The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study.

BACKGROUND: This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS). METHODS: First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS. RESULTS: PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019). CONCLUSIONS: The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.

[Extensor tendon injuries of the thumb]. / Strecksehnenverletzungen des Daumens.

Extensor tendon injuries of the thumb include lesions of the tendons of the extensor pollicis longus, extensor pollicis brevis and abductor pollicis longus muscles. The latter is practically only affected in open injuries. Open injuries require a tendon reconstruction by suture followed by immobilization in the distal and an adequate aftercare depending on the zone of injury. In distal injuries static splinting is applied, whereas proximal injuries from T4 on require a dynamic after-treatment. Different courses of the tendon of the extensor pollicis brevis muscle exist distal to the metacarpophalangeal joint and must be considered. The rare ruptures of the extensor hood at the metacarpophalangeal joint provoke an ulnar displacement of the extensor pollicis longus or both extensor tendons with concomitant lack of active extension in the metacarpophalangeal and interphalangeal joints. This injury is often misdiagnosed as a rupture of the ulnar collateral ligament of the metacarpophalangeal joint. It should be treated by refixation of the ruptured structures. Closed chronic ruptures of the extensor pollicis longus tendon go along with a defect that requires a tendon transfer or a tendon autograft.

[Surgical treatment strategy for traumatic luxation of the posterior tibial tendon : Case report and literature review]. / Operative Versorgungsstrategie einer traumatischen Luxation der Tibialis-posterior-Sehne : Fallbericht und Literaturvergleich.

Based on a case study, the injury pattern and surgical procedure for traumatic dislocation of the posterior tibial tendon is presented. A 32-year-old ice hockey player suffered a direct impact from a puck at the dorsomedial aspect of the inner ankle. In the course of the injury a ganglion developed due to recurrent dislocation of the posterior tibial tendon. Intraoperatively, a distracted retinaculum and a flattened retromalleolar sulcus were present. An open wedge osteotomy and suture anchor refixation of the retinaculum were performed. This procedure is described in the context of a review of the literature.

Biomechanical analysis of polyaxial locking vs. non-locking plate fixation of unstable fractures of the distal fibula: A cadaver study with a bone only model.

BACKGROUND: Open reduction and internal fixation is the current standard of treatment of displaced distal fibula fractures, whereupon using a lag screw often is impossible because of a multifragmantary fracturezone. This study investigates in what extend polyaxial-locking plating is superior to non-locking constructs in unstable distal fibula fractures. METHODS: Seven pairs of human cadaver fibulae were double osteotomized in standardized fashion with a 5mm gap. This gap simulated an area of comminution, where both main fragments were no longer in direct contact. One fibula of the pair was managed using a 3.5-mm screw in a polyaxial-locking construct and the other fibula in a non-locking construct.

[Course of operative treatment of a sacral insufficiency fracture : Successful or serious treatment?] / Behandlungsverlauf der operativen Versorgung einer Sakruminsuffizienzfraktur : Erfolgreiches oder folgenreiches Handeln?

A monolateral sacrum fracture was primarily diagnosed with a CT and treated with PMMA augmented SI screw fixation. The following CT showed an unexpected contralateral fracture which led to the need for a lumbopelvic stabilization. In the course of 6 months, successively occurring adjacent fractures required recurrent vertebroplasty. Most of these fractures could only be diagnosed through MRI. It remains unclear, whether initially even the contralateral sacral ala was fractured.

Spondylodiscitis severity code: scoring system for the classification and treatment of non-specific spondylodiscitis.

