Effect of subsequent vertebral body fractures on the outcome after posterior stabilization of unstable geriatric fractures of the thoracolumbar spine.

PURPOSE: The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively. METHODS: Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters. RESULTS: Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01). CONCLUSION: Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender.

[Treatment strategies for pathological fractures of the spine]. / Versorgungsstrategien bei pathologischen Frakturen der Wirbelsäule.

BACKGROUND: Pathological fractures and instabilities of the spine are most often caused by primary tumors that hematogenously metastasize into the spine. In this context breast, prostate, kidney cell and bronchial carcinomas are the most relevant causative diseases. Furthermore, multiple myeloma is another frequent entity. Primary tumors of the spine are correspondingly rare and only make up a small proportion of all malignant processes in the spine. DECISION MAKING: The main symptom of pain is prognostically unfavorable in this context and is often associated with progressive instability or pathological fractures. To objectify the treatment approach the neurological status, an oncological assessment, the biomechanical stability and (systemic) general condition (NOMS criteria) of the patient have to be considered. Another major factor is the radiation sensitivity of the tumor. The spinal instability neoplastic (SIN) score is recommended to assess stability. Regardless of whether conservative or surgical treatment is carried out, interdisciplinary cooperation between the specialist departments must be guaranteed in order to achieve adequate treatment for the patient. TREATMENT: If a curative approach is followed an individualized and interdisciplinary surgical strategy must be performed to achieve an R0 resection, usually as a spondylectomy. In the case of palliative treatment, the goal of surgical treatment must be pain reduction, stability and avoidance or restoration of neurological deficits. This requires stabilization in a percutaneous or open technique, possibly in combination with decompression and local tumor debulking.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]. / Die Chronische Symphyseninstabilität : Ätiologie, Diagnostik und Behandlungsmanagement.

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.

Open versus Percutaneous Stabilization of Thoracolumbar Spine Fractures: A Short-Term Functional and Radiological Follow-up.

PURPOSE OF THE STUDY: A prospective cohort study evaluates the functional and radiological outcome of thoracolumbar spine fractures treated either with open or percutaneous dorsal instrumentation. In recent years, several studies advocate percutaneous stabilization of spinal fractures in patients without neurological deficits. However, it is still debated whether percutaneous stabilization is superior to open dorsal instrumentation in spinal trauma. MATERIAL AND METHODS: This study was performed between 2010 and 2012 at a Level 1 trauma center. Patients treated either with an open or a percutaneous dorsal instrumentation for traumatic fractures of the thoracolumbar spine (T11 to L2) were included. Fracture morphology, screw positioning and clinical parameters were analyzed. Standardized questionnaires (VAS-spine-score; Oswestry-disability-score; SF-36) and follow up radiographs were performed. RESULTS: Overall 72 patients (29 percutaneous; 43 open) could be included. The surgical and the early postsurgical course were similar between both groups. Furthermore the operative approach had no influence on the functional and radiological outcome one year after surgery, but the questionnaires showed moderate impairments within both groups. Also both groups showed a significant loss of reduction after the first postoperative month (p < 0.01). Within the open group a significantly higher amount of fracture reduction (p < 0.01) and a significantly reduced intraoperative radiation exposure was seen (open 105.9 sec.; percutaneous 143.1 sec; p < 0.05); whereas the percutaneous approach was associated with significantly reduced intraoperative blood loss (open 2.2 g/dl; percutaneous 1.2 g/dl; p < 0.001). CONCLUSION: The functional and the radiological outcome of both groups was comparable one year after trauma. Minor advantages of the percutaneous system was less blood loss, whereas the open approach was associated with a significantly higher amount of initial reduction and significantly less intraoperative radiation exposure. Independent from the type of posterior fixation loss of reduction was already significant in the early postoperative course.

Measurement of compartment elasticity using pressure related ultrasound: a method to identify patients with potential compartment syndrome.

