change in the leg circumference from T1 to T4 was greater by 4.6 cm in the intervention group (95% confidence interval: 1.2-8.0, P = 0.005). No adverse event associated with anti-gravity treadmill rehabilitation was observed. CONCLUSION: No significant difference was noted in patient-reported outcomes between the two groups. Significant differences in muscular atrophy of the thigh were observed six weeks after operation.

Integrity of the pectineal ligament in MRI correlates with radiographic superior pubic ramus fracture displacement.

BACKGROUND: Estimating the stability of pelvic lateral compression fractures solely by static radiographs can be difficult. In this context, the role of anterior pelvic soft tissues as potential secondary stabilizer of the pelvic ring has hardly been investigated. PURPOSE: To correlate the initial radiographic appearance of the pubic ramus fracture with the integrity of the pectineal ligament, a strong ligament along the pecten pubis. MATERIAL AND METHODS: In total, 31 patients with a pelvic lateral compression fracture (AO/OTA 61- B1.1/B2.1) with 33 superior pubic ramus fractures and available post-traumatic radiographs (pelvis anteroposterior, inlet, outlet) and magnetic resonance imaging (MRI) of the pelvis with fat-suppressed coronal images were reviewed retrospectively. Radiographic superior pubic ramus fracture displacement was measured and correlated to the degree of MR-morphologic alterations of the pectineal ligament (grade 0 = intact, grade 3 = rupture). RESULTS: In the majority of fractures (72.7%), associated MR-morphologic alterations of the pectineal ligament were present. Radiographic displacement and MRI grading showed a strong positive correlation (Spearman rho = 0.783, P < 0.001). The sensitivity and specificity for a radiographic displacement of >3 mm on plain radiographs to detect a structural ligament lesion on MRI (grade 2 and higher) were 73% and 100%, respectively. CONCLUSION: Radiographic displacement of superior pubic ramus fractures >3 mm is a strong indicator for a structural lesion of the pectineal ligament. Future studies should investigate the potential biomechanical importance of this ligament for pelvic ring stability.

Intake of aspirin prior to metamizole does not completely prevent high on treatment platelet reactivity.

PURPOSE: Metamizole can sterically inhibit aspirin (ASA) from binding to cyclooxygenase 1 (COX1). It is recommended that ASA should be taken 30 min prior to metamizole to maintain the irreversible inhibition of arachidonic acid (AA)-induced platelet aggregation. We aimed to analyse the inhibitory effect of ASA and metamizole on AA-induced platelet aggregation over the course of the day. METHODS: We analysed hospitalized patients who ingested ASA at least 30 min prior to metamizole (recommended dosing group, n = 15), metamizole prior or simultaneously with ASA (not recommended dosing group, n = 16) and patients with unknown or mixed intake (mixed dosing group, n = 5). AA-induced light transmission (LTA) and impedance aggregometry (IA) were measured before, 1-2 and 5-6 h after the intake of ASA ± metamizole. RESULTS: Maximum AA-induced LTA prior to the intake of ASA was significantly lower and the rate of high on treatment platelet reactivity (HTPR) higher in the recommended compared with the not recommended dosing group (19.6% vs. 46.9%, p = 0.011 and 4/15 vs. 12/16 patients, p = 0.017). There was no difference when IA was used. Maximum AA-induced LTA after the intake of ASA ± metamizole was lower in patients in the not recommended but not in the recommended dosing group. All patients with HTPR in the recommended dosing group had regular inhibition of AA-induced LTA after discontinuation of metamizole. CONCLUSION: Co-medication of ASA and metamizole significantly influences platelet inhibition with variations during the day and can cause HTPR in patients taking ASA prior to metamizole or simultaneously.

Mortality, complications and long-term functional outcome in elderly patients with fragility fractures of the acetabulum.