INTRODUCTION: Established treatment options of spondylodiscitis, a rare but serious infection of the spine, are immobilization and systemic antibiosis. However, the available data for specific treatment recommendations are very heterogeneous. Our intention was to develop a classification of the severity of spondylodiscitis with appropriate treatment recommendations. MATERIALS AND METHODS: From 10/1/1998 until 12/31/2004, 37 cases of spondylodiscitis were examined regarding medical history, gender status, location and extent of spondylodiscitis, type and number of operations. Subsequently, a classification of six grades according to severity has been developed with specific treatment recommendations. The further evaluation of our classification and corresponding treatment modalities from 1/1/2005 to 12/31/2009 including further 132 cases, resulted in a classification of only three grades of severity (the SSC--spondylodiscitis severity code), with a follow-up until 12/31/2011. Between 01/01/2012 and 12/31/2013, a prospective study of 42 cases was carried out. Overall, 296 cases were included in the study. 26 conservatively treated cases were excluded. RESULTS AND CONCLUSION: The main localization of spondylodiscitis was the lumbar spine (55%) followed by the thoracic spine (34%). The classification of patients into 3 grades of severity depends on clinical and laboratory parameters, the morphological vertebral destruction seen in radiological examinations and the current neurological status. Therapies are adapted according to severity and they include a specific surgical management, systemic antibiotic therapy according to culture and sensitivity tests, physiotherapy and initiation of post-hospital follow-up. 40.6% of patients are associated with neurological deficits, classified as severity grade 3 and treated surgically with spinal stabilization and decompression. 46.9% of patients corresponded to severity grade 2, with concomitant vertebral destruction were dorsoventrally stabilized. The 31 patients of severity Grade 1 were treated surgically with dorsal stabilization. From 1998 to 2013, the time from the onset of symptoms to the first surgical treatment was about 69.4 days and has not changed significantly. However, the time from admission to surgical treatment had been reduced to less than 2 days. Also the time of hospitalization was reduced and we see positive effects regarding the sensation of pain. 270 patients underwent surgery. We treated 89% dorsally and 21% dorsoventrally. With the spondylodiscitis severity code, a classification of the severity of spondylodiscitis could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway.

Clinical presentation and blood gas analysis of multiple trauma patients for prediction of standard coagulation parameters at emergency department arrival.

OBJECTIVES: Trauma-induced coagulopathy (TIC) in multiple trauma patients is a potentially lethal complication. Whether quickly available laboratory parameters using point-of-care (POC) blood gas analysis (BGA) may serve as surrogate parameters for standard coagulation parameters is unknown. The present study evaluated TraumaRegister DGU® of the German Trauma Society for correlations between POC BGA parameters and standard coagulation parameters. METHODS: In the setting of 197 trauma centres (172 in Germany), 86,442 patients were analysed between 2005 and 2012. Of these, 40,129 (72% men) with a mean age 46 ± 21 years underwent further analysis presenting with direct admission from the scene of the accident to a trauma centre, injury severity score (ISS) ≥ 9, complete data available for the calculation of revised injury severity classification prognosis, and blood samples with valid haemoglobin (Hb) measurements taken immediately after emergency department (ED) admission. Correlations between standard coagulation parameters and POC BGA parameters (Hb, base excess [BE], lactate) were tested using Pearson's test with a two-tailed significance level of p < 0.05. A subgroup analysis including patients with ISS > 16, ISS > 25, ISS > 16 and shock at ED admission, and patients with massive transfusion was likewise carried out. RESULTS: Correlations were found between Hb and prothrombin time (r = 0.497; p < 0.01), Hb and activated partial thromboplastin time (aPTT; r = -0.414; p < 0.01), and Hb and platelet count (PLT; r = 0.301; p < 0.01). Patients presenting with ISS ≥ 16 and shock (systolic blood pressure < 90 mmHg) at ED admission (n = 4,329) revealed the strongest correlations between Hb and prothrombin time (r = 0.570; p < 0.01), Hb and aPTT (r = -0.457; p < 0.01), and Hb and PLT (r = 0.412; p < 0.01). Significant correlations were also found between BE and prothrombin time (r = -0.365; p < 0.01), and BE and aPTT (r = 0.327, p < 0.01). No correlations were found between Hb, BE and lactate lactate. CONCLUSIONS: POC BGA parameters Hb and BE of multiple trauma patients correlated with standard coagulation parameters in a large database analysis. These correlations were particularly strong in multiple trauma patients presenting with ISS > 16 and shock at ED admission. This may be relevant for hospitals with delayed availability of coagulation studies and those without viscoelastic POC devices. Future studies may determine whether clinical presentation/BGA-oriented coagulation therapy is an appropriate tool for improving outcomes after major trauma.