PURPOSE OF THE STUDY Decision-making in treatment of an acute compartment syndrome is based on clinical assessment, supported by invasive monitoring. Thus, evolving compartment syndrome may require repeated pressure measurements. In suspected cases of potential compartment syndromes clinical assessment alone seems to be unreliable. The objective of this study was to investigate the feasibility of a non-invasive application estimating whole compartmental elasticity by ultrasound, which may improve accuracy of diagnostics. MATERIAL AND METHODS In an in-vitro model, using an artificial container simulating dimensions of the human anterior tibial compartment, intracompartmental pressures (p) were raised subsequently up to 80 mm Hg by infusion of saline solution. The compartmental depth (mm) in the cross-section view was measured before and after manual probe compression (100 mm Hg) upon the surface resulting in a linear compartmental displacement (Δd). This was repeated at rising compartmental pressures. The resulting displacements were related to the corresponding intra-compartmental pressures simulated in our model. A hypothesized relationship between pressures related compartmental displacement and the elasticity at elevated compartment pressures was investigated. RESULTS With rising compartmental pressures, a non-linear, reciprocal proportional relation between the displacement (mm) and the intra-compartmental pressure (mm Hg) occurred. The Pearson's coefficient showed a high correlation (r2 = -0.960). The intraobserver reliability value kappa resulted in a statistically high reliability (κ = 0.840). The inter-observer value indicated a fair reliability (κ = 0.640). CONCLUSIONS Our model reveals that a strong correlation between compartmental strain displacements assessed by ultrasound and the intra-compartmental pressure changes occurs. Further studies are required to prove whether this assessment is transferable to human muscle tissue. Determining the complete compartmental elasticity by ultrasound enhancement, this application may improve detection of early signs of potential compartment syndrome. Key words: compartment syndrome, intra-compartmental pressure, non-invasive diagnostic, elasticity measurement, elastography.

[Biomarkers in pediatric polytrauma]. / Biomarker beim kindlichen Polytrauma.

BACKGROUND: Trauma represents one of the leading causes of death in children. Beside an injury pattern that differs from adult trauma patients, children seem to develop multiple organ dysfunction syndrome (MODS) less frequently. Compared to adult MODS, pediatric MODS has also been described to occur earlier in the posttraumatic course. METHOD: Biomarkers for early identification of patients at high-risk for posttraumatic complications are of high clinical relevance. However, little is known from clinical studies about the relevance of biomarkers during the posttraumatic course. AIM: Therefore, the purpose of this review is to summarize current knowledge on this topic in order to investigate the prognostic significance of different parameters.

Compressive effect and collapse behavior of three different transsacral implants in sacral fragility fractures - a retrospective analysis of 106 cases.

PURPOSE: The aim of this study were the retrospective evaluation of the compressive effect and complication rates of transsacral stabilization of osteoporosis-associated sacral fragility fractures in 106 patients using three different implants (6.0 mm sacral bar, n = 32; 7.3 mm screw, n = 26; 7.5 mm ISG-Rod System, n = 48) with regard to the image morphological and clinical-perioperative outcome. METHODS: For this purpose, the sacral width was determined preoperatively and postoperatively using multiplanar CT reconstructions and correlated with the measured bone density (HU). The results were compared with each other on an implant-specific basis. RESULTS: A significant compressive effect was found for all implants (6.0 mm sacral bar 7.1 ± 3.4 mm, 7.3 mm screw 6.9 ± 1.8 mm, 7.5 mm ISG-Rod System 8 ± 2.4 mm). No implant-specific difference in compression could be detected. Overall, the washers broke into the iliac cortex in 9% of cases. The subgroups did not differ significantly in this respect (6.0 mm sacral bar: 4 [13%], 7.3 mm screw 1 [1%], 7.5 mm ISG-Rod System (5 [10%], p = 0.581). A correlation between the degree of osteoporosis and the compressive effect could not be demonstrated. Significant implant-specific differences were found in the incision-suture time, with only ø0:39 ± 0:13 h required for implantation of the 7.5 mm ISG Rod System (6.0 mm sacral bar: ø1:09 ± 0:22 h, 7.3 mm screw: ø0:55 ± 0:20 h). The fluoroscopy time was significantly lower with the 7.3 mm screw (ø0:57 ± 0:23 min) and the 7.5 mm ISG Rod System (ø0:42 ± 00:17 min) than with the 6.0 mm sacral bar (ø1:36 ± 0:46 min). CONCLUSION: A significant compressive effect was demonstrated with all three implants. No implant-specific complications or surgical site complications were identified in either the overall cohort or the subgroups. The 7.5 mm ISG Rod System shows advantages with regard to the duration of surgery and fluoroscopy.

[Modified Masquelet technique : Technique of the induced membrane in the course of time]. / Modifizierte Masquelet-Plastik : Technik der induzierten Membran im Wandel der Zeit.

