Treatment and clinical outcome in patients with femoral head fractures: a long-term follow-up.

INTRODUCTION: A femoral head fracture (Pipkin fracture) is a rare but severe injury. The optimal treatment is controversial, and there is a lack of research focusing on treatment strategies. The study aimed to analyze the treatment strategies in comparison to the outcome in patients after traumatic hip joint dislocation (THD) with concomitant femoral head fractures. MATERIALS AND METHODS: A retrospective multicenter study at three Level I Trauma Centers was performed over a 12 year period from January 2009 to January 2021. Epidemiological data, associated injuries, and treatment were recorded. Patients were followed up for further treatment, re-operations, complications, and long-term functional outcomes using patient-reported outcome measures (PROMs), specifically the modified Harris Hip Score (mHHS) and the Tegner Activity Scale (TAS). RESULTS: 45 patients with a mean age of 44 ± 16.11 years were finally evaluated. The majority of 38 patients (84%) were treated surgically. The mean follow-up time was 5.75 years (range 2-12 years). 8 patients (31%) developed post-traumatic osteoarthritis and 4 patients (15%) developed osteonecrosis of the femoral head. 7 patients (27%) underwent total hip arthroplasty (THA). Fixation of the Pipkin fracture was more common in younger patients but had no statistically significant impact on PROMs. Patients with a higher BMI were significantly less likely to undergo fragment fixation (p < 0.05). TAS was significantly worse in patients who underwent THA (p < 0.05). CONCLUSIONS: A femoral head fracture is a severe injury with overall limitations in activities of daily living and a high rate of post-traumatic osteoarthritis and osteonecrosis of the femoral head. Fragment fixation had no statistically significant impact on the outcome and PROMs. Treatment strategies should be guided by the fracture type, the patient's condition, and associated injuries. However, concomitant and life-threatening injuries may affect the treatment and limit the outcome.

Controlled antibody release from gelatin for on-chip sample preparation.

A practical way to realize on-chip sample preparation for point-of-care diagnostics is to store the required reagents on a microfluidic device and release them in a controlled manner upon contact with the sample. For the development of such diagnostic devices, a fundamental understanding of the release kinetics of reagents from suitable materials in microfluidic chips is therefore essential. Here, we study the release kinetics of fluorophore-conjugated antibodies from (sub-) µm thick gelatin layers and several ways to control the release time. The observed antibody release is well-described by a diffusion model. Release times ranging from ∼20 s to ∼650 s were determined for layers with thicknesses (in the dry state) between 0.25 µm and 1.5 µm, corresponding to a diffusivity of 0.65 µm(2) s(-1) (in the swollen state) for our standard layer preparation conditions. By modifying the preparation conditions, we can influence the properties of gelatin to realize faster or slower release. Faster drying at increased temperatures leads to shorter release times, whereas slower drying at increased humidity yields slower release. As expected in a diffusive process, the release time increases with the size of the antibody. Moreover, the ionic strength of the release medium has a significant impact on the release kinetics. Applying these findings to cell counting chambers with on-chip sample preparation, we can tune the release to control the antibody distribution after inflow of blood in order to achieve homogeneous cell staining.

Phenoloxidase activity acts as a mosquito innate immune response against infection with Semliki Forest virus.

Several components of the mosquito immune system including the RNA interference (RNAi), JAK/STAT, Toll and IMD pathways have previously been implicated in controlling arbovirus infections. In contrast, the role of the phenoloxidase (PO) cascade in mosquito antiviral immunity is unknown. Here we show that conditioned medium from the Aedes albopictus-derived U4.4 cell line contains a functional PO cascade, which is activated by the bacterium Escherichia coli and the arbovirus Semliki Forest virus (SFV) (Togaviridae; Alphavirus). Production of recombinant SFV expressing the PO cascade inhibitor Egf1.0 blocked PO activity in U4.4 cell- conditioned medium, which resulted in enhanced spread of SFV. Infection of adult female Aedes aegypti by feeding mosquitoes a bloodmeal containing Egf1.0-expressing SFV increased virus replication and mosquito mortality. Collectively, these results suggest the PO cascade of mosquitoes plays an important role in immune defence against arboviruses.