[Impairment of oxygenation of patients in surgical intensive care : Early symptom of severe sepsis]. / Die Veränderung der Oxygenierung chirurgischer Intensivpatienten : Frühes Leitsymptom der schweren Sepsis.

BACKGROUND: Sepsis and septic shock are major contributors to morbidity and mortality in intensive care patients. Early identification and adequate therapy are of utmost importance to reduce the still high mortality in patients with severe sepsis. Many of the pathophysiologic changes are nonspecific. Thus, a combination of symptoms and laboratory results are necessary to confirm the diagnosis. Impairment of the Horovitz index is identified as being a primal prognostic criterion for early diagnosis in serious progression of sepsis, after exclusion of a few differential diagnoses. Based on this fact, the prevalence of this symptom compared to other sepsis parameters is of specific interest. METHOD: In a retrospective study 33 cases of serious sepsis were analysed during the patient's course of intensive care treatment focusing on oxygenation. The deterioration of oxygenation, meaning a drop in the Horovitz index below 200 mm Hg (25.7 kPa) or a decrease in paO2 by 67.5 mm Hg (9 kPa) in spontaneously breathing patients with sepsis was the mean inclusion criteria. We compared the sequence of occurrence of known sepsis markers (e. g. PCT, WBC, CRP) with the deterioration in oxygenation to answer the question whether impairment of oxygenation could be an early symptom of severe sepsis. The Mann Whitney U­test and a discriminant analysis were performed to verify differences of the variables investigated between surviving and deceased patients. Furthermore a regression analysis was performed to confirm the results of the discriminant analysis. RESULTS: The mean drop in the Horovitz index was 90 ± 24 mm Hg (12 ± 3.2 kPa) within 4.5 h respectively. This was highly significant (p < 0.001). In all patients impairment of oxygenation indicated an individual onset and further progression of a serious sepsis. In more than ¾ of all cases this symptom occurred in an earlier stage than other organ dysfunctions. In 79 % of cases, patients showed an impairment of oxygenation before PCT increased on values of >2 ng/ml. In 76 % of cases impairment of oxygenation occurred earlier than all other investigated parameters. Significant differences were found between surviving and deceased patients regarding to their age as well as the timeframe from the beginning of impaired oxygenation to the onset of the effect of the administered antibiotics. These two parameters (age, time to sufficient antibiotic therapy) were confirmed by regression analysis and showing similar effect coefficients, age 1.09 and time to sufficient antibiotic therapy 1.04 respectively. CONCLUSION: An urgent worsening of pulmonary function in patients in intensive care requires immediate differential diagnostics due to substantial therapeutic consequences. Our results confirm that impairment of pulmonary oxygenation is the first prognostic symptom of severe onset of sepsis. Consequently, we recommend that this parameter be considered in diagnostic staging. After exclusion of a few differential diagnoses impairment of oxygenation can be the very first symptom of severe sepsis. The patient's age and time to sufficient antibiotic therapy are two very important prognostic factors with respect to mortality. Early and sufficient antibiotic therapy, and in a few cases surgical intervention are of utmost importance.

[The time-related risk for knee osteoarthritis after ACL injury. Results from a systematic review]. / Das zeitabhängige Arthroserisiko nach vorderer Kreuzbandverletzung. Ergebnisse einer systematischen Literaturrecherche.

AIM: The aim of this review was to evaluate the time-related risk for knee osteoarthritis in patients after ACL injury. MATERIALS AND METHODS: The primary search was carried out in different medical databases with the deadline 12.01.2014. The search strategy for the evaluation was [ACL] AND [osteoarthritis] including "all fields". All 1656 title/abstracts were reviewed by two independent researchers who selected 140 papers for full text review. Finally, a total of 21 relevant publications were identified for inclusion in this current paper. RESULTS: The incidence of knee osteoarthritis rises significantly over time. Two years after injury it was 6.9%, after 5 years 32.2%, after 7 years 36.3%, and after 10 years 79.6%. At the same time, the crude relative risk of OA rises as the time interval since injury increases. The relative risk of OA has already doubled by 2 years after ACL injury). By 7 years it has increased fivefold and compared with OA status at the time of injury it is still increasing significantly after 10 years. CONCLUSIONS: The ACL injury is a significant risk factor for the development of early-onset secondary knee osteoarthritis. Within 5 years of the injury the knee shows clear signs of osteoarthritis on MRI. However, these lesions are often not associated with any clinical signs. Knee osteoarthritis as a severe disease starts 8 years or later after the injury, when it requires treatment.

