3D C-arm navigated acromioclavicular joint stabilization.

INTRODUCTION: Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures. MATERIALS AND METHODS: The implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed. RESULTS: All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well. CONCLUSION: Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

Intraoperative 3D imaging in plate osteosynthesis of proximal humerus fractures.

INTRODUCTION: Proximal humerus fractures are common and often associated with osteoporosis in the elderly. Unfortunately, the complication and revision rate for joint-preserving surgical treatment using locking plate osteosynthesis is still high. Problems include insufficient fracture reduction and implant misplacement. Using conventional intraoperative two dimensional (2D) X-ray imaging control in only two planes, a completely error-free assessment is not possible. MATERIALS AND METHODS: The feasibility of intraoperative three-dimensional (3D) imaging control for locking plate osteosynthesis with screw tip cement augmentation of proximal humerus fractures was retrospectively studied in 14 cases with an isocentric mobile C-arm image intensifier set up parasagittal to the patients. RESULTS: The intraoperative digital volume tomography (DVT) scans were feasible in all cases and showed excellent image quality. One patient showed inadequate fracture reduction in the imaging control, which then could be corrected. In another patient, a protruding head screw was detected, which could be replaced before augmentation. Cement distribution in the humeral head was consistent around the screw tips with no leakage into the joint. CONCLUSION: This study shows that insufficient fracture reduction and implant misplacement can be easily and reliably detected by intraoperative DVT scan with an isocentric mobile C-arm set up in the usual parasagittal position to the patient.

Is new always better: comparison of the femoral neck system and the dynamic hip screw in the treatment of femoral neck fractures.

BACKGROUND: Hip fractures in the elderly population are common and the number of patients is rising. For young and geriatric patients with undisplaced fractures osteosynthesis is the primary type of treatment. The dynamic hip screw (DHS) is around for many years and proved its value especially in displaced fractures. Since 2018 the femoral neck system (FNS) is available as an alternative showing promising biomechanical results. The aim of this study is to evaluate clinical results of the FNS and compare it to the DHS. MATERIALS AND METHODS: Patients older than 18 years with Garden I-IV fractures that were treated with osteosynthesis in a level 1 trauma center were included in the study. Between January 2015 and March 2021, all patients treated with FNS (1-hole plate, DePuy-Synthes, Zuchwil, Switzerland) or DHS (2-hole plate, DePuy-Synthes, Zuchwil, Switzerland) for proximal femur fractures were included in the study. Closed reduction was achieved using a traction table. All operations were carried out by experienced orthopedic trauma surgeons. Primary outcome measures were rate of implant failure (cut out) and surgical complications (hematoma, infection). Secondary outcome measures were Hb-difference, length of hospital stay and mortality. RESULTS: Overall, 221 patients were included in the study. 113 were treated with FNS, 108 with DHS. Mean age was 69 ± 14 years. There were 17.2% Garden I, 47.5% Garden II, 26.7% Garden III and 8.6% Garden IV fractures. No difference between the groups for age, body mass index (BMI), Charlson comorbidity index (CCI), time to surgery, Pauwels and Garden classification, rate of optimal blade position or tip apex distance was found. FNS showed lower pre- to postoperative Hb-difference (1.4 ± 1.1 g/l vs. 2.1 ± 1.4 g/l; p < 0.05), shorter operating time (36.3 ± 11.6 min vs. 54.7 ± 17.4 min; p < 0.05) and hospital stay (8.8 ± 4.3 d vs. 11.2 ± 6.8 d; p < 0.05). Surgical complications (FNS 13.3% vs. DHS 18.4%, p > 0.05), rate of cut out (FNS 12.4% vs. DHS 10.2%, p > 0.05) and mortality (FNS 3.5%; DHS 0.9%; p > 0.05) showed no difference between the groups. Logistic regression showed that poor blade position was the only significant predictor for cut out and increased the risk by factor 7. Implant related infection (n = 3) and hematoma/seroma (n = 6) that needed revision was only seen in DHS group. CONCLUSION: FNS proved to be as reliable as DHS in all patients with hip fractures. Not the type of implant but blade positioning is still key to prevent implant failure. Still due to minimal invasive approach implant related infections and postoperative hematomas might have been prevented using the FNS.

Clinical performance of the Femoral Neck System within 1 year in 125 patients with acute femoral neck fractures, a prospective observational case series.

