Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany.

PURPOSE: The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany. METHODS: Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed. RESULTS: Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability. CONCLUSIONS: OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

The surgical treatment of unstable osteoporotic pelvic ring fractures with bilateral vertebropelvic stabilization using a less invasive technique.

By immobilizing the joint partners between the lumbar spine and the pelvis, the vertical and horizontal forces on the sacrum are both transferred through the ilium caudally. Therefore persistent stress on the fracture is avoided. To ensure sufficient soft tissue coverage the pedicle screws are inserted via small incisions in the lumbar spine area and the iliac screws via slightly oblique incisions on both sides laterally of the posterior iliac spine. At the end the instrumentation is completed by connecting the lumbar longitudinal carriers with the cross connection between the two iliac screws via the pre-existing incisions. Due to this less invasive technique, disorders of wound healing can be avoided. Due to the lower Morbidity rate and its associated reduction in blood loss, there is corresponding decrease in the number of postoperative symptoms, which has a positive effect on early mobilization. None of the described patients showed neurological deficits preoperatively or postoperatively. LEVEL OF EVIDENCE: IV; Technical note, retrospective.

OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures.

OBJECTIVES: Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement. This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP. METHODS: A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process. To assess the interRR of the OF-Pelvis categories, Fleiss' kappa (κF) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall's tau (τK). The presence of a modifier was calculated with κF for interRR and Cohen's kappa (κC) for intraRR. RESULTS: The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination. In both surveys, the interRR for subgroups was substantial: κF = 0.764 (Survey 1) and κF = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κF Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κF min.-max. Survey 1/Survey 2: 0.708-0.827/0.747-0.852). The existence of at least one modifier was rated with substantial agreement (κF Survey 1/Survey 2: 0.646/0.629). The intraRR for subgroups showed almost perfect agreement (τK = 0.894, DR: τK = 0.901, UR: τK = 0.889). The modifier had an intraRR of κC = 0.684 (DR: κC = 0.723, UR: κC = 0.651), which is also considered substantial. CONCLUSION: The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score.

Classification of Osteoporotic Thoracolumbar Spine Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: Expert opinion. OBJECTIVES: Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed. METHODS: The working group "Osteoporotic Fractures" of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature. RESULTS: The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63). CONCLUSIONS: The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.

Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development). OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. METHODS: a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. RESULTS: A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately. CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.

Reduction and fixation of displaced U-shaped sacral fractures using lumbopelvic fixation: technical recommendations.

PURPOSE: U-shaped sacral fractures are extremely rare injuries that usually occur as a result of falls from considerable heights. Almost all treatment methods described to date aim solely at stabilizing the fracture but do not contribute to supporting the reduction of such fractures. Using existing implants the purpose of this study is to present a surgical technique that facilitates both the reduction and the stabilization of these injuries. The presented technique was evaluated in a series of three cases. METHODS: Polyaxial pedicle screws were placed through vertebral bodies L4 and L5. Two long pedicle screws were implanted in the posterior iliac spine. The lumbar pedicle screws were held with two longitudinal rods, and the pelvic screws with one transverse connecting rod. The lumbar longitudinal and pelvic transverse rods were connected via two hinge-like connecting elements. First, distraction was performed between lumbar pedicle screws L5 and the sacral transverse rod. Lordosis was then restored via the hinge joint, thereby eliminating kyphosis. After tightening all moving elements, the fracture was reduced and stabilized. RESULTS: Computed tomography documented anatomical reduction and fracture healing was achieved in all cases. Two of three patients could be fully mobilized immediately; mobilization of the third patient was delayed due to multiple injuries. Two patients showed neurological symptoms. In one case, complete remission was achieved within 3 weeks, while in the other patient a clear improvement was observed. In all cases, the implant was removed after 8-12 months. There were no post-operative complications, such as infections, wound-healing disorders, neurological deterioration, implant failure, or premature loosening. CONCLUSIONS: The surgical procedure was successful, since it considerably facilitated reduction, thereby shortening surgery time. The stabilization was sufficient to fully mobilize the patients. The procedure is based on existing implant components and is thus routinely available.

The role of biological sex in severely traumatized patients on outcomes: a matched-pair analysis.