BACKGROUND: Early operative treatment of acetabulum fractures in geriatric patients has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality, complications and functional outcome after operative and non-operative treatment. METHODS: Patients aged ≥60 years with operative treatment of low-energy fragility fracture of the acetabulum from 2009 to 2016 and a follow-up of at least 24 months were identified. The patients were contacted by phone and a modified Merle d'Aubigné score was obtained. If patients or their relatives were not available for follow-up, mortality data was assessed using a national social insurance database. RESULTS: One hundred seventy-six patients (mean age 78, SD 10 years; 73 female) were available for analysis of mortality data. At final follow-up (68 months, SD 26, range, 24 to 129), 99/176 patients (56.3%) had deceased. One-year-mortality was 25.0% and 2-year mortality 35.8%. Type of treatment (non-operative vs. operative) did not affect mortality at 1 and 2 years (p = .65 and p = .10). Hospital-acquired infections were observed in 31/176 cases (17.6%), thromboembolic events and delirium in 6 patients (3.4%). In-hospital mortality was 5.7%. Patients who underwent operative treatment were more likely to have an in-hospital infection (p = .02) but less likely to sustain thromboembolic events (p = .03). The mean hospital stay was 14 days (SD 10 days, range, 1 to 66). Patients with operative treatment were longer hospitalized than patients with non-operative treatment (p < .001). The rate of secondary conversions to THA was 12.4%, this was not affected by initial treatment. The mean modified Merle d'Aubigné Score of those patients available for a final follow-up (n = 47; follow-up 56 months, SD 28, range, 24 to 115) was 14/18 points, SD 3 (range 7 to 18). Functional results at final follow-up between operatively and non-operatively treated patients were without difference. CONCLUSIONS: All-cause mortality and in-hospital complications are high among geriatric patients with low-energy fractures of the acetabulum even when treated operatively. Secondary conversion rates to THA are similar to those seen in younger patients. Mid-term functional outcome in those surviving is fair.

Epidemiology and management of atlas fractures.

PURPOSE: The purpose of this study was to gain new insights into the epidemiologic characteristics of patients with atlas fractures and to retrospectively evaluate complication rates after surgical and non-surgical treatment. METHODS: In a retrospective study, consecutive patients diagnosed with a fracture of the atlas between 01/2008 and 07/2018 were analyzed. Data on epidemiology, concomitant injuries, fracture patterns and complications were obtained by chart and imaging review. RESULTS: In total, 189 patients (mean age 72 years, SD 19; 57.1% male) were treated. The most frequent trauma mechanism was a low-energy trauma (59.8%). A concomitant injury of the cervical spine was found in 59.8%, a combined C1/C2 injury in 56.6% and a concomitant fracture of the thoraco-lumbar spine in 15.4%. When classified according to Gehweiler, there were: 23.3% type 1, 22.2% type 2, 32.8% type 3, 19.0% type 4 and 1.1% type 5. Treatment of isolated atlas fractures (n = 67) consisted of non-operative management in 67.1%, halo fixation in 6.0% and open surgical treatment in 26.9%. In patients with combined injuries, the therapy was essentially dictated by the concomitant subaxial cervical injuries. CONCLUSIONS: Atlas fractures occurred mainly in elderly people and in the majority of the cases were associated with other injuries of the head and spine. Most atlas fractures were treated conservatively. However, surgical treatment has become a safe and valid option in unstable fracture patterns involving the anterior and posterior arch (type 3) or those involving the articular surfaces (type 4). LEVEL OF EVIDENCE: IV (Retrospective cohort study). These slides can be retrieved under Electronic Supplementary Material.

Magnetic resonance tomography for the early detection of occult fractures of the spinal column in patients with ankylosing spondylitis.

