Autologous bone cylinder transplantation with cannulated screw re-stabilisation: a new treatment option for delayed fracture healing of the femoral neck.

AIM: Delayed fracture healing and non-unions of the femoral neck after lag screw osteosynthesis occur particularly in multiply injured young patients, and then surgical revision is often required. Currently no evidence-based treatment guidelines exist and therapeutic options include both hip arthroplasties and femoral head-maintaining operations. Here we report on young patients with delayed fracture healing of the femoral neck. Patients underwent revision surgery by autologous bone cylinder transplantation with mechanical re-stabilisation by cannulated lag screws. MATERIAL AND METHODS: We reviewed all patients after femoral neck screw osteosynthesis and identified eight patients at 7.3 [3-24] months after initial osteosynthesis with persisting, or reoccurring postoperative pain. Average patient age was 43 [35-57] years and patient Harris Hip Score (HHS) numbers were low (52 ± 19). Before revision surgery the preoperative CT scans showed a partial bone consolidation (anterior and/or posterior cortices) in the absence of a complete bone consolidation of all cortices. Seven patients were treated by bone cylinder transplantation from the patient's own iliac crest; one patient underwent an inverse bone cylinder procedure. Seven patients were additionally treated by re-insertion of 1-2 lag screws to increase mechanical stability. RESULTS: After revision surgery the average patient follow-up period was 42 [12-89] months. Five patients achieved favourable clinical and radiographic outcome with both complete bone union and return to work within 7.2 ± 2.75 months. One patient showed fracture healing but developed an aseptic femoral head osteonecrosis. Two patients failed to achieve complete bone consolidation. The postoperative HHS was 92 ± 4 in patients with favourable clinical outcome (n = 5) and 89 ± 2 after second revision surgery (2 hip arthroplasties; 1 valgus osteotomy). Both groups had significantly better HHS numbers compared with before surgical revision (p < 0.05). DISCUSSION: These data show that in this difficult-to-treat subset of young patients with delayed fracture healing of the femoral neck, autologous bone cylinder transplantation with mechanical re-stabilisation should be considered as a promising surgical revision strategy before hip arthroplasty.

[Total hip replacement for coxarthrosis following acetabular fracture. Significance of age and injury severity]. / Hüftendoprothese bei koxarthrose nach azetabulumfrakturen. Bedeutung von alter und verletzungsschwere.

AIM: this study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component. MATERIAL AND METHOD: a total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component. RESULTS: of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53-55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment. CONCLUSION: patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.

[Outpatient surgery in hospital. An instrument for resource optimization?]. / Ambulante Chirurgie am Krankenhaus. Ein Instrument zur Belegungssteuerung?

The societies of western countries are facing enormous economic and social challenges. Despite a declining population size the number of elderly patients is growing and will lead to an increase in cases of trauma in the near future. In addition, the health care system will have to be financed by a reduced labor force. To realize the ambitious political goal of providing comprehensive medical care an economization of hospital treatment must be achieved. The bottleneck within the surgical specialties in case of efficient scheduling will be the capacity utilization of the operating theatres. Additional separate outpatient operating theatres adjacent to hospitals could be an efficient instrument for using resources and economizing medical procedures. Considering the socio-demographic alterations of our society an adequate discussion regarding the general medical conditions is essential.

[Standardised primary care of multiple trauma patients. Prehospital Trauma Life Support und Advanced Trauma Life Support]. / Standardisierte Primärtherapie des polytraumatisierten Patienten. Prehospital Trauma Life Support und Advanced Trauma Life Support.