[Infected pseudarthrosis of the symphysis with persisting instability : Revision osteosynthesis with tantalum cage and silver ionized ITS plate after peri-implant infection with MRSE after osteosynthetic stabilization of a type C pelvic injury]. / Symphyseninstabilität mit Infekt : Rekonstruktion mittels Tantalum-Cage und silberbeschichteter ITS-Platte nach periimplantärem Infekt mit MRSE nach osteosynthetischer Stabilisierung einer Becken-C-Verletzung.

Overall symptomatic pseudathrosis after pelvic ring fracture is rare. A pseudarthrosis of the dorsal pelvic ring often leads to persisting pain due to instability and needs a consequent treatment strategy. Often a bacterial infection can be found in persisting pseudarthrosis notably in the anterior pelvic ring region. It is assumed that the peculiar anatomical site of the surgical approach - pubic region and abdominal skinfold - in particular accompanied with adipositas is predestined. Often patients with pseudathrosis and proof of bacterial infection show no symptoms. In these cases treatment is not mandatory. Patients however who complain about persisting pain limited treatment options exist.The following case report demonstrates a treatment strategy to achieve pelvic ring stability and infection eradication using a silver ionised plate and screws as well as a tantalum cage.

Early Stabilization Does Not Increase Complication Rates in Acetabular Fractures of the Elderly: A Retrospective Analysis from the German Pelvis Registry.

Background: The incidence of acetabular fractures in geriatric patients has increased. Although there are strong data supporting the early operative treatment of hip fractures in geriatric patients, the optimal timing for acetabular fractures remains unclear and for several reasons, delayed treatment after trauma is common. Methods: A retrospective analysis of the German Pelvis Registry between 2008 and 2017 was performed. Ultimately, 665 patients with fractures of the anterior column or anterior column and posterior hemitransverse were enrolled. Patients above and below 65 years of age with these fracture types were analyzed regarding surgery day (within 48 hours, between 2 and 4 days, after 4 days), complication rate, reduction quality, and hospital stay. Results: The complication rate of the geriatric group was twice as high as that of younger patients; however, this finding was independent of the timing of surgery. Reduction quality and hospital stay were independent of surgical timing. Conclusions: In contrast to other fracture types, such as proximal femur fractures, the timing of surgery for acetabular fractures does not have a significant impact on the patient's outcome. The optimal time for surgery cannot be determined using the current data. However, as expected, there is a significantly higher risk for postoperative complications in the geriatric population.

The encapsidated genome of Microplitis demolitor bracovirus integrates into the host Pseudoplusia includens.

Polydnaviruses (PDVs) are symbionts of parasitoid wasps that function as gene delivery vehicles in the insects (hosts) that the wasps parasitize. PDVs persist in wasps as integrated proviruses but are packaged as circularized and segmented double-stranded DNAs into the virions that wasps inject into hosts. In contrast, little is known about how PDV genomic DNAs persist in host cells. Microplitis demolitor carries Microplitis demolitor bracovirus (MdBV) and parasitizes the host Pseudoplusia includens. MdBV infects primarily host hemocytes and also infects a hemocyte-derived cell line from P. includens called CiE1 cells. Here we report that all 15 genomic segments of the MdBV encapsidated genome exhibited long-term persistence in CiE1 cells. Most MdBV genes expressed in hemocytes were persistently expressed in CiE1 cells, including members of the glc gene family whose products transformed CiE1 cells into a suspension culture. PCR-based integration assays combined with cloning and sequencing of host-virus junctions confirmed that genomic segments J and C persisted in CiE1 cells by integration. These genomic DNAs also rapidly integrated into parasitized P. includens. Sequence analysis of wasp-viral junction clones showed that the integration of proviral segments in M. demolitor was associated with a wasp excision/integration motif (WIM) known from other bracoviruses. However, integration into host cells occurred in association with a previously unknown domain that we named the host integration motif (HIM). The presence of HIMs in most MdBV genomic DNAs suggests that the integration of each genomic segment into host cells occurs through a shared mechanism.

