Comparison of kyphoplasty with use of a calcium phosphate cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures.

One of the current standard treatment options for younger patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improved physical function. The purpose of this prospective study was to clarify whether patients with acute traumatic vertebral fractures benefit more from kyphoplasty or from conservative treatment with a brace. A prospective study was undertaken in two centers. Forty patients with acute painful traumatic vertebral body fractures type A1-A3 (AO-classification) after adequate trauma, without osteoporosis, suitable for kyphoplasty or therapy by brace were included into the study. Follow-up was 12 months. Patients of the kyphoplasty group showed an immediate beneficial and significant effect postoperatively, and better outcomes 1 and 3 months after operation compared to the conservatively treated group in pain feeling, mobility and vertebral body height. After 12 months the difference between both groups was not significant excepting the vertebral body height. Kyphoplasty provides early and lasting reduction of pain and improvement of daily activity. However, there are clinically asymptomatic cement leakages in up to 45% of which we do not know the consequences in long term. Every patient with traumatic vertebral body fracture treated by kyphoplasty has to be informed about that. Long-time results are outstanding and our findings require confirmation by randomized controlled trials.

Transarterial embolization of primary and secondary tumors of the skeletal system.

Percutaneous transcatheteral embolizations of primary and secondary bone tumors are important minimal invasive angiographic interventions of the skeletal system. In most of the cases embolization is performed for preoperative devascularization or as a palliative measure to treat tumor-associated pain or other tumor bulk symptoms. The transarterial embolization of primary and secondary tumors of the skeletal system has been developed to a safe and very effective method. Indications, techniques, results and complications of this minimal invasive interventional therapy for treatment of primary and secondary bone tumors are described and discussed and compared with the newer literature and our own results.

Open reduction and palmar plate-osteosynthesis in combination with a nanocrystalline hydroxyapatite spacer in the treatment of comminuted fractures of the distal radius.

In a prospective study, we used the nanocrystalline hydroxyapatite paste Ostim (Osartis, Obernburg, Germany) in combination with a palmar plate to treat comminuted radius fractures with a metaphyseal and articular component in order to examine the clinical use of Ostim as a bone substitute. Twenty-one patients with 22 radius fractures of AO types C2 and C3 were included in the study. The measurements, taken 10.2+/-1.3 months after the initial treatment, revealed a dorsopalmar tilt of 8.8+/-3.7 degrees , a radioulnar inclination of 18.8+/-2.8 degrees and an ulnar variance of 0.8+/-1.8mm. According to the Gartland and Werley evaluation, eight of the treated fractures attained an excellent, 11 a good and the remaining three a fair result. The study demonstrates that Ostim, in combination with angularly stable osteosynthesis, can be used as an acceptable bone substitute for the treatment of type C2 and C3 radial fractures.

Problems and costs associated with alcohol and drug abuse in emergency medicine.

Preclinical care refers to patients with life-threatening conditions. It remains unclear how alcohol and drug abuse contribute to the frequency and severity of emergency cases. This study evaluated the influence of these psychotropic substances on preclinical emergencies and the social security costs arising from this. The records of 400 emergency patients were analyzed prospectively regarding type and severity of emergency, intake of psychotropic substances before the emergency, and their influence on patients' outcome. Psychotropics were detected in 19% of patients; 84% of these patients (vs. 55% overall) were scored below 4 (not life threatening) on the National Advisory Committee for Aeronautics scale and therefore did not require a physician on-site. Alcohol or drug intake frequently causes emergencies with physicians on-site; retrospectively 84% of these interventions were thus found to be unnecessary, caused by difficulties in recognizing the severity of the disorder, especially in mental or respiratory disorders. Extrapolated to Germany overall this means 675,000 drug-related emergencies yearly, costing euro 310,000,000.

[Evaluation of tibial torsion--comparison of clinical methods and computed tomography]. / Bestimmung der Tibiatorsion--Vergleich von klinischen Winkelmessungen zur Computertomographie.