INTRODUCTION: Standardised management improves treatment results in seriously injured patients. For conditions like stroke or acute coronary syndrome (ACS) there are set treatment pathways which have been established for prehospital and primary hospital care. The treatment of critical trauma patients, however, follows varying procedures in both the prehospital and primary hospital phases. From an analysis of the trauma register of the German Society for Trauma Surgery (DGU), we know that a seriously injured patient remains on the road for 70 min on average before transferral to hospital. This requires improvement. With the 2003 introduction of the ATLS programme in Germany, the initial clinical phase could be improved upon simply by means of standardised training. PHTLS und ATLS complement one another. RESULTS: PHTLS und ATLS represent training concepts which teach standardised, priority-based prehospital and hospital trauma management. The aim is to make an initial rapid and accurate assessment of the patient's condition, thereby identifying the"critical" patient. The concepts also make priority-based treatment possible and facilitate decision-making as to whether patients can receive further on-the-spot treatment or whether immediate transport is necessary. The procedure is identical in the shock room. The primary consideration is to prevent secondary damage, not to lose track of time and to ensure consistent quality of care. The courses teach systematic knowledge, techniques, skills and conduct in diagnosis and therapy. The courses are oriented to all medical specialities associated with trauma care. With the support of the German Society for Trauma Surgery (DGU) and the German Society for Anesthesiology and Intensive Medicine (DGAI), the German Professional Organisation of Rescue Services (DBRD) has adopted the PHTLS course system on licence from the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and has been offering it in Germany since late 2007. ATLS was established by the DGU in 2003 and represents successful and similarly structured shock-room management. CONCLUSION: PHTLS und ATLS are established and standardised concepts, which are constantly reviewed and updated according to the latest medical knowledge. They provide the opportunity to standardise prehospital and primary clinical trauma management for all specialties and hospitals, while incorporating own knowledge.

[The challenge of auditing by medical health insurance inspectors: development of individual case inspections according to 275ff SGB V]. / Herausforderung: MDK-Prüfung: Entwicklung der Einzelfallprüfungen gemäss 275ff SGB V.

BACKGROUND: The German DRG (diagnosis-related groups) system has changed since the inauguration in 2005, whereby written inquiries and on-site auditing have been carried out by the medical inspection service for health insurance companies (MDK). Modifications in the G-DRG system are reflected in changes in the MDK visitations. This article describes exactly how these examinations have changed over time. In order to achieve this all auditing reports were evaluated. RESULTS: In the beginning correct coding and documentation were the most interesting items for the health insurance fund inspectors. Nowadays, length of in-patient treatment and specific points relating to current changes in the G-DRG system are being questioned. All areas of the hospital have now been examined during this period. There was no change in the loss resulting from the regular examinations over the years. However, the effort and input of manpower are extremely high. CONCLUSIONS: To cope with the changes in the German DRG system hospitals have to be flexible. The experiences with the regular MDK visitations can positively influence hospital organizational structures.

Cystic pseudotumours in both upper ankle joints in gouty arthritis.

This case demonstrates a yet unreported clinical entity of bilateral tophaceous cystic lesions of the tibiotalar joints of an 37-year-old white male who presents with moderate painful swelling in both upper ankle joints for 2 years. Radiodiagnostic studies show cystic lesions in both upper ankle joints and the right talus considering neoplastic processes in the differential diagnosis. The incisional biopsy reveals chalk-like material of the intraosseous lesions which was pathognomonic for tophaceous gout. Antihyperuricemic medication led to a stagnation of growth of the lesions without a sign of osseous remodeling. However, due to limitation of discomfort, personal preferences and a lack of surgical options conservative treatment was maintained.

TGF-beta1 as a marker of delayed fracture healing.

Mitogens of the TGF-beta superfamily have been shown to be crucial local and systemic regulatory molecules involved in fracture healing. However, there exists only little information about systemic regulation of bone regeneration by growth factors and no reports comparing serum levels of bone growth factors between normal and failed fracture healing have been published so far. We hypothesized that quality of fracture healing might be reflected by systemic alterations of key regulatory growth factors involved in bone formation and remodeling. Therefore, the aim of this study was to evaluate possible differences in serum levels of BMP-2, BMP-4, and TGF-beta1 in patients with normal and delayed fracture healing. 103 patients with diaphyseal fractures of long bones were recruited prospectively. Peripheral blood samples were collected over a period of 6 months following a standardized time schedule. At the end of the individual investigation period, growth factor serum levels were measured using commercially available enzyme immunoassays. For the elimination of disturbing influences, patients in both groups were matched by gender, age, fracture type, and localization as well as applied technique of osteosynthesis. During a study period of 1 year, 10 patients with an atrophic type of delayed union could be retrieved and matched to 10 patients with normal fracture healing. The diagnosis of delayed union was assumed in case of failed consolidation 4 months after trauma. We found an increase of TGF-beta1 serum levels up to 2 weeks after fracture in both groups with a following return to the reference value within 6 weeks after trauma. However, decline of serum concentration occurred earlier in patients with delayed fracture healing. At 4 weeks after trauma, serum levels of TGF-beta1 were significantly lower in patients of the delayed union group. Serum levels of BMP-2 and BMP-4 were below detection level in all patients, respectively. These findings support the critical role of TGF-beta1 in fracture healing. Events during the consolidation phase seem to be dependent on sufficient availability of TGF-beta1.