Hook plate fixation for acromioclavicular joint separations restores coracoclavicular distance more accurately than PDS augmentation, however presents with a high rate of acromial osteolysis.

INTRODUCTION: Hook plate fixation of acromioclavicular (AC) joint separations carries the disadvantage of compulsory implant removal, occasional implant fatigue and secondary loss of reduction. This study compares the clinical and radiological outcome of a new polyaxial angular stable hook plate (HP) with absorbable polydioxansulfate (PDS) sling. MATERIALS AND METHODS: Between 2002 and 2009, out of a consecutive series of 81 patients with symptomatic Rockwood type V lesions 52 patients received clinical and radiographic follow-up (HP: n = 27; PDS: n = 25). HP patients were prospectively analyzed and retrospectively compared with the PDS group. Radiological follow-up included comparative coraco- and acromioclavicular distance (CCD/ACD) measurements as percentage of the uninjured shoulder. For clinical follow-up a standardized functional shoulder assessment with Constant Score, DASH Score, Taft Score and a self-report questionnaire including the visual analog scale (VAS) was carried out. RESULTS: Direct postoperative radiographs showed an overcorrection of CCD in the HP group (-4.4% of the uninjured side) and failure of anatomic correction in the PDS group (+11.0%). After implant removal, CCD increased in the HP group extensively to 16.7% (overall loss of reduction: 21.1%) and 23.9% in the PDS group. Redisplacement (100% increase of CCD) occurred in five cases (HP: 2, PDS: 3) and partial loss of reduction in four cases of each group. Comparing functional results no differences could be seen between both the groups (Constant-Score HP: 91.2 points, PDS: 94.6 points; Taft-Score HP: 9.4 points, PDS: 10.0 points). The DASH-Score revealed better results for PDS group (3.4 points, HP: 8.0 points). Signs of acromial osteolysis appeared in five cases (18.5%) in HP group. There was no case of implant failure. The X-rays of six patients (HP: 4, PDS: 2) showed AC-joint-osteoarthritis. CONCLUSION: Hook plate fixation employing a polyaxial angular stable plate finally restores the coracoclavicular distance more accurately than augmentation with a PDS sling. Although in HP group no implant failure occurred, major disadvantages are initial overcorrection and acromial osteolysis. Both have no influence on final functional results.

Reliability and consequences of intraoperative 3D imaging to control positions of thoracic pedicle screws.

INTRODUCTION: The insertion of thoracic pedicle screws (T1-T10) is subject to a relevant rate of malplacement. The optimum implantation procedure is still a topic of controversial debate. Currently, a postoperative computed tomography is required to evaluate the screw positions. The present study was undertaken to clarify whether intraoperative 3D imaging is a reliable method of determining the position of thoracic pedicle screws. METHODS: This prospective study involved 40 consecutive patients with thoracic spinal injuries, with intraoperative 3D scans being performed to determine the positions of 240 pedicle screws in T1-T10. The results of the 3D scans were compared with the findings of postoperative CT scans, using a clinical classification system. RESULTS: The positions of 204 pedicle screws could be viewed by means of both 3D and CT scans and the results compared. The 3D scans achieved a sensitivity of 90.9 % and a specificity of 98.8 %. The rate of misclassification by the 3D scans was 2.5 %. Nine pedicle screws were classified as misplaced and their position corrected intraoperatively (3.8 %). No screws required postoperative revision. CONCLUSIONS: Performing an intraoperative 3D scan enables the position of thoracic pedicle screws to be determined with sufficient accuracy. The rate of revision surgery was reduced to 0 %.

Treatment options in non-unions of the pelvis: A retrospective analysis of a single center experience over 12 years.