INTRODUCTION: Osteosynthesis of femoral neck fractures (FNFs) is an important treatment option, especially for younger patients. We aimed to assess the rate of early implant-related complications in FNF osteosynthesis using the Femoral Neck System (FNS). PATIENTS AND METHODS: Consecutive patients diagnosed with displaced or nondisplaced FNFs were treated with FNS in this prospective, observational, multicenter investigation. Patients were followed up for minimally 3 months and up to 12 months if radiologic bone union and no pain was not achieved beforehand. Predefined treatment-related adverse events (AEs, defined as implant failure, loss of reduction, iatrogenic fractures, deep infection, and surgical revision), radiologic bone union, and patient-reported Harris hip score (HHS) and EQ-5D-5L index score were assessed. RESULTS: One hundred and twenty-five patients were included in the study. Thirty-eight (30.4%) fractures were displaced (Garden III and IV), and 37 (29.6%) were vertical fractures (Pauwels type III). Predefined treatment-related AE rate at 3 months was 8 patients, 6.4% (95% CI, 2.8-12.2), and at 12 months, 11 patients, 8.8% (95% CI, 4.5-15.2). Cumulative incidences of bone union were 68% at 3 months, 90% at 6 months, and 98% at 12 months. The mean changes of HHS and EQ-5D-5L index score between preinjury and at 12 months were -7.5 (95% CI, [ - 21.1] to [6.2]) and - 0.03 (95% CI, [ - 0.21] to [0.15]), respectively; neither were statistically significant. CONCLUSION: The current study on osteosynthesis of FNFs with the FNS resulted in treatment-related complication rates of 6.4% (95% CI, 2.8-12.2) at 3 months and 8.8% (95% CI, 4.5-15.2) at 12 months. On average, patients returned to preinjury function and quality of life. The current study may also indicate that the conventional wisdom of treating stable FNF in patients aged between 60 and 80 years with osteosynthesis may need to be reconsidered. REGISTRATION: The study is registered with ClinicalTrials.gov (registration number: NCT02422355).

Analysis of partial weight bearing after surgical treatment in patients with injuries of the lower extremity.

INTRODUCTION: After surgical treatment of injuries of the lower extremity, partial weight bearing is often suggested until soft tissue consolidation. It is doubtful, if this recommendation can be implemented, even in the case that a patient is performing partial weight bearing with a physical therapist. Consequently the question remains, if patients are able to implement partial weight bearing after surgery and which factors favor incompliance. MATERIALS AND METHODS: 49 patients, who underwent surgical treatment after injuries of the lower extremity, were equipped with electronic shoe insoles on both sides. Different weight bearing instructions were given depending on the type of injury and surgery (full weight bearing vs. 20 kg weight bearing vs. non-weight bearing). Besides loading, other factors like age, gender, weight and physical activity were evaluated. Statistical analysis was performed using Chi-square and Fisher's exact test with significance set at a p value < 0.05. RESULTS: 25 of the 40 patients, who had to perform non- or partial weight bearing, were not able to follow postoperative instructions (compliance rate 37.5%). The average loading of the whole collective was 32.6 kg (4.8-109.2 kg). The specification of loading had no statistically significant influence on real loading (p-value 0.39). Elderly patients were less able to follow instructions than younger patients (36 vs 30.2 kg). Physically active compared to non-active patients overloaded their injured extremity (37.8 vs 28.7 kg). Patients with a high body mass index (BMI) encountered more difficulties to perform partial weight bearing than lightweight patients (36.9 vs 25.1 kg). CONCLUSIONS: Most patients were not able to follow loading limitation, even a few days after surgery and even if the patients were trained by a physiotherapist. Excessive weight bearing-related complications should be evaluated.

[Complications after intramedullary stabilization of clavicle fractures]. / Komplikationen nach intramedullärer Stabilisierung von Klavikulafrakturen.

BACKGROUND: Operative treatment of clavicle fractures by intramedullary nailing with titanium elastic nailing (TEN) has been established as an alternative to plate osteosynthesis for many years. The main complication after TEN osteosynthesis is nail migration. The goal of this study was evaluation of predictors for medial nail migration and comparison with plate osteosynthesis. MATERIAL AND METHODS: A retrospective analysis of electronic patient charts, surgical protocols and radiographs of all operatively treated clavicle shaft fractures between 2010-2014 (n = 141) was performed. When evaluating the patient charts and the surgical protocols special attention was paid to the fracture type, the duration of the operation, the need for an open reduction and the onset of complications as well as the duration until implant removal. Radiographs were analyzed concerning the implant location and an implant migration. RESULTS: Surgery time (39 vs. 83 min) as well as the time to implant removal (226 vs. 495 days) were significantly reduced (p = 0.00), while complication (39% vs. 21.4%) as well as reoperation rates (15% vs. 7.1%; p = 0.033) were increased in TEN compared to plate osteosynthesis. The main complication was medial nail migration. The following predictors regarding medial migration could be identified: open or closed reduction (p = 0.021), multifragmentary fractures (p = 0.049), oblique fractures (p = 0.08) and TEN thickness (33% at 2 mm, 0% at 3 mm). DISCUSSION: Advantages of TEN are a shorter surgery time as well as a shorter duration until implant removal. The TEN osteosynthesis led to a significantly increased complication rate, with nail migration representing the major reason. When predictors for medial TEN migration are considered, type B and C fractures can also be sufficiently treated by a large diameter TEN.