[A 44 year old patient presenting with Ewing's sarcoma of the big toe]. / 44-jährige Patientin mit Ewing­Sarkom der Großzehengrundphalanx.

We present the case of a patient with osseous Ewing's sarcoma of the big toe occurring during the healing process after a fracture of the little toe, which significantly delayed diagnosis, despite striking findings on imaging. We subsequently performed further diagnostics, neoadjuvant chemotherapy, tumor resection in the form of a resection of the first ray, and adjuvant chemotherapy. This case shows that the occurrence of a secondary disease should always be considered in untypical courses of healing.

[Whole-body-CT in Severely Injured Children. Results of Retrospective, Multicenter Study with Patients from the TraumaRegsiter DGU®]. / Ganzkörper-CT bei schwerverletzten Kindern. Ergebnisse einer retrospektiven Multizenterstudie anhand des TraumaRegister DGU®.

BACKGROUND: A fast and comprehensive diagnostic by means of whole-body CT has been shown to reduce mortality in the adult trauma population. Therefore whole-body CT seems to be the standard in adult trauma-patients. Due to the higher radiation exposure of whole-body CT the use of this diagnostic toll in pediatric trauma patients is still under debate. It is not yet clear if whole-body CT in children can increase the probability of survival. METHOD: In a retrospective, multicenter study, we used the data recorded in the TraumaRegister DGU(®) to calculate the probability of survival according to the revised injury severity classification (RISC) and standardized mortality ratio (SMR). The SMR reflects the ratio of recorded to expected mortality. Included in the study were all children (1-15 years) and adults (16-50 years) with an Injury Severity Score (ISS)>9, who were directly admitted to the hospital from the scene of accident. We compared the groups of patients given whole-body CT or non-whole-body CT. Subgroup analysis was performed for children 1-9 years, children 10-15 years and adults. RESULTS: A total of 1,456 pediatric trauma patients (mean age 9.9 years) and 20,796 adults (mean age 32.7 years) were included in the study. In contrast to adult trauma patients, were the SMR in the whole-body CT group was significant lower; we observed no advantage for the whole-body CT in pediatric trauma patients. CONCLUSION: Due to the missing advantage of whole-body CT in the pediatric trauma population and the higher radiation exposure of whole-body CT a non-whole-body CT approach seems equivalent with a lower radiation exposure.

[Residual limb and phantom pain : Causes and therapeutic approaches]. / Stumpf- und Phantomschmerzen : Ursachen und Therapieansätze.

INTRODUCTION: Residual limb pain and phantom pain are severe complications following an amputation. Various reasons are responsible for these complaints. It must be distinguished between amputation stump pain, phantom sensations and phantom pain. CAUSE AND THERAPY: In this paper we describe the most common reasons for stump pain and propose some non-operative therapeutic approaches. Furthermore path physiology and phantom pain therapy will be discussed. The recommendations offered in this paper are based on practical experience over three decades in a specialized out-patient department for patients with amputation injuries.

[Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon]. / Repositionshindernis des hinteren Volkmann-Dreiecks durch Interposition der Sehne des M. flexor digitorum longus.

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

[Cervical myelopathy after low grade distortion of the cervical spine. Possible association with pre-existing spondylosis of the cervical spine]. / Zervikale Myelopathie nach leichter HWS-Distorsion Grad 1. Möglicher Zusammenhang mit vorbestehender Spondylose der HWS.

A patient with spondylosis deformans of the cervical spine with no neurological deficits developed rapidly progressive tetraparesis 1 day after a whiplash injury due to a car accident (rear end collision), although initially there were no clinical symptoms. Surgical decompression and spondylodesis led to relief of the neurological deficits. This case demonstrates that even a low grade whiplash injury (grade 1) can cause severe neurological symptoms later and that a degenerative disease of the spine is a predisposing factor.