BACKGROUND: Non-unions and chronic instability of the pelvis remain rare complications after complex high velocity injuries with vertical and rotational instability of the pelvis. Treatment options are insufficiently supported by data evidence due to the rareness of this condition. PATIENTS AND METHODS: we conducted a single center, retrospective study of all non-unions and pelvic instabilities between 1.1.2008 and 1.1.2019, excluding fragility fractures. Patients' characteristics, fracture patterns, procedures and outcomes with regard to developing treatment options and successful union in the follow-up were obtained. RESULTS: 26 patients were included in this retrospective analysis. The mean age was 55 years (range 34-78 years). Seventy-seven percent of the patients were male. The standard procedure consisted of radical debridement of the non-union, interposition of autologous bone graft and rigid stabilization systems. Three patients were lost to follow up. In the remaining n = 23 patients (88%) consolidation of the non-union was achieved. The mean follow up was 31.3 months (range 6-144). Follow up showed that an iliolumbar fixation seems to be favorable regarding outcome and complications. DISCUSSION: Non-union and remaining instability of the pelvic ring represent a rare complication after high grade pelvic trauma. There are only limited data regarding the incidence and the treatment regimen is based on small study populations only. Based on our findings we recommend to combine autologous bone grafts with rigid fixation systems especially for non-union of the pelvis to restore the posterior sacroiliac arch.

Patients with complex proximal tibial fractures overestimate the prognosis of their injury.

PURPOSE: To investigate, if patients with complex proximal tibial fracture have realistic expectations on open reduction and internal fixation. METHODS: 114 patients (mean 49 years, SD ± 13) with closed AO-type B and C proximal tibial fracture were grouped (group B, respectively C). Prior to surgery expectations concerning knee function, pain, return to work/sports, and the risk for osteoarthritis was assessed with the Hospital for Special Surgery-Knee Surgery Expectations Survey (HFSS-KSE) and a non-validated ten-item survey. RESULTS: 92% of patients expected at least an almost natural knee postoperatively. All items regarding restoring knee function were ranked to be at least important in both groups. 65% in group B and 47% in group C expected at most occasional pain. 83% in group B and 67% in group C expected full return to work without any limitations. Patients with low physical work intensity expected significantly shorter incapacity to work in both groups (7.8, respectively 8.9 weeks). 71% in group B and 60% in group C expected to return to sports with at most small limitations. 33% in group B and 22% in group C assumed risk for osteoarthritis will be prevented by surgery. CONCLUSION: Expectations on surgery for complex proximal tibial fracture are high regardless of fracture type. The prognosis of many health and lifestyle domains was overestimated. The risk for osteoarthritis was underestimated. This study should sensitize surgeons to discuss realistic expectations. This may help to improve patient comprehension what leads to sensible expectations, resulting in improved patients´ satisfaction. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION NUMBER: 14104, Date of registration: 06/2015.

[Das unterschätzte Verletzungsrisiko beim Freizeitschlittenfahren]. / Das unterschätzte Verletzungsrisiko beim Rodeln im Freizeitsport.

BACKGROUND: Sledding is generally considered to be a relatively harmless winter leisure activity. The increased incidence of injuries, some of them severe, in our emergency department in the catchment area of several sledding slopes prompted an analysis of this patient population with respect to frequency and severity of injuries. PATIENTS AND METHODS: Based on the hospital documentation system, a retrospective evaluation of all emergency department visits in the winters 2016-2019 was performed. The words "sled", "sledge", "bob", "sledding", "sleighing", "sledging" were used as keywords, and the recorded data were analyzed with respect to outpatient treatment, inpatient treatment, inpatient treatment days, treatment days in the intensive care unit, number of necessary operations, injury patterns, and injury severity. RESULTS: A total of 175 injured patients were recorded over the 3­year period. In 94 patients (54%) the injury was classified as mild, 70 patients (40%) required inpatient treatment with an average length of stay of 8 days, resulting in a total of 590 inpatient treatment days. Surgical treatment was given to 49 (28%) of the injured with a total of 66 operations, 81 patients suffered from severe injuries up to multiple trauma with an injury severity score (ISS) of 34. DISCUSSION: The study demonstrates that sledding has a significantly higher injury potential than generally assumed and that the resulting costs and consequences of accidents are relevant. Especially on the designated sledge slopes, an increase in safety standards could be achieved through appropriate measures and rules.