PURPOSE: To determine variability between clinical goniometric methods and computed tomography (CT) in measuring posttraumatic malrotation of the tibia. MATERIALS AND METHODS: In a prospective study, absolute tibial torsion of both legs after unilateral fracture of the tibia as well as the difference between both legs (intra-individual torsional difference) was postoperatively determined with two goniometric and two CT methods in 40 patients (female : male = 16 : 24, mean age = 46 +/- 34 years). RESULTS: The mean difference between goniometric and CT methods in determining intra-individual torsional difference was not significant. Nevertheless, variance of values was higher in goniometric measurement (up to +/- 11 degree), with the measurements of torsional difference showing two times greater standard deviation in interobserver variability of goniometric methods as compared to CT. CONCLUSION: Goniometric methods do not significantly differ from the CT methods for determination of intraindividual torsional difference. The higher variance of interobserver values limits accuracy of goniometric methods. Therefore, goniometric determination of tibial torsion can only be considered an estimate but not a precise measurement.

[Subsequent fractures of the femur shaft. Classification, etiology and treatment--a retrospective study]. / Folgefrakturen des Femurschaftes. Einteilung, Ursachen und Behandlung--Ein retrospektive Studie.

Refractures of the femur frequently occur after open fractures or following an infection. There has to be distinguished between aseptic and septic refractures. Both forms have in common dystrophy as a favoring factor at the time point of refracture. Traumatizing means of osteosynthesis, missing soft tissue protection and lack of medial support after internal fixation are the main factors concerning the development of refractures. In case of aseptic refractures of the femur we propose intramedullary nailing if possible independent of the method of primary osteosynthesis. In case of septic refractures infect repair comes first. Besides internal fixation, autogenous cancellous or cortico-cancellous bone graft and plastic soft tissue repair are of most importance. We propose the following procedure for fractures of the femur with severe soft tissue damage: Primary fixation with fixateur externe, after soft tissue repair electively intramedullary nailing or internal fixation, in case of missing medial support combined with autogenous cancellous or cortico-cancellous bone graft. This procedure showed a rate of 0.9% of refractures after primary operative treatment of 2073 fractures of the femur at the Berufsgenossenschaftliche Unfallklinik Tübingen.

[Results of "expanded" arthrolysis of the knee joint]. / Ergebnisse "erweiterter" Kniegelenksarthrolysen.

This report shows the results of 20 patients, suffering on severe knee stiffness, who were treated between 1980-1989 at the Berufsgenossenschaftliche Unfallklinik in Tübingen with an expanded knee arthrolysis. The knee stiffness of all patients was caused by trauma (65% polytrauma) or infection. More than 2/3 of the patients (70%) had a preoperative degree of motion which was less than 60 degrees. In average 9 months after the initial trauma the expanded knee arthrolysis was performed. The arthrolysis was in most of the cases (n = 15) combined with a supracondylar correction osteotomy. The average preoperative range of motion from (ext./flex.) 0-15-62 degrees has postoperatively been increased to (ext./flex.) 0-5-92 degrees which corresponds to a relative improvement of motion of 43%. Eleven patients showed good or fair results. The prognosis of knee stiffness is influenced by the etiology, the pre-operative loss of motion and the period of time between initial trauma and arthrolysis, and as well by the intraoperatively achieved range of motion and the post-operative application of continuous passive motion. The expanded arthrolysis of the knee is a usefull instrument in the therapy of severe posttraumatic knee stiffness.

[Trans-scaphoid perilunar dislocation of the wrist (de Quervain) as a rare complication of electric injury]. / Die transscaphoidale perilunäre Luxation der Handwurzel (de Quervain) als seltene Komplikation einer Stromverletzung.

We describe the case of a 67-year-old man with an electricity inflicted injury in the left hand and a transscaphoidal perilunear dislocation of the opposite right hand. On admission, the injury was missed on the standard ap-radiogram of the right hand, so the operative reconstruction was delayed. Later on, the lunate showed aseptic necrosis and wrist collapse as consequence.

[Arthrolysis as a surgical treatment concept of post-traumatic stiffness of the knee joint]. / Die Arthrolyse als operatives Behandlungskonzept der posttraumatischen Kniegelenksteifen.