The Application of a Surgery Supporting Computer System Does Not Seem to Influence the Surgeons' Radiation Exposure: A Retrospective Analysis.

Since 2019, a surgery supporting system (SPM, surgical process manager; Johnson & Johnson, New Brunswick, New Jersey, Vereinigte Staaten) has been used in a Level I trauma center for common trauma surgery procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures). The hypothesis of this study was that implementing standardized procedures (by using SPM) may reduce radiation exposure, especially for unexperienced surgeons.Workflows were developed for different surgical procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures) and added into the SPM. Between October 2019 and June 2022, 90 surgeries using the SPM were included in the study. A control group was included with 107 surgeries using the same surgical technique. The values measured were the radiation exposure during the surgical procedure, the experience of the head surgeon, and whether or not the SPM was used. A statistical analysis was performed by using the chi square and Fischer exact tests, with significance set at a p value < 0.05.SPM was applicated in 51 cases for the distal radius (control group 54 patients), 20 cases for distal fibula fractures (control group 21 patients), 9 cases for the proximal femur (control group 19 patients), 5 cases for vertebral fractures (control group 7 patients), and 5 cases for the proximal humerus (control group 6 patients). No difference concerning the median radiation exposure was observed by plating distal radius fractures with 5.7 Gy/cm² in the SPM group and a median radiation exposure of 6.4 Gy/cm² in the control group (p = 0.96). The distal fibula fractures showed no significant difference in the intraoperative radiation (17.4 Gy/cm² vs. 6.4 Gy/cm², p value 0.53). Radiation exposure was lower when a consultant performed surgery without showing any significance, independent if SPM was used or not.In this study, no significant difference in the intraoperative radiation dose was observed when using a surgery supporting computer system. The experience of the surgeon showed no influence as well, regardless if SPM was used or not. Additional data should be collected questioning these findings.

3D C-arm navigated suture button implantation for AC joint dislocations - the pilot study.

PURPOSE: The surgical treatment of acute traumatic AC joint dislocations is still a subject of scientific debate in the literature. The arthroscopically assisted stabilization procedure with a suture button system has been successfully established and is widely used in daily practice. It is minimally invasive and allows the anatomical reconstruction of the torn coracoclavicular ligaments in one step with a permanent implant that does not have to be removed in a second operation. This clinical pilot study is the first to describe the new method of navigated suture button implantation with the future aim of further reducing surgical invasiveness and further increasing surgical precision. MATERIALS AND METHODS: 10 patients with a Rockwood 3b/5 injury could be included in the prospective study (DRKS00031855) within 5 months according to inclusion and exclusion criteria. Surgical stabilization was performed with a suture button system via a navigated coracoclavicular drill tunnel. Demographic and radiological data as well as information on health and shoulder function were collected from patient records, X-rays, DVT scan and 3 questionnaires (DASH, NHS and Eq. 5D) at the preoperative, intraoperative and postoperative (discharge, 6 weeks and 3 months) time points. RESULTS: All operations could be performed within 8.8 days (± 6.81) after trauma. The average operation time was 50.3 min (± 8.81). The mean distance of the drill hole in the clavicle to the AC joint was 26.6 mm (± 2.63). The radiologically measured vertical coracoclavicular distance was 38.8 mm (± 6.16) at discharge and 41.11 mm (± 7.51) at 3 months. This loss of reduction was not statistically significant. In contrast, the DASH, NHS and Eq. 5D results showed significant improvement from discharge to 3 months postoperatively. CONCLUSION: Image-guided 3D C-arm navigated AC joint suture button stabilization is feasible in everyday surgical practice. It may be possible to achieve a further reduction in invasiveness while at the same time increasing the accuracy of implant positioning. Further clinical studies with a larger number of patients and a longer follow-up period are necessary to enable a comparison with conventional methods.

Epidemiology, patterns, and mechanisms of pediatric trauma: a review of 12,508 patients.