The reconstruction of long bone defects as a result of primary traumatic, secondary infection or tumor-related loss of substance continues to represent a surgical challenge. Callus distraction via segment transport, vascularized bone transfer and the induced membrane technique (IMT) are established methods of reconstruction. In recent decades IMT has experienced increasing popularity due to its practicability, reproducibility and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This overview is intended to explain the basic principles of IMT and to provide an overview of the various modifications and their complications.

Non-invasive assessment of muscle compartment elasticity by pressure-related ultrasound in pediatric trauma: a prospective clinical study in 25 cases of forearm shaft fractures.

BACKGROUND: Soft-tissue swelling after limb fractures in pediatric patients is well known to be a risk factor for developing acute compartment syndrome (ACS). Clinical assessment alone is uncertain in specific cases. Recently, we proposed a non-invasive ultrasound-based method to objectify muscle compartment elasticity for monitoring. We hypothesize a strong correlation between the soft-tissue swelling after stabilization of upper limb fractures and the compartment elasticity objectified with a novel ultrasound-based approach in pediatric trauma. PATIENTS AND METHODS: In a prospective clinical study, children suffering forearm fractures but not developing an ACS were included. The muscle compartment elasticity of the m. flexor carpi ulnaris was assessed after surgical intervention by a non-invasive, ultrasound-based method resulting in a relative elasticity (RE in %) in both the control (healthy limb) and study group (fractured limb). Soft-tissue swelling was categorized in four different levels (0-3) and correlated with the resulting RE (%). RESULTS: The RE in the study group (15.67%, SD ± 3.06) showed a significantly decreased level (p < 0.001) compared with the control (22.77%, SD ± 5.4). The categorized grade of soft-tissue swelling resulted in a moderate correlation with the RE (rs = 0.474). CONCLUSIONS: The presented study appears to represent a novel approach to assess the posttraumatic pressure changes in a muscle compartment after fracture stabilization non-invasively. In this first clinical study in pediatric cases, our measurement method represents a low-cost, easy, and secure approach that has the potential to substitute invasive measurement of suspected ACS in muscle compartment conditions. Further investigations in lager cohorts are required to prove its daily clinical practicability and to confirm the expected reliability.

[Therapy of chronic osteomyelitis: soft tissues as "key to success"]. / Therapie der chronischen Osteomyelitis: Die Weichteile als "Schlüssel zum Erfolg"

Chronic osteomyelitis is a severe complication characterized by soft tissue and bone pathogenic infection resulting in osseous destruction. Surgical management is demanding and poses a challenge in achieving the goals of treatment, which are control of infection, bone healing as well as satisfactory functional outcome. Therapeutic strategies are based on a combined application of radical surgery and systemic antibiotic therapy. The bony defects which remain after extensive debridement have to be reconstructed with bone grafting after soft tissue coverage and the healing process is decisive for a successful outcome.

The biomechanical effect of specific labral and capsular lesions on posterior shoulder instability.

PURPOSE: In contrast to anterior shoulder instability there seems to be no single key lesion in posterior shoulder instability. Therefore, the purpose of this study was to determine the biomechanical effect of specific posterior capsulolabral lesions. Our hypothesis was that a posterior capsule lesion will have a predominant effect compared to a labrum detachment (Bankart lesion). METHODS: Stability testing of 16 cadaveric human shoulders was performed. The specimens were distributed to two groups: the labrum lesion group and the capsular lesion group. In the labrum lesion group three different conditions were tested consecutively: posteroinferior Bankart lesion, additive pHAGL lesion, additive posterosuperior Bankart lesion. In the capsular lesion group two conditions were tested: posteroinferior capsule cut including a glenoidal transection of the pIGHL, additive rotator interval and superior capsule lesion (SGHL and CHL cut). All lesions were set arthroscopically. Biomechanical testing was performed in two positions: the sulcus-test position and the jerk-test position each with a passive humerus load of 50 N in the posterior, posteroinferior and inferior direction. RESULTS: A posteroinferior Bankart lesion resulted in a percentage increase of 86% posterior translation in the jerk position and an increase of 31% inferior translation in the sulcus position. An additional pHAGL lesion resulted in a significant increase of posterior and inferior translation given by 31 and 41% in the jerk position. Regarding the capsular lesions, a cut of the posteroinferior capsule and the pIGHL resulted in a significant increased inferior translation of 53% in the sulcus position but did not cause a significant increase of posterior translation in the jerk position. If an additional rotator interval lesion is set the inferior translation is again significantly increased. CONCLUSIONS: On the basis of our results traumatic posterior shoulder instability must be suspected to be bidirectional posteroinferior independently if a posterior capsule lesion or a posterior Bankart lesion is evident. CLINICAL RELEVANCE: Capsular and labral lesions both have a significant biomechanical effect but differ in the predominant direction of instability, which is posterior for the Bankart lesion and inferior for the capsular lesion. An additional pHAGL or rotator interval lesion aggravates the posteroinferior instability and must be respected in the surgical treatment strategy.