[Arthroscopic studies of pedicled autogenic tendon grafts for the replacement of the anterior cruciate ligament]. / Arthroskopische Untersuchungen von gestielten autogenen Sehnentransplantaten zum Ersatz des vorderen Kreuzbandes.

Combined knee ligament instabilities with injury of the anterior cruciate ligament need reconstruction of the anterior cruciate ligament as a central pivot. Our investigations show that after reconstruction with pedicle autogenous tendon grafts, a viable transplant does occur if certain technical principles are taken into account. The surviving transplants show typical fiber structure and synovial vessels. Tension was tested by clinical draw-forward sign and a hook.

[Determination of torsion angle after shaft fractures of the lower extremity--clinical relevance and measurement techniques]. / Torsionswinkelbestimmung nach Schaftfrakturen der unteren Extremität--klinische Relevanz und Messmethoden.

In the treatment of femoral and tibial fractures the frontal and sagittal planes are controlled and documented by conventional X-ray films. Computed tomography permits exact measurement of the coronal plane. Between June 1993 and December 1997, 161 computed tomographic measurements of femoral torsion and 55 of tibial torsion after shaft fracture were carried out. The results were analyzed in a clinical study. A CT examination was carried out if the clinical examination aroused suspicion of a difference in torsion. 28.5% of the patients examined with femoral fractures and 23.8% of those with tibial fractures and torsion differences of more than 20 degrees. Between June 1993 and June 1997, 30 corrective derotating osteotomies of the femur and 9 of the tibia were carried out. The average preoperative difference of torsion of the femur was 29 degrees and of the tibia 25 degrees. After the operation the average femur difference was 7 degrees and of the lower leg 6.5 degrees, which are inside normal physiological limits. The osteotomies were carried out in the metaphysis near the fracture. Additional corrections in other planes were necessary on the femur in 27% and on the lower leg in 46%. With the aim of avoiding torsion differences, or at least to recognize them at an early stage, CT measurements of torsion after osteosythetic treatment of fresh unilateral femur-shaft fractures were carried out in 49 patients between October 1996 and December 1997. The torsion measurements during the operations had to be carried out clinically. No sufficiently exact method of measurement is available in the operating room. Three patients with increased differences of 28 degrees, 26 degrees or 19 degrees had their osteosyntheses corrected. The measurements after correction were inside the normal spread.

[Fusion of the craniocervical transition with "CerviFix" after survived atlanto-occipital dislocation]. / Die Fusion des craniocervicalen Ubergangs mit dem "CerviFix" nach überlebter atlanto-occipitaler Dislokation.

We report a rare case of a young moped rider who suffered atlanto-occipital dislocation. He survived with tetraplegia. We discuss the accident mechanism, the anatomical particulars, and the clinical features and compare our operative treatment with the cases described in the literature.

[Traumatic cysts of the spleen]. / Traumatische Milzcysten

During a routine clinical examination of a 7-year-old girl and a 17-year-old man a large tumor was discovered in the left upper quadrant of the abdomen. Large splenic cyst were found in the spleen at splenectomy. The traumatic etiology of the cysts can be assumed on the basis of histologic results, as well as of a significant history of previous trauma. The etiology, differential diagnosis, therapy, and classification of splenic cysts are discussed.

[Intraoperative three-dimensional navigation for pedicle screw placement]. / Navigation an der Brust- und Lendenwirbelsäule mit dem 3D-Bildwandler.

The mobile SIREMOBIL Iso-C(3D) C-arm (Siemens, Erlangen, Germany) is the first device permitting intraoperative, three-dimensional representation of bone structures. A high-resolution, isotropic 3D data cube in the isocenter with sides of approximately 12 cm is calculated simultaneously. The SIREMOBIL Iso-C(3D) is linked to the navigation system. This makes it possible to transfer the generated 3D data directly to the linked navigation system without the need for surgeon-dependent registration. In this prospective clinical trial, we evaluated the accuracy of pedicle screw placement using this device. In 61 patients, a total of 302 pedicle screws were placed. Only in five cases (1.7%) were misplacements of > or =2 mm shown in postoperative control CT. The average fluoroscopy time was 1.28+/-0.56 min, and the average operative duration was 103.26+/-23.3 min. There were no postoperative neurological complications in any of the 30 patients. From these data, we conclude that Iso-C(3D) navigation is a very accurate method for the placement of pedicle screws.