BACKGROUND: Pediatric traumas are common and remain a unique challenge for trauma surgeons. Demographic data provide a crucial source of information to better understand mechanisms and patterns of injury. The aim of this study was to provide this information to improve treatment strategies of potentially preventable morbidity and mortality in children. MATERIAL AND METHODS: A retrospective review of every pediatric trauma treated in the emergency department (ED) between 2015 and 2019 was performed. Inclusion criteria were the age between 0 and 14 years and admission to the ED after trauma. Demographic data, time of presentation, mechanism of injury and pattern of injury, treatment, and outcome were analyzed. Different injury patterns were assessed in relation to age group, sex, mechanism of injury and treatment. RESULTS: A total of 12,508 patients were included in this study. All patients were stratified into five age groups: babies under the age of 1 (8.8%), toddlers between 1 and 3 (16.8%), preschool children between 4 and 6 (19.3%), young school children between 7 and 10 (27.1%), and young adolescents between 11 and 14 (27.9%). The predominant sex in all age groups was male. 47.7% of patients were admitted between 4 and 10 pm; 14.8% of the patients arrived between 10 pm and 8 am. Peak months of admissions were May to July. Overall, 2703 fractures, 2924 lacerations and superficial tissue injury, 5151 bruises, 320 joint dislocations, 1284 distortions, 76 burns, and 50 other injuries were treated. Most common mechanisms for fractures were leisure activities, falls, and sports-related activities. Forearm fractures were the most common fractures (39.5%) followed by humerus fractures (14%) and fractures of the hand (12.5%). A total of 700 patients with fractures (25.9%) needed surgery. 8.8% of all patients were hospitalized for at least one day. 4 patients died in the hospital (0.03%). CONCLUSION: Despite of higher risk, severe injuries in children are rare. Minor injuries and single fractures are common. Treatment should be managed in specialized centers to ensure an interdisciplinary care and fast recovery. Peak times in the late afternoon and evening and summer months should be taken into consideration of personnel planning.

Blade Augmentation in Nailing Proximal Femur Fractures-An Advantage despite Higher Costs?

BACKGROUND: Proximal femoral fractures occur with increasing incidence, especially in the elderly. Commonly used implants for surgical treatment are cephalomedullary nails. To increase stability, a perforated femoral neck blade can be augmented with cement. The study investigated whether this results in a relevant clinical advantage and justifies the higher cost. MATERIALS AND METHODS: This is a single-center retrospective study of 620 patients with proximal femur fractures treated with cephalomedullary nailing. Between January 2016 and December 2020, 207 male and 413 female patients were surgically treated with a proximal femur nail (DePuy Synthes) using a perforated blade and cement augmentation in cases with severe osteoporosis. Primary outcome measures were the rate of cut-out, tip apex distance and the positioning of the blade in the femoral head. Secondary outcome measures were the implant costs and operating times. RESULTS: Of the 620 femoral neck blades, 299 were augmented with cement. A total of six cut-outs were seen in the first 3 months after the operation. There were three in the cement-augmented group (CAB = cement-augmented blade) and three in the conventional group (NCAB = non-cement-augmented blade). There was a significant positive correlation between age and augmentation, with a mean difference of 11 years between the two groups (CAB 85.7 ± 7.9 vs. NCAB 75.3 ± 15.1; p < 0.05). There was no difference in the tip-apex distance (CAB 15.97 vs. 15.69; p = 0.64) or rate of optimal blade positions between the groups (CAB 81.6% vs. NCAB 83.2%; p = 0.341). Operation times were significantly longer in the cemented group (CAB 62.6 21.2 min vs. NCAB 54.1 7.7 min; p < 0.05), and the implant cost nearly doubled due to augmentation. CONCLUSION: When the principles of anatomic fracture reduction, optimal tip-apex distance and optimal blade position are combined with cement augmentation in cases of severe osteoporosis, a cut-out rate of less than 1% can be achieved. Nevertheless, it should be noted that augmentation remains expensive and prolongs surgery time without definite proof of mechanical superiority.

First experiences with a surgery supporting computer system in regard to education, efficiency and complications.