[Trauma bay haemoglobin level. Predictor of coagulation disorder in major trauma]. / Schockraumhämoglobin. Prädiktor für eine Gerinnungsstörung beim Traumapatienten.

BACKGROUND: Trauma-induced coagulopathy is common in patients with major trauma and requires early and appropriate treatment for bleeding control. Even in emergency laboratory, the availability of standard coagulation tests is associated with certain latencies and devices for viscoelastic haemostasis diagnosis (thromboelastometry) are not routinely established in major trauma centres. PURPOSE: We searched for a laboratory parameter with fast availability by point of care blood gas analysis and reliable correlation with coagulation parameters. METHODS: We analyzed the trauma patients of a single level one trauma centre from 2005-2011 and particularly evaluated the correlation between haemoglobin (Hb) and coagulation parameters and the correlation of Hb and parameters indicating tissue perfusion. All patients who were directly admitted from the scene of an accident to the trauma centre had an injury severity score (ISS) > 9, had a complete revised injury severity classification (RISC) and blood samples that were taken in the emergency department (ED) immediately after admission were included. Correlations were tested using the Pearson test (r) with a two-tailed significance level of p < 0.05. RESULTS: A total of 425 patients met inclusion criteria presenting with a mean age of 43 years, 76% male gender and mean ISS of 30.4. Significant correlation (p < 0.01) between Hb and prothrombin time (Quick) (r = 0.652), Hb and partial thromboplastin time (PTT) (r = - 0.434), Hb and platelet count (r = 0.501) and Hb and base excess (BE) (0.408) was found. No significant correlation between Hb and lactate was found. CONCLUSION: We found a robust correlation of Hb and Quick in a single centre trauma population. These data suggest that especially severely injured trauma patients with persistent bleeding might benefit from an Hb-based algorithm for early correction of coagulation disorders. Further studies with larger trauma populations are required to confirm our findings.

[Knee-related Pain Problems during Pregnancy Correlate with an Increase in Body Weight. Results of a Prospective Study]. / Knieschmerz im Verlauf der Schwangerschaft in Bezug zum Anstieg des Körpergewichts. Ergebnisse einer prospektiven Studie.

PURPOSE: This study aimed to evaluate the incidence of knee pain or the intensification of knee-related problems during pregnancy. We hypothesised that the occurrence of knee problems correlates with an increase in body weight during pregnancy. METHODS: A total of 326 women (30(th)-40(th) week of pregnancy) were involved in this study. At onset of the pregnancy, the patients were 29.4 [95% CI 28.8-29.9] years of age. We asked all patients retrospectively about their anthropometric data at the beginning of pregnancy. All patients provided information about former knee problems, knee problems occurring after onset of pregnancy or any increase in these problems. These knee patients were re-evaluated 6 weeks after childbirth. At follow-up, the patients were asked about their knee problems and about their body weight. RESULTS: At the beginning of pregnancy, the mean body weight was 68.0 kg (95% CI 64.4-69.6; range 41-117). The mean BMI of all patients was 24.5 kg/m² (25% CI 23.9-25.0; range 17.0-26.0). The absolute body weight increased by 13.8 kg (95% CI 13.2-1.5; range 3-38). A total of 24 patients (7.4%) reported new knee problems during pregnancy. 2 patients reported an increase in knee-related problems during pregnancy (0.6%). The incidence of knee-related problems (new cases and increase of problems n=26) was 26/326 or 7.6/100 pregnancies. In patients without knee problems, the pregnancy-related increase in the BMI (ΔBMI) was 4.8 kg/m² (95% CI 4.6-5.1, range 1.1-14.1). In cases with incident knee problems, the ΔBMI was 5.9 kg/m² (95% CI 4.9-6.9, range 2.1-11.8). The increase in body weight (Δbody weight) in patients without knee problems was 13.5 kg (95% CI 12.9-14.2, range 3-38). Patients with incident knee pain experienced a Δbody weight of 16.8 kg (95% CI 13.9-19.4, range 6-35). The differences in ΔBMI and Δbody weight were significant (p=0.009). A Δbody weight >20 kg was a significant risk factor for pregnancy-related knee pain significant risk factor pregnancy related pain. A total of 23 incident cases (92%) underwent a follow-up interview 6 weeks after parturition. At this time, a total of 6 patients (26.1%) had not experienced further knee problems, whereas persistent knee problems were reported in the remaining patients (73.9%). Patients without any knee complaints [body weight 72.5 kg (CI 95% 60.9-83.9)] tended to have a lower body weight at follow-up than patients with persistent knee pain [85.5 kg (CI 95% 71.8-99.1), p=0.162]. CONCLUSION: There is a body weight-associated increase in the incidence of functional knee pain in pregnant women. In about one-third of the cases, knee problems persist after pregnancy and are associated with a residual increase in body weight. Thus, we conclude that body weight is a potential risk factor for functional knee pain.