PURPOSE: The purpose of this study was to determine the extent to which magnetic resonance imaging (MRI) performed in patients with ankylosing spondylitis (AS) after low- and no-energy trauma leads to an improved diagnosis and, as a result, to a change in the therapeutic strategy. METHODS: All patients with AS, who underwent surgery after minor traumas (low-energy traumas, LETs) and patients without trauma history (NET: no-energy trauma), were retrospectively analysed. The diagnostic and planned surgical procedure was examined initially and again after total spine MRI in patients with persistent and/or new complaints. RESULTS: One hundred and thirty-six patients with AS after trauma were surgically treated. A total of 92 patients with LETs and 12 patients with NETs were included. After initial diagnostics (CT and X-ray) were performed in 15.4% of the patients with LET or NET (n = 16), we found occult fractures on MRI scans. In ten of these patients (6 LET, 4 NET) in which a previous decision was made to follow conservative therapy, no fracture indication was found on CT or X-ray. Two fracture heights were observed in six patients who experienced LET. However, on X-ray and CT, the fractures were only visible at one height. All fractures were treated surgically with stabilization and decompression if indicated. CONCLUSION: Considering the high percentage of our patient population with occult fractures, we recommend supplementing the basic diagnostic procedures with an MRI of the entire spinal column in patients with painful spinal column findings after minor trauma and for those with persistent pain without trauma. These slides can be retrieved under Electronic Supplementary Material.

Outcomes of tissue reconstruction in distal lower leg fractures: a retrospective cohort study.

BACKGROUND: Open and closed fractures can be associated with posttraumatic or postoperative soft tissue defects caused by initial trauma, operative procedures, or infections. This study evaluated the postoperative outcomes in patients with open or closed lower leg fractures, related soft tissue defects, and subsequent flap coverage. METHODS: We performed a retrospective single-center cohort study in a level 1 trauma center. We analyzed the patients treated from January 2012 through December 2017 and recorded demographics, treatment, and outcome data. The outcome data were measured via patient-reported Foot and Ankle Outcomes Scores (FAOS) and EQ-5D-5L scores. RESULTS: We included 22 patients with complicated fractures (11 open and 11 closed) and subsequent soft tissue defects and flap coverages. The mean follow-up time was 41.2 months. Twenty-one patients developed infections, and necrosis at the site of surgery manifested in all closed fractures. Therefore, all patients needed soft tissue reconstructions. Preoperatively, 16 patients underwent arterial examinations via angiography and six underwent ultrasound examinations of the venous system. Ten patients had complications involving the flaps due to ischemia and consequent necrosis. The mean EQ-5D index was 0.62 ± 0.27, and EQ-5D VAS score was 57.7 ± 20.2. The mean FAOS was 60.7 ± 22.2; in particular, quality of life was 32.3 ± 28.8. The rate of returning to work in our patient group was 37.5% after 1 year. CONCLUSIONS: Distal tibial fractures often require revisions and soft tissue reconstruction. The evaluated patient population had poor outcomes in terms of function, quality of life, and return to work. Furthermore, patients suffering from flap ischemia have worse outcomes than those without flap ischemia.

Percutaneous versus open posterior stabilization in AOSpine type A3 thoracolumbar fractures.

BACKGROUND: The purpose of this retrospective cohort study was to compare treatment strategies of two level-one trauma centers regarding clinical and radiological outcomes focusing on non-osteoporotic AOSpine type A3 fractures of the thoracolumbar spine at levels T11 to L2. METHODS: Eighty-seven patients between 18 and 65 years of age that were treated operatively in either of two trauma centers were included. One treatment strategy includes open posterior stabilization whereas the other uses percutaneous posterior stabilization. Both included additional anterior fusion if necessary. Demographic data, McCormack classification, duration of surgery, hospital stay and further parameters were assessed. Owestry Disability Index (ODI), Visual Analog Scale (VAS) and SF-36 were measured for functional outcome. Bisegmental kyphosis angle, reduction loss and sagittal alignment parameters were assessed for radiological outcome. Follow up was at least 24 months. RESULTS: There was no significant difference regarding our primary functional outcome parameter (ODI) between both groups. Regarding radiological outcome kyphosis angle at time of follow up did not show a significant difference. Reduction loss at time of follow up was moderate in both groups with a significantly lower rate in the percutaneously stabilized group. Surgery time was significantly shorter for posterior stabilization and anterior fusion in the percutaneous group. Time of hospital stay was equal for posterior stabilization but shorter for anterior fusion in the open stabilized group. CONCLUSION: Both treatment strategies are safe and effective showing only minor loss of reduction. Clinical relevant differences in functional and radiographic outcome between the two surgical groups could not be demonstrated. TRIAL REGISTRATION: It was conducted according to ICMJE guidelines and has been retrospectively registered with the German Clinical Trials Registry (identification number: DRKS00015693, 07.11.2018).