Purpose: Since October 2019 a computer software named SPM (surgical process manager) is used in a Level I Trauma center. Workflows were developed for distinct surgical procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures and vertebral fractures). In addition, these workflows were separated in a shortened "Expert"-versions for consultants and a more detailed "Learner"- versions for residents.This investigation was intended to show, if and what kind of benefits in regard to efficiency (incision to suture and suture to incision time), education and complications a surgery supporting software can bring. Methods: SPM was used in 90 cases during October 2019 to June 2022. A control trial with 108 patients was developed, including patients of the same age, having same kind of injuries, receiving the same surgery technique without using the SPM.The software was installed on the computer in the operation room, projected on head monitors and operated by a foot pedal. Complications could also be documented using the pedal.Groups were divided in surgical procedures and fracture type, qualification of the surgeon, complications and surgery time. Surgery times were taken from the hospital computer system (SAP IS-H). A statistical analysis was performed by using the chi square and Fischer exact test with significance set at a P value <0.05. Results: In 51 cases the software was used for the distal radius (control group 54 patients), in 20 cases for Weber fractures (control group 21 patients), in 9 cases for the proximal femur (control group 19 patients), in 5 cases for vertebral fractures (control group 7 patients) and in 5 cases for the proximal humerus (control group 6 patients).Time from incision to closure was significant higher in the intervention group (49 vs 42 min, p- value 0,018) and wasn't significant lower in the "expert" group, fixing radius and ancle fractures (39 to 46 min, p value 0,186).Comparing the SPM and control group concerning closing to incision time, no difference could be observed (56 to 58,5 min, p value 0,828).The greatest time deviation between "Learners"und "Experts"was observed in reduction and fixation (p value 0,006) in ankle fractures. The "Expert"group also needed less time for the approach (p value 0,008) in case of distal radius fractures.Unexpected events were more often observed in the intervention group (5,5 vs 3,7 %). Conclusions: A surgery supporting computer system might be a good tool for detecting and optimizing workflows in the operation room and for improving and analyzing the training of residents and surgical assistants.In addition, it offers the opportunity to document intraoperative complications. However, a saving of time wasn't observed in this study. Further investigations with bigger number of cases and a longer follow-up are necessary to proof these findings statistically.

Influence of Weight Bearing on Postoperative Complications after Surgical Treatment of the Lower Extremity.

PURPOSE: In order to prevent implant failure and secondary fracture dislocation, it is often recommended that patients perform partial weight-bearing after surgery of the lower extremity. Previous examinations showed that patients are often not able to follow these instructions. In this study, patients who had undergone surgery of the lower extremity were studied in order to analyze whether incorrect loading influenced the number and severity of complications. METHODS: Fifty-one patients were equipped with electronic shoe insoles, which measure loading and other parameters. The measurement period was 24 to 102 hours. Median duration of follow-up was 490 days. The primary outcome parameter was postoperative complications leading to revision surgery. Statistical analysis was performed using the chi-square and Fisher exact tests with significance set at a p < 0.05. RESULTS: Seven out of fifty-one patients had postoperative complications. Four wound complications, one implant failure, chronic instability after fracture of the tibia, and one implant loosening of a hip prosthesis were recorded. In total, 26 of 39 patients were not able to follow the postoperative instructions. Five of the twenty-six patients with difficulties in partial weight-bearing suffered a postoperative complication. In comparison, only 2 of the other 25 patients were affected. There was no statistically significant correlation between high weight-bearing and occurrence of complications (p = 0.29). CONCLUSION: Most of the patients were unable to follow the surgeon's instructions for partial weight-bearing. Excessive loading did not seem to influence the number and severity of postoperative complications, especially regarding implant failure. Therefore, we should continue with measurements and reevaluate the "partial weight-bearing doctrine".

The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome.

PURPOSE: To assess long-term clinical and oncological outcome in women undergoing radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer. METHODS: From 1995 to 2010, a total of 121 women with clinically organ-confined urothelial carcinoma underwent radical cystectomy with an orthotopic ileal neobladder. Median follow-up was 56 months. Clinical course, functional, pathological, and oncological outcome of these women were analyzed. RESULTS: Seventy-six patients (62.8%) experienced a complication of some type within 90 days of the procedure. 56 patients (46.3%) experienced minor complications, whereas 20 patients (16.5%) experienced major complications. Pathological subgroups included 70 patients (57.9%) with organ confined, lymph node-negative tumors, 24 (19.8%) with extravesical, lymph node-negative disease and 27 (22.3%) patients with lymph node-positive disease. The 5-year overall survival rate in patients with organ-confined (≤pT2, pN0), locally advanced (≥pT3, pN0), and metastatic disease was 80.2%, 81.9%, and 45.1%, respectively. 4 women (3.3%) experienced a local (pelvic) recurrence. One patient presented with a urethral recurrence (0.8%). Daytime and nighttime urinary continence (0-1 pad) was reported by 82.4 and 76.5%, respectively. Clean intermittent self-catheterization was required by 58.0%. The retrospective study design was the major limitation of the study. CONCLUSIONS: Despite a considerable complication rate, radical cystectomy with orthotopic diversion in female patients with bladder cancer may be considered a standard therapeutic option for selected patients with excellent oncological outcome including a low incidence of local and urethral recurrence.