[Arthrolysis in the treatment of post-traumatic joint stiffness of the knee and elbow joints]. / Die Arthrolyse in der Behandlung posttraumatischer Gelenksteifen an Knie- und Ellbogengelenk.

In the treatment of posttraumatic limitation of the range of motion, arthrolysis is a proved procedure in the hand of an experienced surgeon. In this paper, indication, operative details and postoperative treatment are discussed. The results of 51 cases of arthrolysis of the knee joint and 33 cases of arthrolysis of the elbow joint carried out over a time of seven years are reported.

[Management strategy of multiple fractures of long tubular bones within the scope of polytrauma]. / Versorgungsstrategie von Mehrfachfrakturen langer Röhrenknochen im Rahmen des Polytraumas.

Fractures of both femura in multitrauma patients have a high incidence of secondary respiratory failure. To avoid this vital complication as the first step to multiple organ failure femur fractures should be stabilised as soon as possible after successful treatment of hypovolaemic shock and acute life saving operations. The use of an external fixation in concomitant thoracic injury as a quick stabilisation, together with prophylactic mechanical ventilation, will probably lower the incidence of respiratory failure.

[Stable osteosynthesis following ilial resection in intraosseous Ewing sarcoma]. / Stabile Osteosynthese nach Beckenschaufelresektion bei intraossärem Ewing-Sarkom.

A case of a young man with Ewing's sarcoma of the os ilium is demonstrated. The tumor is removed by resection of the os ilium and the adjacent musculature. The bony stability is reconstructed by means of a double autogenous free fibula graft in combination with a broad plate, braced between os sacrum and the roof of the acetabulum. Full weight bearing is possible, at present there is no evidence of a local recidive or of metastases.

[Treatment of acromioclavicular joint dislocation by tension band and ligament suture]. / Die Behandlung der Akromioklavikulargelenksverrenkung durch Zuggurtung und Bandnaht.

From 1. 1. 1988 until 30. 6. 1990 54 patients with acromio-clavicular luxation and 3 patients suffering from lateral fractures of the clavicula were treated with tension-bend-wiring combined to suturing the acromio- and coracoclavicular ligaments at the BG-Unfallklinik Ludwigshafen. In 8 cases (14%) complications due to the implant occurred. Infection was found in 4 cases (7%). 47 patients (82.5%) could be followed clinically with mean follow-up time of 21.5 month. Clinical criteria like interpretation of the result by the patient, clinical and radiological findings were quantitatively and qualitatively interpreted by a score.

[Preclinical and clinical primary therapy of multiple fractures of the leg]. / Präklinische und klinische Primärtherapie von Mehrfachfrakturen der unteren Extremitäten.

A successful clinical primary treatment of multiple fractures of the lower extremities depends on a rapidly administered preclinical therapy with short care periods. The early biomechanically stable osteosynthesis leads to improved haemodynamics by haemostasis and elimination of pain. Early functional treatment and hypostasis therapy will promote the prophylaxis of pneumonia. 14 patients with multiple fractures of the lower extremities were treated by the concept that provides for preclinical emergency therapy and clinical primary treatment as a unit.

[Problems of fresh rupture of the anterior cruciate ligament]. / Zur Problematik des frischen vorderen Kreuzbandschadens.

The importance of the anterior cruciate ligament as a part of the central pivot and the necessity of reconstruction in cases of fresh rupture is pointed out. In 400 arthroscopies of the knee joint we found 69 old ruptures of the anterior cruciate ligament. This number shows that a rupture of the anterior cruciate ligament is often not diagnosed early. In 28 fresh cases of knee joint trauma with haemarthrosis and without clinical or radiological instability arthroscopy was performed within 7 days after trauma. There was a fresh rupture of the anterior cruciate ligament in 20 cases. Haemarthrosis was the leading clinical sign in all cases of fresh ruptures.

[Results of an operative therapy of dislocated fractures of the humeral head in adults (author's transl)]. / Technik und Ergebnisse einer operativen Therapie der Humeruskopfluxationsfraktur des Erwachsenen.

Dislocated fractures of the humeral head are problematic injuries. The result of an operative therapy of 30 adult patients are given. Intra- and postoperative complications, advantages and disadvantages are pointed out. Traumatic and posttraumatic damages of the cartilage, partial necrosis of humeral head and the combination with lesions of the soft tissues and nerves are the limits to a good functional result.