In the period from 1977 to 1989 105 arthrolyses were performed in 102 patients. There were mainly posttraumatic fibroarthroses: 51 consecutive to fractures, 39 after ligamentous injuries, 13 post-infectious of which 11 were also post-traumatic and only 2 patients with rheumatological diseases. Remarkable is the increased number of fibroarthrosis after polytrauma (n = 26). The preoperative range of motion was under 30 degrees in 26 patients and 48 patients had a severely limited range of motions between 30 and 60 degrees. The follow-up examination performed in an average of 2 years after the operative mobilization showed that the initial mobility was more than doubled. These results are related to atiology, operative procedure and degree of severity of the preoperative stiffness. Fair to excellent results were obtained in almost 3/4 of the patients. We explain these results by an adapted extraarticular or combined procedure which were used in 63 cases. The open release is backed by an intensive rehabilitation program in which painlessness through PDA and an immediate postoperative continuous passive motion are of most importance.

[Suture of fresh Achilles tendon rupture. Comparison of open with percutaneous suture technique]. / Die Naht der frischen Achillessehnenruptur. Vergleich der offenen mit einer perkutanen Nahttechnik.

INTRODUCTION: The open repair of the acute Achilles' tendon rupture reduces the incidence of rerupture compared with nonsurgical treatment; however, it yields more surgical complications. Early mobilization of the patients improves the postoperative outcome. Percutaneous suture techniques have a low incidence of rerupture and improve the conditions for early mobilization. METHODS: This study includes all patients (n = 97) with acute subcutaneous rupture of the Achilles' tendon with surgical treatment at the University of Heidelberg from 1992 to 1999. Open surgical repair and postoperative immobilization has been compared with a percutaneous suture technique and postoperative early mobilization. Altogether, 77 patients (80%) have been interviewed and 62 patients (65%) have undergone a clinical examination. RESULTS: There were local complications in 18% of the patients after open repair (n = 49) compared with 6% of the patients after percutaneous suture. In both groups there were two patients (4%) who sustained a rerupture. In the control group there were two patients with deep vein thrombosis (4%) and 1 lung embolism (2%). The clinical examination revealed no difference between open and percutaneous repair except for some disturbances in sensitivity of the sural nerve after percutaneous repair. The lower expenditure of therapy in percutaneous versus open sutures show the comparison of the hospitalization rates (29% versus 88%) and the rates of endotracheal anesthesia (53% versus 90%). CONCLUSION: Percutaneous suture technique for the repair of the Achilles' tendon is a simple and safe surgical procedure which allows early mobilization with a low rerupture rate. Thus this method should be performed as standard procedure for acute subcutaneous rupture of the Achilles' tendon.

[The pre-positioned intracutaneous suture--a method for treatment of soft tissue defects after fascia splitting in acute compartment syndrome]. / Die vorgelegte Intracutannaht--eine Methode zur Behandlung von Weichteildefekten nach Fascienspaltung beim akuten Compartmentsyndrom.

In the treatment of the acute compartment syndrome open fasciotomy gives rise to a wide soft tissue opening. The persistence of this opening prevents a timely change to internal osteosynthesis in case of additional fractures usually treated by a fixateur externe. Closure of the skin defect itself requires additional surgery. The cosmetical results particular in cases of a mesh-grafting are unsatisfactory. After open fasciotomy the prepositioned intracutaneous suture is a simple operation technique leading to early wound closure with a good cosmetical result.

[Pigmented villonodular synovitis. Case reports and review of the literature]. / Pigmentierte villonoduläre Synovitis. Kasuistiken und Literaturüberblick.

Because this disease is so rare the optimum treatment of pigmented villonodular synovitis (PVNS), in particular the diffuse form differs in the literature. The most important surgical procedures are arthroscopic and open synovectomy. The prevention of disease progression, as well as joint destruction and dysfunction, depends upon the early diagnosis of PVNS. During 1994 and 1995, we treated four cases of PVNS surgically and followed the patients for a time period of more than 12 months. Two patients were treated with complete synovectomy, one patient underwent partial synovial resection, and in the final case an arthrodesis was performed. Our results indicate that an MRI is essential for diagnosis and treatment planning. For the localized form of PVNS, it appears that a partial synovectomy is appropriate. However, in the event of diagnostic uncertainty or obvious diffuse involvement of the synovium, a total synovectomy is indicated because of the high recurrence rate. In our study, all four patients had disease involving secondary bony lesions and, in one case, joint destruction. Based on our findings, it is clear that early surgical therapy is the only recommended curative intervention. The decision regarding the surgical approach, arthroscopic versus open, depends on the form of PVNS, the extent of the disease and secondary changes of the joint.