Monitoring CD4 in whole blood with an opto-fluidic detector based on spatially modulated fluorescence emission.

We describe a new optical detection technique, termed "spatially modulated fluorescence emission," that delivers high signal-to-noise discrimination without precision optics to enable a flow cytometer that can combine high performance, robustness, compactness, low cost, and ease of use. The detection technique is demonstrated with measurements of absolute CD4+ and percentage CD4 counts in human blood. Benchmarking against a commonly used commercial instrument for this test yields excellent agreement for both absolute CD4 and percentage CD4.

Endoscopically assisted implant removal of a symphyseal pelvic plate - A case report.

INTRODUCTION: The approach-related morbidity rate in the care of pelvic fractures is still high. Endoscopic procedures are known to significantly reduce access-related complications. Recently, a new endoscopically assisted implantation technique for plate osteosynthesis on the anterior pelvic ring has been described as the "Endoscopic Approach to the Symphysis". CASE REPORT: We present a case of a 29-year old male with a pelvic injury (AO type 61B2.3a) initially treated with a supraacetabular external fixator. After one week the definitive stabilization was performed by an endoscopically assisted symphyseal plating as well as a percutaneous iliosacral screw on the right side. One year after primary surgery, we performed an endoscopically assisted removal of the symphyseal plate using standard laparoscopic instruments. RESULTS: We demonstrate the feasibility of an endoscopically assisted implant removal at the anterior pelvic ring. No complications occurred during the procedure. The patient was discharged after a regular time of surveillance and with an adequate decline of pain. DISCUSSION: While we were able to show that the endoscopically assisted implantation as well as the removal of a plate osteosynthesis on the anterior pelvic ring is possible, there is still further research necessary, especially regarding the development of specific endoscopic instruments. This should enable operating times similar to the standard open procedures.

FOOTPRINTS study protocol: rationale and methodology of a 3-year longitudinal observational study to phenotype patients with COPD.

INTRODUCTION: A better understanding is needed of the different phenotypes that exist for patients with chronic obstructive pulmonary disease (COPD), their relationship with the pathogenesis of COPD and how they may affect disease progression. Biomarkers, including those associated with emphysema, may assist in characterising patients and in predicting and monitoring the course of disease. The FOOTPRINTS study (study 352.2069) aims to identify biomarkers associated with emphysema, over a 3-year period. METHODS AND ANALYSIS: The FOOTPRINTS study is a prospective, longitudinal, multinational (12 countries), multicentre (51 sites) biomarker study, which has enrolled a total of 463 ex-smokers, including subjects without airflow limitation (as defined by the 2015 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report), patients with COPD across the GOLD stages 1-3 and patients with COPD and alpha1-antitrypsin deficiency. The study has an observational period lasting 156 weeks that includes seven site visits and additional phone interviews. Biomarkers in blood and sputum, imaging data (CT and magnetic resonance), clinical parameters, medical events of special interest and safety are being assessed at regular visits. Disease progression based on biomarker values and COPD phenotypes are being assessed using multivariate statistical prediction models. ETHICS AND DISSEMINATION: The study protocol was approved by the authorities and ethics committees/institutional review boards of the respective institutions where applicable, which included study sites in Belgium, Canada, Denmark, Finland, Germany, Japan, Korea, Poland, Spain, Sweden, UK and USA; written informed consent has been obtained from all study participants. Ethics committee approval was obtained for all participating sites prior to enrolment of the study participants. The study results will be reported in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT02719184.

A VLP-based vaccine targeting domain III of the West Nile virus E protein protects from lethal infection in mice.