The innervation of synovium of human osteoarthritic joints in comparison with normal rat and sheep synovium.

OBJECTIVE: To study whether osteoarthritis (OA) in the knee is associated with a change of the innervation pattern in the synovial layer. DESIGN: In synovial tissue from the normal knee joint of rat and sheep we studied the presence of vessels and of nerve fibres using transmission electron microscopy and immunohistochemistry. Synovial material was also obtained from patients who underwent total knee replacement surgery. This material was examined for inflammatory changes, and the presence of vessels and nerve fibres was assessed. RESULTS: The synovium in the parapatellar region of the normal knee joint of rat and sheep exhibited a dense capillary and neuronal network. It was entered by calcitonin gene-related peptide containing sensory fibres and tyrosine hydroxylase-positive sympathetic nerve fibres. Synovial material from patients with knee OA exhibited different degrees of inflammation. Synovial material without inflammation exhibited a similar vascular and neuronal network as the normal knee joint from rat and sheep. However, in synovium with inflammatory changes we found a significant decrease of nerve fibres in depth ranges close to the synovial lining layer depending on the degree of inflammation whereas deeper regions were less affected. CONCLUSIONS: Inflammatory changes in the synovium of OA joints are associated with a massive destruction of the capillary and neuronal network which is present in normal synovium. Due to the disappearance of the sensory fibres it is unlikely that OA pain is initiated directly in the synovium. The loss of normally innervated vascularisation may have multiple consequences for the physiological functions of the synovium.

2D-fluoroscopic based navigation for Gamma 3 nail insertion versus conventional procedure- a feasibility study.

BACKGROUND: Intramedullary nailing is a standard surgical procedure for fixation of proximal femoral fractures, but is associated with considerable radiation exposure for controlling the implant placement, due to the percutaneous insertion technique.The aim of this study was the evaluation of potential benefits of 2D-fluoroscopic based navigation focused on the reduction of radiation exposure, a decrease of procedure time, as well as an increase of accuracy for Gamma3 nail insertions. METHODS: Twenty randomized Gamma3 nail insertions were performed in non-fractured synthetic femora according to the manufactures operation guidelines (group I) or with use of a 2D-fluoroscopic based navigation system (group II). Time of different steps of the procedure and the radiation exposure were measured, as well as the accuracy evaluated in postoperative CT scans. RESULTS AND DISCUSSION: All Gamma3 nails were placed without any technical problems. Independent of the used procedure, the overall operating time (group I: 584 ± 99.2 sec; group II: 662 ± 64.9 sec; p=0.06) and accuracy of the final nail-positions were equivalent, but the radiation exposure was significantly reduced (92% reduction in fluoroscopic images and 91% reduction in fluoroscopic time, p< 0.01), using the 2D fluoroscopic based navigation procedure. CONCLUSIONS: 2D-fluoroscopic based navigation for Gamma3 nail insertion facilitates a relevant reduction of radiation exposure with equivalent accuracy of the final implant position and no prolonged operating time. This promising procedure modification is independent of different cephalomedullary implant manufacturers and specific implant designs, but needs to be evaluated in further clinical settings.