[The subacromial shoulder dislocation]. / Die subacromiale Schulterluxation.

We report on a case of subacromial shoulder dislocation, which resulted from a combination of a cranial glenoid fracture and an acromial fracture. The patient sustained this rare injury while playing handball. The whole implication of the injury was revealed only after extensive workup with CT scan of the shoulder. After reduction of the shoulder dislocation, the glenoid fracture was stabilized by osteosynthesis. The postoperative results showed anatomical reconstruction of the glenoid joint surface. After completion of therapy, the patient has achieved good functional results with a full range of motion (abduction 180 degrees ) and has been able to work full-time again.

[The long gamma nail--indications, technique and results]. / Der lange Gammanagel--Indikationen, Technik und Ergebnisse.

The introduction of the Gamma nail (GN) as an intramedullar implant for pertrochanteric femoral fractures that allowed full weight bearing decreased the death rate from 17% (methods without full weight bearing) to 6%. The long Gamma nail (LGN) is a logical supplement of the standard version, designed to treat unstable per-, subtrochanteric and segmental fractures. This study evaluated 44 consecutive operations. Seventy percent of the patients had to be classified ASA III and IV, due to their high morbidity. The median age was 73.5 years. Multiple injuries occurred in 30.2%. All fractures were considered unstable. Surgery was usually performed within 24 h. The median duration of the surgical treatment was 120 min. In five cases technical problems were observed. Radiological controls showed a good positioning of the head screw. Early complications consisted of four local wound infections, three of them deep infections with a osteomyelitis. Deep venous thrombosis was observed in four cases, two of which included a pulmonary embolism (conservative treatment). The 30-day death toll was 2.3% (one patient). The median survival time (using Kaplan-Meier) in the study was 46 months, compared to 80 months in a matched population. This difference has to be linked to high premorbidity. The median duration of admission was 15 days. Mobilisation with full weight bearing was theoretically possible in all cases, but additional injuries or preoperatively impaired walking ability prevented full mobilisation in 15 cases. Functional assessment uncovered a decrease in Merle d,Aubigne score of 26.7% due to an impaired walking ability. Seventy-three percent of the patients regained their preoperative social status. In conclusion the long Gamma nail is a universal, less invasive implant with high early weight bearing. It thus allows early remobilization and reduces lethality in the treatment of complex, unstable coxal fractures.

[Kyphoplasty and vertebroplasty in fractures in the elderly: effort and effect]. / Kyphoplastie und Vertebroplastie bei Frakturen im hohen Lebensalter. Aufwand und Ergebnisse.

Kyphoplasty and vertebroplasty are two minimally invasive percutaneous techniques used for treatment of osteoporotic vertebral compression fractures in the thoracic and lumbar spine. The injection of polymethylmetacrylate (PMMA) is often a final attempt at therapeutic treatment of complications due to such fractures. Vertebroplasty involves injection of cement via one or both pedicles under high pressure, thus filling and stabilizing the vertebra without reduction of fracture. Extravertebral cement leakage is a common complication: an intact posterior wall normally prevents cement leakage into the epidural space. Kyphoplasty involves transpedicular inflation of balloon tamps, thus creating a cavity which is then filled with PMMA under low pressure. Restoration of vertebral height is possible and the potential for extravertebral cement leakage lessened.

[Angle- and rotation-stable internal fixation of proximal humerus fractures with the humerus fixator plate. Early clinical experience with a newly developed implant]. / Die winkel- und rotationsstabile Osteosynthese proximaler Humerusfrakturen mit der Humerus-Fixateurplatte. Erste klinische Erfahrungen mit einem neu entwickelten Spezialimplantat.

INTRODUCTION: The Humerus Fixator Plate is presented as a new implant for angle- and rotation-stable internal fixation for the operative treatment of proximal humerus fractures at the surgical neck. METHODS: In an ongoing two-centre study, 47 patients were treated with the new implant. To date, 31 patients had clinical and radiological postoperative follow-up examinations with a mean interval of 10 months (range: 6-14 months). RESULTS: In 46 patients (97.9%), complete angle and rotational stability was achieved without limiting the range of motion or requiring immobilization. Good pain relief was obtained in 43 patients (91.5 %), and 3 patients (6.4%) showed moderate pain relief following surgery. There was one implant failure. Utilizing the Constant-Raw score (without any correction factors), a mean result of 82.8 points (range: 46-100 points) was ascertained. The majority of the patients (87.1%) achieved "excellent" or "good" clinical results. X-ray analysis revealed no non-union nor humerus head necrosis. In 4 cases (12.9%), protrusion of a humerus head screw was observed which mandated removal of the implant. CONCLUSION: The first clinical investigations of the novel Humerus Fixator Plate are encouraging and provide essential advances in the treatment of unstable proximal humerus fractures.