BACKGROUND: Since its first appearance in the USA in 1999, West Nile virus (WNV) has spread in the Western hemisphere and continues to represent an important public health concern. In the absence of effective treatment, there is a medical need for the development of a safe and efficient vaccine. Live attenuated WNV vaccines have shown promise in preclinical and clinical studies but might carry inherent risks due to the possibility of reversion to more virulent forms. Subunit vaccines based on the large envelope (E) glycoprotein of WNV have therefore been explored as an alternative approach. Although these vaccines were shown to protect from disease in animal models, multiple injections and/or strong adjuvants were required to reach efficacy, underscoring the need for more immunogenic, yet safe DIII-based vaccines. RESULTS: We produced a conjugate vaccine against WNV consisting of recombinantly expressed domain III (DIII) of the E glycoprotein chemically cross-linked to virus-like particles derived from the recently discovered bacteriophage AP205. In contrast to isolated DIII protein, which required three administrations to induce detectable antibody titers in mice, high titers of DIII-specific antibodies were induced after a single injection of the conjugate vaccine. These antibodies were able to neutralize the virus in vitro and provided partial protection from a challenge with a lethal dose of WNV. Three injections of the vaccine induced high titers of virus-neutralizing antibodies, and completely protected mice from WNV infection. CONCLUSIONS: The immunogenicity of DIII can be strongly enhanced by conjugation to virus-like particles of the bacteriophage AP205. The superior immunogenicity of the conjugate vaccine with respect to other DIII-based subunit vaccines, its anticipated favourable safety profile and low production costs highlight its potential as an efficacious and cost-effective prophylaxis against WNV.

Should one consider primary surgical reconstruction in charcot arthropathy of the feet?

UNLABELLED: Charcot neuroosteoarthropathy of the feet can induce severe instability and deformity with subsequent plantar ulceration leading to substantial disability or even amputation. Traditionally, nonoperative treatment is regarded as the primary option of treatment while surgery is restricted to treating complications or failure of nonoperative treatment. Failed nonoperative treatment essentially prolongs treatment period. We retrospectively reviewed 22 patients (26 feet) with midfoot (n = 9) or hindfoot (n = 17) neuropathy who underwent primary surgical reconstruction and reorientation arthrodesis due to manifest instability, nonplantigrade foot position, and deformity with overt (n = 8) or what we judged was impending ulceration (n = 9). The minimum followup was 0.5 years (mean, 2.7 years; range 0.5-7 years). All eight ulcers healed without recurrence of ulceration or manifestation of new ulcers during the followup period. We observed complications leading to further surgery in nine patients: five with perioperative hematoma and four with instability. AOFAS scores rose from a preoperative mean of 39 to 70 points (hindfoot cases) and from 51 points to 84 (midfoot cases). Early surgical reconstruction in high-risk patients can provide timely restoration of a plantigrade and stable foot and improved quality of life of the patient at complication rates comparable to those after secondary surgery following failed nonoperative treatment; however we emphasize we had no control group in this small case series for which we could compare nonoperative treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study (case series). See Guidelines for Authors for a complete description of levels of evidence.

A novel polydnavirus protein inhibits the insect prophenoloxidase activation pathway.

Pathogens often suppress the melanization response of host insects, but the underlying molecular mechanisms are largely unknown. Here we report that Microplitis demolitor bracovirus (MdBV) carried by the wasp M. demolitor produces a protein, Egf1.0, which inhibits the phenoloxidase (PO) cascade. Egf1.0 belongs to a larger gene family that shares a cysteine-rich motif with similarities to the trypsin inhibitor-like (TIL) domains of small serine proteinase inhibitors (smapins). Gain-of-function and RNAi experiments indicated that the Egf genes are the only MdBV-encoded factors responsible for disabling the insect melanization response. Known smapins bind target proteinases in a substrate-like fashion and are cleaved at a single reactive site bond. The P1-P1' position for Egf1.0 has the sequence Arg-Phe, which suggested that its target proteinase is a prophenoloxidase-activating proteinase (PAP). Wild-type Egf1.0 inhibited PAP-3 from Manduca sexta, whereas Egf1.0(R51A), whose reactive-site arginine was replaced with an alanine, had no PAP-3 inhibitory activity. Other experiments using wild-type and mutant constructs indicated that Egf1.0 blocks activation of the PO cascade via PAP inhibition. Overall, our results identify a novel inhibitor of the PO cascade and indicate that suppression of the host melanization response is functionally important for both the virus and its associated wasp.