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

INTRODUCTION: Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss. METHODS: This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed. RESULTS: 29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 - L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24-58 months). The mean reduction loss was 7.7° (range: 1-25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient. CONCLUSIONS: The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

Validation of a new method for evaluation of syndesmotic injuries of the ankle.

PURPOSE: To define a new parameter in CT that could make imaging of the contralateral ankle dispensable evaluating the position of the fibula after syndesmotic injury. METHODS: Thirty bilateral CTs of 30 patients were included. Five parameters were defined in axial CT for the injured (_inju) and uninjured (_unin) ankle. Reproducibility was examined for inter-observer and intra-observer reliability. Comparisons for all parameters were performed between the CT scans of both ankles. RESULTS: All measurements had a high agreement for the inter-observer and intra-observer correlation coefficients. A large interindividual variance could be found between all parameters. If the difference of the anterior tibiofibular distance antTFD_unin and antTFD_inju was less than 2 mm, there was a strong significant pairwise correlation between all parameters between both sides. CONCLUSION: Bilateral CT is still to be recommended, as it is the only way to exactly assess anterior posterior reduction of the fibula.

[Complex treatment of pyoderma gangrenosum after minor trauma and primary surgical intervention with suspected necrotizing fasciitis]. / Komplexe Therapie des Pyoderma gangraenosum nach Bagatelltrauma und primär chirurgischer Intervention bei Verdacht auf nekrotisierende Fasziitis.

This article presents the case of a rapidly progressing pyoderma gangrenosum (PG) following a minor trauma and surgical intervention. A 46-year-old patient was admitted to hospital after a minor trauma of the right lower leg with a suspected diagnosis of erysipelas bullosum. A magnetic resonance imaging (MRI) scan showed the suspicion of necrotizing fasciitis (NF) with indications for immediate incision and fascia resection. According to the results of the histopathological analysis and microbiological assessment without signs for a bacterial infection, high-dose steroid treatment and immunosuppressive treatment with cyclosporin A were initiated under the assumption of PG. Additionally, the patient was treated with hyperbaric oxygenation (HBO). The 2­year follow-up showed a gradual restitution of the soft tissues.

[U-shaped fractures of the sacrum-what is the correct treatment? : A presentation of three cases]. / U-Frakturen des Os sacrum ­ Wie therapiert man richtig? : Eine Präsentation dreier Fälle.

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

[Which factors influence the inpatient course for patients with spondylodiscitis?] / Welche Parameter haben Einfluss auf den stationären Verlauf bei Patienten mit Spondylodiszitis?