[3-dimensional sonography in the diagnosis of meniscal lesions. An experimental and clinical study]. / Die dreidimensionale Sonographie in der Diagnostik von Meniscusläsionen. Eine experimentelle und klinische Studie.

There is no consensus regarding the clinical significance of conventional two-dimensional ultrasound in the diagnosis of meniscal tears of the knee. Three-dimensional ultrasound spatially reconstructs a transparent image of subsequent ultrasound scans. In an experimental study of 96 menisci, radial and oblique tears were detected more often by three-dimensional ultrasound. In a clinical study of 60 menisci the two- and three-dimensional ultrasound reached a sensitivity of 92% and 100%, a specificity of 83% and 88%, a positive predictive value of 58% and 67%, and a negative predictive value of 98% and 100%, respectively. Altogether, there was no statistically significant difference between both methods. The high negative predictive value, however, shows that the three-dimensional ultrasound may be a clinically relevant examination for special questions in the diagnostics of meniscal tears.

Detection of high-energy phosphates in cortical bone as an indicator of bone healing and remodelling: use of a rabbit model.

UNLABELLED: PURPOSE; To study high-energy phosphates in cortical bone through experiments on inbred white New Zealand rabbits. METHODS: Tibial fractures were induced in 80 rabbits and then stabilised by screw osteosynthesis. After 3 (group A; n=40) or 7 days (groups B; n=40), the defective tissue was covered by local muscle flaps. At increasing intervals (from 1 to 16 weeks), the screws were removed and the animals were euthanised (n=8 per group). The bone was removed and analysed histomorphologically; adenosine triphosphate (ATP) levels were determined by high-performance liquid chromatography. RESULTS: The mean ATP concentration in healthy cortical bone at 16 weeks was 0.092 (standard error, 0.009) nmol/mg dry mass, which was significantly higher than that in the group with delayed healing: 0.081 (0.011) nmol/mg in group A and 0.005 (0.001) nmol/mg in group B (paired t test, p<0.05). Earlier healing led to lower rates of necrosis (0 vs 38; groups A vs B) and osteomyelitis. CONCLUSION: Early muscle-flap coverage can revascularise the cortical bone, which is reflected in the higher ATP content in the cortical bone measured by high-performance liquid chromatography. Measuring changes of ATP levels can help investigate the metabolism of the pathological bone.

Laser doppler flow imaging of open lower leg fractures in an animal experimental model.

PURPOSE: Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap. METHODS: 80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically. Cortical microcirculation was measured by 2-channel laser doppler flowmetry. RESULTS: Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%). CONCLUSION: Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

[Injuries of the acromioclavicular joint]. / Verletzungen des Schultereckgelenkes.

The injuries of the acromio-clavicular joint require a differentiated diagnosis and treatment. The classification of the acromio-clavicular dislocations from grade I to grade III according to Tossy is proved. The diagnosis of a complete acromio-clavicular dislocation (Tossy III) is an indication for a surgical repair. Many and different methods are reported in the literature. 178 patients with a fresh acromio-clavicular dislocation (Typ Tossy II and III) were treated at the BG-Unfallklinik Tübingen from 1970 to 1987 by suturing the ligaments, inserting pins across the joint and tension wire bending. In old cases with Tossy III dislocation of the acromio-clavicular joint an oblique osteotomy combined with the reduction of the clavicle is recommended as a method of choice. The results of these procedures and there possible intra- and postoperative complications are reported. The incision along the clavicle quite often gives scar problems. Therefore the advantages of an arched incision across the acromio-clavicular joint is pointed out. Because of there biomechanical relationship fractures in the lateral third of the clavicle are similar to dislocations of the acromio-clavicular joint. The classification of these fractures according to Jäger, Buschle and Breitner allows a differentiated management of these lesions.