[Kyphoplasty and vertebroplasty. Indications, techniques, complications and results]. / Kyphoplastie und Vertebroplastie. Indikationen, Techniken, Komplikationen und Ergebnisse.

The indications, technical principals, and results after vertebroplasty and kyphoplasty are presented in detail. We focus on the complications of both procedures. The benefit of vertebroplasty has been fundamentally questioned by two papers which have recently been published in the New England Journal of Medicine. Our paper discusses the present knowledge and policy about indication. The contradictory results from different studies are presented. In general, there is a lack of randomized clinical trials. Therefore, a final judgement of these two techniques is not possible. New procedures like stent-kyphoplasty or lordoplasty are briefly described. However, at present an assessment of these new techniques is impossible. A similar situation is give for the application of resorbable bone cements.

Non-invasive and reliable assessment of compartment elasticity by pressure related ultrasound: An in-vitro study.

PURPOSE: The development of acute compartment syndrome is a serious threat to trauma patients. The clinical assessment alone is not reliable enough to determine the need for fasciotomy in many cases. The Physician´s assessment of the elasticity of the muscle compartment might be particularly important to objectively evaluate the pressure in this enclosed space. The purpose of this study was to determine the observer´s reproducibility, of compartment elasticity measurements by a novel ultrasonic approach. METHODS: Increasing intra-compartmental pressures (ICP) were simulated in a water filled in-vitro model. Pressure related ultrasound was used to determine the relative elasticity (RE) of soft tissue compartments. A pressure transducing probe head was combined with the ultrasonic probe to obtain cross section views of the simulated compartment and to detect the amount of applied pressure by the observer. In this model, the compartment depth without compression (P0) was set to be 100%. Changes of the compartment depth due to a probe pressure of 80 mmHg (P80) were correlated to P0 and an elasticity quotient as a value for RE (%) was calculated. Twelve blinded observers performed measurements for RE determination (%) under three pressure conditions. Reproducibility was calculated using intraclass correlation coefficient (ICC). RESULTS: Measurements (n = 432) revealed that the RE (%) in the control group was 17,06% (SD+/-2,13), whereas the RE of the group ICP30 significantly decreased to 12,66% (SD+/- 1,19) (p<0,001). The ICP50 group revealed a further significant decrease to 8,43% (SD+/- 0,67) (p<0,001). Repeated measurement of RE and ICP showed a high level of correlation (spearman correlation coefficient: roh=0,922). A RE <14% resulted in a sensitivity of 96% and a specificity of 90,3% for diagnosis of an ICP >30 mmHg. ICCinter was 0,986; 95%, CI: 0,977-0,992 (p<0,001). DISCUSSION: The presented ultrasound-based approach reliably assesses the elasticity in a simulated compartment model. In this pioneer study investigating the inter- and intra-observer reproducibility, this method of measurement appears to be of low cost in addition to being an easy and secure approach that may have the potential to substitute invasive measurement. Further investigations are required to improve its feasibility and to confirm the reliability under clinical conditions.

[Planning of corrective osteotomies of the lower limb]. / Planung von Korrekturosteotomien der unteren Extremität.

Deformities of the lower extremities can result in local complications, chronic pain and early arthritis. To correct these deformities, several techniques of osteotomies are available. In general continuous deformity correction and acute, one step procedures are available. The exact diagnostics and precise planning of the operative correction is crucial to avoid iatrogenic complications. This summary describes basic principles and indications for different types of osteotomies.

Non-invasive measurement of muscle compartment elasticity in lower limbs to determine acute compartment syndrome: Clinical results with pressure related ultrasound.