BACKGROUND: Spondylodiscitis is a rare disease with an increasing incidence. METHODS: In this retrospective study 112 patients with spondylodiscitis surgically treated from 1 January 2005 to 31 December 2012 in a level I spine center were investigated with respect to potential prognostic criteria. The time period covered by the investigation was the duration of hospitalization. The parameters analyzed were mortality, age, localization of the spondylodiscitis, detection of abscesses and pathogens, neurological status and body mass index (BMI). RESULTS: The average age of the patients was 68.3 years (±12.9 years). The mortality rate during hospitalization was 10.7% (N = 12). Older patients had a significantly higher in-hospital mortality rate (p = 0.008). Abscess formation was found in 49.1% of the patients and was associated with a significantly longer hospital stay (p = 0.001) and in the intensive care unit (ICU, p = 0.001) as well as a higher risk of revision surgery (p = 0.018). In addition, obese patients had a significantly higher occurrence of abscesses (p = 0.034). Pathogen detection was successful in 60.7 % of the cases with Staphylococcus aureus as the most frequent pathogen. Detection of pathogens was associated with a longer hospital stay (p = 0.006) and a greater need of intensive care monitoring (p = 0.017). Patients with a nephropathy had a significantly increased mortality, longer duration of hospitalization and a more frequent occurrence of multilevel afflictions. CONCLUSION: Old age, abscess formation, positive detection of pathogens and renal failure can be used as prognostic criteria. Risk factors for formation of abscesses include a lumbar localization of spondylodiscitis, nephropathy as well as detection of a pathogen and obesity.

Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years.

PURPOSE: The aim of this study was to evaluate midterm results after hybrid stabilization of unstable osteoporotic fractures of the thoracolumbar junction. METHODS: This retrospective study was performed at a level I trauma center. A total of 113 patients aged 61 and older were stabilized using hybrid stabilization consisting of short-segmental posterior instrumentation and augmentation of the fractured vertebral body after suffering an unstable osteoporotic vertebral body fracture at the thoracolumbar spine. All patients were treated by hybrid stabilization. The primary outcome parameters were the ODI score and loss of reduction. Secondary radiological outcome parameters were the sagittal alignment parameters. RESULTS: Seventy-two women and 41 men (74.6 ± 6.8 years) were included. Sixty-nine patients (61%) were re-evaluated after a mean of 48 months. Seventeen patients have died during the follow-up period (15%). A total of five in-patient complications were documented (4.4%). Additionally, 12 patients (17.4%) suffered from further osteoporotic vertebral body fractures affecting vertebral bodies of different levels. The average ODI score at the final follow-up was 29.9 (± 22.0). Thereby, 66.6% of all patients had low to moderate limitations. The average regional sagittal loss of reduction was 7.4% (± 5.6%). Loss of reduction was below 10° in 78% of the patients. There were statistically significant correlations between the loss of reduction and the ODI score, pelvic incidence and latest Cobb angle, and between the ODI scores and the lumbar lordosis. CONCLUSIONS: The majority of patients had low or moderate limitations and low to moderate reduction loss. Thereby, high loss of reduction correlated directly with inferior outcomes. These slides can be retrieved under Electronic Supplementary Material.

Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall.

BACKGROUND: At present, data describing patients' long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). METHODS: This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. RESULTS: The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35-85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88-76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26-118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2-118). CONCLUSIONS: Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.

Age and "general health"-beside fracture classification-affect the therapeutic decision for geriatric pelvic ring fractures: a German pelvic injury register study.

PURPOSE: Pelvic ring fractures in the elderly gain increasing importance. Nonetheless, data on factors influencing treatment decision in relation to fracture classification, age, and the resulting treatment are still rare. METHODS: Prospectively collected data of the German Pelvic Injury Registry from patients aged over 65 years with a pelvic ring fracture were evaluated retrospectively. Acetabular fractures, as well as type A1 and A3 fractures, were excluded. The variables age, injury pattern, type of treatment, the reason for conservative treatment, and Orthopaedic Trauma Association (OTA)/Tile classification were analyzed. Furthermore, the fracture distribution was examined after dividing patients into six age groups. RESULTS: A total of 1814 patients with a mean age of 80.7 ± 7.6 years, predominantly female (79.0%), were available for evaluation. The majority of patients suffered from isolated pelvic ring fractures (70.1%) and 8.2% were severely injured (ISS > 16). The most common fracture types were type A2 (35.4%), type B2 (38.0%), and type C1 (7.3%). Especially pelvic ring fractures of type A2 (96.9%) and type B2 (83.0%) were treated conservatively (overall 76.9%). Fracture instability according to the OTA/Tile classification increased the probability for an operative treatment (generalized odds ratio [OR] 6.90 [5.62; 8.52]). In contrary, increasing age independent of the fracture pattern decreased this probability (OR 0.47 [0.41-0.53]). With increasing fracture instability, general health conditions were up to 50% of the reasons for conservative treatment. CONCLUSION: The results of the present study underline the importance of the factors age and general health besides fracture classification for therapeutic decision-making in the treatment of pelvic ring fractures in the elderly.