How Safe and Time Consuming is the Surgical Training of Young Orthopaedic Surgeons? A Retrospective Analysis of Proximal Femur Fractures. / Wie sicher und zeitintensiv ist die operative Ausbildung in der Orthopädie und Unfallchirurgie ­ eine Auswertung von Ausbildungseingriffen am proximalen Femur.

BACKGROUND: Fractures of the proximal femur in the elderly population are rising. Teaching the appropriate surgical treatment of these fractures is of paramount importance. The aim of the study was to evaluate differences in outcome of surgical procedures between supervised trainees and senior surgeons. OBJECTIVE: Are there more surgical complications, poorer quality or an increased operating time if the procedure (in this case: fixation of proximal femur fractures) is performed by trainees under supervision in comparison to experienced surgeons. MATERIAL AND METHODS: All patients treated with the proximal femur nail antirotation (PFNA) between 2015 and 2016 at a level one trauma centre were included in this study. The retrospective review of the 299 patients compared supervised surgical trainees and senior surgeons. Parameters included operating time, tip apex distance, position of the blade, Hb-difference, transfusion rate, surgical complications as well as mortality, and were compared between the groups. RESULTS: 153 of 299 procedures were performed by supervised surgical trainees. In comparison to senior surgeons, there was no significant difference in operating time (WA 54.48 min; OA 60.47 min; p > 0,05), Hb-difference (WA 2.8 g/dl; OA 2.6 g/dl; p > 0.05), tip-apex distance (WA 21.2 mm; OA 20.5 mm, p = 0.37) or rate of surgical complications. There was no difference in the rate of optimal blade positions between the groups (WA 87.5%; OA 89.0%; p = 0.366). Furthermore, mortality showed no difference between the groups, but was greater in older patients or high ASA grade. CONCLUSION: Supervised surgical training during treatment of proximal femur fractures shows no increase in operating time, complications or mortality and no difference in quality. With the fast growth of the elderly population, surgical training of fragility fractures should receive more attention in the future.

No Excess Mortality in Geriatric Patients With Femoral Neck Fractures Due to Shorter Intensive Care Caused by COVID-19.

Background Since March 2020, increasing numbers of hospitalized patients with coronavirus disease-2019 (COVID-19) infections have been registered. The first and the second waves necessitated the extensive restructuring of hospital infrastructure with prioritization of intensive care capacity. Elective surgeries in all surgical disciplines were postponed to preserve intensive care capacity for COVID-19 patients. However, emergency care for trauma patients had to be maintained. Especially, geriatric patients with hip fractures often require intensive care. This study sought to investigate the possible excess mortality of geriatric patients with femoral neck fractures due to shorter intensive care unit stays because of COVID-19. Material and methods All patients over the age of 70 between March 2019 and February 2020 who underwent surgical treatment for femoral neck fractures were included. This cohort (group 1) was compared with all patients over 70 who received surgical treatment for hip fractures during the period of the pandemic between March 2020 and February 2021 with attention to potential excess mortality due to low intensive care capacity (group 2). Demographic data, American Society of Anesthesiologists (ASA) score, surgical modality, ICU stay, complications, and mortality were analyzed and compared. Results A total of 356 patients with 178 in each cohort with a mean age of 82.7 in group 1 and 84.8 in group 2 (p<0.05) were included. No significant difference was seen in sex and ASA scores. During the pandemic, patients with hip fractures had a significantly shorter stay in ICU (0.4 ± 0.9 vs 1.2 ± 2.8 days; p<0.05), shorter time to surgery (29.9 ± 8.2 vs 16.8 ± 5.3 h; p<0.05) and operations were significantly more often performed out-of-hour (4 pm-12 am 47.8% vs 56.7%; 12 am-8 am 7.9% vs 13.5%, p<0.05). Interestingly, mortality was lower during the pandemic, but the difference did not reach significance (6.7% vs 12.4%, p=0.102). Conclusion During the pandemic, ICU capacity was reserved for COVID patients. Due to a change in the law of the Joint Federal Committee with effect from January 1, 2021, all patients with proximal femur fractures had to be operated on within the first 24 hours, which is why a significantly shorter time to surgery was observed during the pandemic period. As a consequence, a lower mortality rate was observed, although no significance could be reached.

ESIN in femur fractures in children under 3: is it safe?