PURPOSE: Close monitoring of patients at risk to develop an acute compartment syndrome (ACS) is well known to be essential. There is a relevant risk that clinical assessment alone is not reliable enough. Reliable assessment of the elasticity of the muscle compartment might represent a helpful tool to assess the pressure in this enclosed space. Therefore, the purpose of this study was to determine the feasibility of muscle elasticity measurements by a non-invasive device. METHODS: In a prospective study, patients with elevated intra-compartmental pressure (ICP) were included. An ultrasound-based measurement approach was used to determine the relative elasticity (RE) of both, the affected and unaffected limb. A pressure transducing ultrasonic probe head was combined with the probe to obtain cross section views of the anterior tibial compartment and to detect the observer´s amount of pressure applied on the limb surface. The compartment depth without compression (P0) corresponds to 100%. The difference to the compartment depth with a probe pressure of 80mmHg (P80) on the limb (delta) related to P0 resulted in a value of relative elasticity (%). These values were compared with the invasive needle measurement (mmHg) regarding their intra-individual difference and correlation of the compartmental pressure. RESULTS: In six trauma patients the relative elasticity in their paired limbs showed a significant difference. The RE in the healthy compartments revealed a level of 17.95% (SD+/-5,4), whereas the RE of the affected limbs significantly decreased to a mean of 5,14% (SD+/-2,1) (p < 0,0001). The average values of the repetitively measured RE and the ICP showed a high level of correlation (spearman correlation coefficient: roh = 0,929). The RE less than 10,5% of the anterior tibial compartment had a sensitivity of 95,8% and a specificity of 87,5% to an appropriate diagnosis of ACS. DISCUSSION: The presented study appears to represent a promising approach to reliably assess the pressure in a muscle compartment. In this first clinical study, our measurement method represents a low cost, easy and secure approach that has the potential to substitute invasive measurement. Further investigations and development in lager cohorts are required to improve its practicality and to confirm the reliability.

IL-10 administration attenuates pulmonary neutrophil infiltration and alters pulmonary iNOS activation following hemorrhagic shock.

OBJECTIVE AND DESIGN: Several studies report immuno-modulatory effects of endogenous IL-10 after trauma. This study investigates the effect of IL-10 administration on systemic and pulmonary inflammation in hemorrhagic shock. MATERIAL AND METHODS: Male C57/BL6 mice (4-6 animals per group) were subjected to volume controlled hemorrhagic shock for 3 hrs followed by resuscitation. Animals were either subcutaneously injected with 0.9 % saline (Shock group) or with recombinant mouse IL-10 (Shock+IL-10 group) 1 h before and 1 h after the induction of hemorrhagic shock. Serum TNF-alpha, IL-6, and keratinocyte (KC) concentrations were measured with the Luminex multiplexing platform. Acute pulmonary inflammation was assessed by pulmonary myeloperoxidase (MPO) and inducible nitric oxide synthase (iNOS) activity. RESULTS: IL-10 administration significantly decreased serum TNF-alpha (10.30 +/- 1.68 vs 37.42 +/- 10.64; p < 0.05), IL-6 (44.22 +/- 6.65 vs 85.24 +/- 7.94; p < 0.05), and KC (276.74 +/- 52.67 vs 465.61 +/- 58.98; p < 0.05) levels following hemorrhagic shock. Further, pulmonary MPO activity was significantly lower (2698.85 +/- 431.10 vs 4580.67 +/- 294.38; p < 0.05) and pulmonary iNOS activity upregulated. CONCLUSION: These findings suggest that administration of IL-10 modulates the degree of hemorrhage-induced systemic and pulmonary inflammation and support the notion of a central role for iNOS in acute lung injury.

[Bilateral hydrothorax and hydromediastinum after puncture of the right subclavian vein]. / Bilateraler Infusothorax und Infusomediastinum nach Punktion der V. subclavia rechts.

Complications after the percutaneous insertion of central venous catheters are pneumothoraces, catheter-associated infections and thrombosis. In rare cases, late problems occur as a disruption of the main thoracic duct or vascular erosion. The developing pleural effusion must be analysed for other causes such as congestive heart disease, inflammatory or tumorous disease, pancreatitis, low blood protein, or subdiaphragmatic abscess. The following case report describes a rare catheter complication in a 16-year-old polytraumatised patient. The differentiation to a chylothorax and suitable therapy are described.

[Bite injuries of the hand]. / Bissverletzungen der Hand.

Bite injuries of the hand have a clearly increased risk for infection compared with other regions. Surgical treatment of the wound is indicated, and the debridement must be done thoroughly and with consideration of the wound closure. Antibiotic therapy may be indicated in addition to the surgery if signs of infection exist. Antibiotics alone are not a suitable treatment. Common complications in cases of deficient primary therapy are flexor tenosynovitis, purulent arthritis, and phlegmons of the dorsal hand. These are emergencies and need immediate surgical intervention.