Os calcaneus secundarius, a relevant differential diagnosis to fracture or pseudarthrosis of processus anterior of the calcaneus: a CT morphologic description.

PURPOSE: A fracture or a pseudarthrosis of the processus anterior calcanei (PAC) as well as a traumatized Os calcaneus secundarius (OCS) is often overlooked. A clinical or conventional radiological differentiation of these is uncertain. Therefore, a CT scan is recommended. The aim of the study was to identify CT morphological differentiators between OCS and pathologies of PAC. METHODS: All CT scans at our trauma center level I from 2010 to 2014, which imaged the entire foot, performed after acute trauma or postoperative control were retrospectively re-examined for OCS, other accessory ossicles (oAOS), fracture or pseudarthrosis of PAC and analyzed for specifiers. RESULTS: In 611 CT examinations, 14 (2.3%) accessory ossicles (AOS) at the PAC were detected. 12 (86%) were identified as typical OCS and 2 (14%) as oAOS. 56 (9.2%) pathologies were detected. Of these, 44 (79%) were declared as fractures and 12 (21%) as pseudarthrosis. 7 OCS (58%) and 25 (46%) of the pathologies were not mentioned in the initial CT reports. The main differentiators of OCS to fracture of PAC were the anteromedial localization into a concave notch at the calcaneal facet at PAC and the continuous corticalization. With increasing size, radiological osteoarthritic signs at the OCS were frequent (p ≤ 0.05). CONCLUSIONS: The study confirms that AOS or pathologies at the PAC often are not exactly described in CT report. In the context of foot trauma, attention should be paid to this region. Based on the presented differentiation criteria, a precise distinction can be made with the help of a CT.

Management of pelvic discontinuity in revision arthroplasty : Cementless acetabular cup with iliac stem and cranial strap.

BACKGROUND: Pelvic discontinuity causes severe destruction of the acetabular bony walls and is particularly difficult to manage. This article reports the short-term results and complications encountered in the management of loosening of the acetabular cup with pelvic discontinuity using an acetabular cup with an intramedullary iliac stem combined with an extramedullary iliac plate. MATERIAL AND METHODS: As part of this monocentric retrospective case analysis all patients who underwent acetabular revision surgery after THR due to loosening of the acetabular cup with pelvic discontinuity in this clinic from January 2016 to June 2017 were identified (n = 16). All patients underwent routine clinical and radiological follow-up. In addition, the Harris hip score (HHS) and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) were evaluated as part of a 1-year follow-up. RESULTS: All patients were treated with an acetabular revision cup of appropriate size with intramedullary iliac stem combined with an anatomical extramedullary iliac plate. On clinical follow-up at 1 year (median follow-up time 14.5 ± 3.3 months), the average HHS was 69.3 ± 14.1 and the average WOMAC was 79.3 ± 11.7. Complications were registered in 7 out of the 16 patients whereby 1 showed aseptic loosening of the revision cup, dislocations were reported in 4 cases and infections in 2 cases. In the case of the two patients with infections a Girdlestone resection arthroplasty had to be performed. CONCLUSION: The overall complications and postoperative outcome in revision surgery after THR reported in the literature were compared to the results of this study. Compared to the results of salvage procedures using large or bipolar heads and Girdlestone resection arthroplasty, satisfactory results were obtained using the acetabular cup with an intramedullary iliac stem combined with an extramedullary iliac plate.