BACKGROUND: Pediatric femur fractures are a major trauma in children. Different treatment algorithms have been developed but indications for surgical treatment, especially in very young patients, are still controversial. Literature recommends surgical stabilization with elastic-stable intramedullary nailing (ESIN) starting at the age of 3 and non-operative treatment in younger patients. This study sought to present the outcome of patients younger than 3 years of age treated with ESIN for femur fractures. MATERIALS AND METHODS: Inclusion criteria were patients younger than 3 treated with ESIN in femur fractures. Patient demographics, fracture characteristics, mechanism of injury, outcomes and complications were recorded using charts and X-rays. Primary outcome measures were time to mobility, fracture consolidation and surgical-related complications. RESULTS: Between 2010 and 2020, 159 patients were treated with ESIN in femur fractures in our institution. A total of 30 patients met the criteria. The mean age was 2.1 ± 0.7 years (13 months-2.9 years). Most common mechanism was fall from standing height (60%). Other mechanisms were motor vehicle accidents as a pedestrian (10%) or as a passenger (10%) as well as direct blow trauma (20%). Femoral shaft fracture was the most common injury (80%). 5 subtrochanteric and one distal metaphyseal femur fractures were found. Mean length of stay was 2.0 ± 1.3 days. Radiographic controls were performed on day 1, 14 and 6 weeks after surgery if not otherwise specified or if complications occurred. 4.6 ± 1.2 (n 2-7) X-rays were performed on average after surgery. First radiographic consolidation signs were seen after 2.4 ± 0.6 weeks. Only one child showed surgical-related complication with a leg length discrepancy of 1 cm. In 10% of the patients, shortening after surgery of 1.7 ± 1.4 mm (0.3-3.1 mm) occurred. One child initially treated with traction therapy showed skin irritations and was operated with ESIN. No non-union or ESIN-related complications were found. Mean follow-up was 5.1 ± 4.4 months (4-24 months). First independent mobilization was seen at an average of 3.4 ± 1.1 weeks (2-6 weeks) after surgery. Implant removal was performed after 3.2 ± 1.3 months (2-8 months). No refracture after implant removal occurred. CONCLUSION: Early results with ESIN show a reasonable and safe treatment option for femur fractures in toddlers and young children under the age of 3 with easy postoperative care, fast fracture union and early independent mobilization.

Geriatric patients with dementia show increased mortality and lack of functional recovery after hip fracture treated with hemiprosthesis.

PURPOSE: Operative timing, perioperative management and postoperative rehabilitation are rising challenges in orthopedic geriatric trauma. The aim of this study was to determine the outcome of patients with dementia or with a high number of comorbidities treated with hemiprosthesis after hip fracture. Literature regarding patients with high comorbidities is scarce, leaving nothing but endoprosthetic treatment for even the sickest, immobile patients. METHODS: A retrospective chart review of 326 patients (mean age 81 ± 9 years; 230 women and 96 men) with hip fractures treated between 2012 and 2017 with a hemiprosthesis was performed. Primary outcome measures were surgical and nonsurgical complication rates, best achievable mobilisation during the hospital stay and mortality. RESULTS: Patients with dementia had 20-fold increased risk to be bedridden after surgery and ninefold increased risk of dying (p < 0.005). Furthermore, they needed significantly more revision surgeries because of surgical complications. Patients classified ASA IV and V had significantly lower postoperative mobilization levels with only 10% able to walk with crutches and 53% bedridden. They also had significantly more non-surgical complications while dementia had no effect on non-surgical complication rate. CONCLUSION: Patients classified ASA IV and V or suffering dementia show poor outcome after hip fracture treated with hemiprosthesis. Multidisciplinary approaches including surgeons, geriatricians, physiotherapists and psychiatrists are needed to improve the outcome of these patients. Especially in a subgroup of patients, where no mobilization is expected, alternative treatment options may be considered.

[Surgical treatment strategies and their radiological potential for correction of proximal radius fractures in children and adolescents]. / Operative Versorgungsstrategien und deren radiologisches Korrekturpotenzial bei proximalen Radiusfrakturen des Kindes und Jugendlichen.

BACKGROUND AND OBJECTIVE: The isolated proximal radius fracture in children is a quite rare injury. In difference to adults a conservative treatment is often possible. But in case of increasing dislocation the indication for surgery is given. Options for an operative treatment are "closed reduction", "percutaneous reduction", "intramedullary nailing", "open reduction" with and without fixation. Aim of this study is to compare these procedures with each other. STUDY DESIGN AND METHODS: This was a retrospective investigation and 82 patients who underwent surgery after an isolated proximal radius fracture were included. Fracture types were classified according to the AO (working group for osteosynthesis questions)/OTA (Orthopedic Trauma Association) classification. The preoperative and postoperative degrees of axis deviation were compared and were considered to be a measure of the quality of treatment. RESULTS: The lowest degree of axis deviation resulted by open reduction and implantation of K­wires (15,8°) and implantation of headless compression screws (HCS, 16°). Closed reduction without any fixation resulted in 19°, with implantation of an TEN (titan elastic nail) in 20° and the open reduction without any fixation resulted in 21° of axis deviation. No correlation was observed concerning the fracture type and the postoperative axis deviation. CONCLUSION: The study shows that the postoperative result does not depend on the fracture type (according to the AO/OTA classification) but on the surgical procedure. Despite the good radiological results in open reduction and internal fixation this procedure should be reserved for difficult situations in which less invasive surgical procedures fail, to avoid aseptic bone necrosis.