Intraoperative position determination of bone cement trocars by 3-dimensional imaging in patients with osteoporotic vertebral fractures.

STUDY DESIGN: A prospective diagnostic study to evaluate the use of intraoperative 3-dimensional (3D) imaging. OBJECTIVE: To evaluate the accuracy of an intraoperative 3D imaging predicting trocar positions in osteoporotic fractured vertebral bodies before cement injection. SUMMARY OF BACKGROUND DATA: Malpositioned needles in vertebroplasty and kyphoplasty increase the risk of extravertebral cement leakage and the associated complications. This study was intended to clarify whether the position of trocars can adequately be determined before the cement application by an intraoperative 3D imaging. METHODS: Between August 2006 and July 2008 the positions of 84 trocars in 42 fractured vertebrae between T11 and L5 were measured by intraoperative 3D imaging before injection of the cement. The external diameter of the needles was 9 to 10 G. The positions of the trocars were classified in the axial plane by a new classification system. RESULTS: Forty 3D scans covered 84 injection cannulae in 42 fractured vertebral bodies. The average duration of the entire scanning procedure was 7.1 minutes. All 3D scans could be evaluated with adequate degree of certainty. Intraoperative evaluation of the 3D scans showed 78 correct needle positions. Two trocars were in an acceptable lateral malposition. There were 4 medial malpositions that required revision. In total, 4.8% of the trocars were positioned not acceptably. Postoperative computed tomography was performed in 17 patients. The positions of 34 needles determined by computed tomography conformed 100% to the results of the 3D scans. CONCLUSIONS: It is possible to reliably determine the position of trocars in vertebral bodies with the aid of an intraoperative 3D scan. This can lead to a reduction in the morbidity rates associated with puncture errors in kyphoplasty and vertebroplasty. The amount of time required is small. The increased radiation exposure is acceptable.

Intraoperative three-dimensional fluoroscopy assessment of iliosacral screws and lumbopelvic implants stabilizing fractures of the os sacrum.

INTRODUCTION: Percutaneous iliosacral screw fixation of unstable sacrum fractures has gained popularity since its introduction in the 1990s. The combination with lumbopelvic implants allows the application even in situations of higher instability. Both manual and navigated screw insertion in the sacrum and vertebra bodies shows unchanged relevant malpositions. The current standard to control the screw position is postoperative computed tomography. The study presents the results of assessment of these implants by intraoperative three-dimensional fluoroscopy. METHODS: From January 2008 through March 2009, 14 patients had stabilization of the dorsal pelvic ring with iliosacral screws alone or in combination with lumbopelvic implants. Intraoperative 3D fluoroscopy was performed to evaluate the position of the implants stabilizing the posterior pelvic ring. RESULTS: Fourteen iliosacral screws and eight pedicle screws were depicted. In all patients, we were able to adequately evaluate the placement of iliosacral screws, lumbar pedicle screws and iliacal screws. As a consequence of intraoperative 3D scan a lumbar pedicle screw was corrected. The entire scanning procedure required 5 min. The time for analyzing the 3D scan took 3 min. CONCLUSIONS: Intraoperative 3D fluoroscopy is a valuable tool for intraoperative assessment of iliosacral screws and lumbopelvic implants. The technique should help us to detect intraoperative malplacement of the screws more reliably than conventional fluoroscopy and allows an immediate correction of malplaced implants. Therefore, a postoperative computed tomography to control the position of implants is dispensable.