Radial vs. Dorsal Approach for Elastic Stable Internal Nailing in Pediatric Radius Fractures-A 10 Year Review.

BACKGROUND: Forearm fractures are one of the most common fractures in children. Over the last years, a tendency towards surgical treatment was seen, especially closed reduction and internal fixation with elastic stable internal nailing (ESIN). Despite an overall low complication rate being described, a risk of intraoperative complications remains. MATERIAL AND METHODS: A total of 237 patients (mean age 8.3 ± 3.4 (1-16) years) with forearm or radius fractures treated with ESIN between 2010 and 2020 were included in the study. The retrospective review of 245 focused on fracture pattern, pre- and postoperative fracture angulation, intra- and postoperative complications, and surgical approach for nail implant. The fracture pattern and pre- and postoperative angulation were measured radiographically. Complications such as ruptures of the extensor pollicis longus (EPL) tendon and sensibility disorders of the superficial radial nerve were further analyzed. RESULTS: In 201 cases (82%), we performed a dorsal approach; 44 fractures (17.9%) were treated with a radial approach. In total, we found 25 (10%) surgery-related complications, of which 21 (8.6%) needed further surgical treatment. In total, we had 14 EPL ruptures (5.7%), 4 sensibility disorders of the superficial radial nerve (1.6%), 2 refractures after implant removal (0.8%), 2 superficial wound infections (0.8%), and 1 child with limited range of motion after surgery (0.4%). No statistical significance between pre- and postoperative angulation correlated to fracture patterns or diameter of the elastic nail was seen. As expected, there was a significant improvement of postoperative angulation. Using radial approach in distal radial fractures showed a lower rate of surgical related complications, 2.3% of which need further surgical treatment as well as better postoperative angulations compared to the dorsal approach (8.5%). CONCLUSION: Especially due to the low risk of damaging the EPL tendon, the radial approach showed a lower complication rate which needed further surgical treatment. The risk of lesions of the superficial radial nerve remains.

Short-term outcome of fragility fractures of the pelvis in the elderly treated with screw osteosynthesis and external fixator.

BACKGROUND: The treatment of fragility fractures of the pelvis is rising challenge for orthopedic trauma surgeons. Operative treatment should allow immediate full weight bearing and early mobilisation but should also be as minimal invasive as possible. Sacroiliac (SI) or transsacral transiliac screws (TSTI) alone or depending on the fracture in combination with an external fixator meets both of these criteria. MATERIAL AND METHODS: The outcome of 121 operatively treated patients with fragility fractures of the pelvis were evaluated in this retrospective study. Depending on the type of fracture the patients were treated with navigated SI screw or TSTI screw alone or in combination with an external fixator. All patients were operated in supine position in a hybrid-OR, which consists of a fixed robotic 3D flatpanel detector (Artis zeego, Siemens Healthineers, Germany) and a navigation system (BrainLab Curve, BrainLab, Germany). RESULTS: 37 patients were treated with either one or two SI screws and 57 with one TSTI screw. An additional external fixator was combined with SI screws in 17 patients and with TSTI screws in 10 patients. The preoperative pain score was significantly higher compared to the postoperative score (5.1 ± 2.5 vs 2.2 ± 1.9, p < 0.05). Follow-up at 6 month was possible for 106 patients which showed screw loosening in 16.3% of the SI Screws (n = 49) compared to only 5.2% of TSTI screws (n = 57). No screw loosening was seen in the combination of TSTI-screw and external fixator (n = 10). There were two septic and three aseptic pin loosenings of the external fixator. Overall only one patient needed revision surgery due to screw loosening and local irritation. Overall 75.2% (n = 91) of the patients could be released in their home or in a rehabilitation unit and only 14% (n = 17) were released to a nursing home due to immobility despite the operation. Non-surgical complications rate was 21.5%. CONCLUSION: SI or TSTI screws with possible combination with an external fixator show early pain relief and allows most of the patients to keep their former level of independence. With an also low surgical complication rate, it proved to be a safe and reliable treatment for fragility fractures of the pelvis. Due the effective pain relief and the minimal invasive approach, early mobilisation is possible and might prevent typical non-surgical complications which are very common during conservative treatment.