OBJECTIVE: Analyze sex differences in TraumaRegister DGU (TR-DGU). BACKGROUND: Sex differences are considered to influence trauma outcomes. However, clinical study results are controversial. METHODS: Of 29,353 prospectively recorded cases of TR-DGU, we included primary trauma room admissions with Injury Severity Score of 9 or more into the analysis. Pairs (n = 3887) were formed from 1 male and 1 female according to age, mechanism, injury severity by Abbreviated Injury Scale (for head, thorax, abdomen, extremities), and occurrence of prehospital shock. Biochemical markers, treatment modalities, length of stay, and outcome (multiple organ failure, sepsis, mortality rates) were assessed. Statistical significance was accepted at P < 0.05. Odds ratios (ORs) are given with 95% confidence interval (CI). RESULTS: Females had less multiple organ failure [OR: 1.18 (95% CI, 1.05-1.33); P = 0.007], particularly in age group of 16 to 44 years; sepsis [OR: 1.45 (95% CI, 1.21-1.74); P < 0.001]), particularly at age more than 45 years; and mortality [OR: 1.14 (95% CI, 1.01-1.28); P = 0.037]. Prehospital chest tube insertions (214 vs 158) and surgical procedures before intensive care unit admission were more often performed in males (79.7% vs 76.4%). Females had lower mean hemoglobin levels [10.7 ± 2.6 vs 11.9 ± 2.8 (mg/dL)]. There were no sex differences in fluid resuscitation, shock index, coagulation, and base excess. CONCLUSIONS: Males are more susceptible to multiple organ failure, sepsis, and mortality after trauma. Differences were not exclusively related to reproductive age and thus cannot be attributed to sex hormones alone. Females aged 16 to 44 years seem to tolerate shock better. Higher susceptibility to sepsis might be explained by male immune function or increased systemic burden from higher rates of surgical interventions.

Hypothermia for prediction of death in severely injured blunt trauma patients.

Hypothermia is considered an independent predictor of death after trauma. The aim of this study was to assess these premises based on data from the TraumaRegistry DGU® (TR-DGU) using its outcome predication tool, the Revised Injury Severity Classification (RISC) score, in comparison with three previously published regression models by Shafi, Martin, and Wang. We hypothesized that body temperature on admission would improve accuracy of the RISC score. Data of 5,197 patients with documented body temperature on admission (T) and complete data for RISC score prognosis were selected from TR-DGU. Hypothermia was defined as T of 35°C or less. Patients were divided into hypothermia and normothermia group. Differences were assessed using Mann-Whitney U and chi-squared tests. Statistical significance was accepted at P < 0.01(*). Moreover, we performed multivariate logistic regression analyses using TR-DGU data on the four models (including RISC) with hospital mortality as dependant variable. Results are given as mean or odds ratio (OR) with 95% confidence intervals (95% CIs). Hypothermic patients were more severely injured (Injury Severity Score, 35.0 vs. 29.2 points*) and had higher rates of shock (38.3 vs. 16.8%*), organ failure (71.8 vs. 46%*), and sepsis (17.5 vs. 10.6%*). Survival was worse (29.2 vs. 13.7%*). Comparison of the above models revealed hypothermia as an independent risk factor (Martin: OR, 1.43 [95% CI, 2.21-1.42*]; and Wang: OR, 1.77 [95% CI, 2.21-1.42*]) only, although it would drop out from the model (RISC: OR, 1.12 [95% CI, 1.41-0.89; P = 0.33] and Shafi: OR, 1,.21 [95% CI, 1.60-0.92; P = 0.17]) as long as parameters to indicate hemorrhage and/or coagulopathy were included in sufficient number, a finding confirmed by a subsequent sensitivity analysis. We conclude that hypothermia is a result of injury severity and therefore unlikely to be an independent predictor of mortality. Our data suggest that hypothermia belongs closely to the hemorrhage/coagulopathy group of predictors.

Screw placement and osteoplasty under computed tomographic-fluoroscopic guidance in a case of advanced metastatic destruction of the iliosacral joint.

We present a case of combined surgical screw placement and osteoplasty guided by computed tomography-fluoroscopy (CTF) in a 68-year-old man with unilateral osteolytic destruction and a pathological fracture of the iliosacral joint due to a metastasis from renal cell carcinoma. The patient experienced intractable lower back pain that was refractory to analgesia. After transarterial particle and coil embolization of the tumor-feeding vessels in the angiography unit, the procedure was performed under general anesthesia by an interdisciplinary team of interventional radiologists and trauma surgeons. Under intermittent single-shot CTF, two K wires were inserted into the left iliosacral joint from a lateral transiliac approach at the S1 level followed by two self-tapping surgical screws. Continuous CTF was used for monitoring of the subsequent polymethylmethacrylate injection through two vertebroplasty cannulas for further stabilization of the screw threads within the osteolytic sacral ala. Both the screw placement and cement injection were successful, with no complications occurring during or after the procedure. With additional nonsteroidal anti-inflammatory and opioid medication, the patient reported a marked decrease in his lower back pain and was able to move independently again at the 3-month follow-up assessment. In our patient with intolerable back pain due to tumor destruction and consequent pathological fracture of the iliosacral joint, CTF-guided iliosacral screw placement combined with osteoplasty was successful with respect to joint stabilization and a reduction in the need for analgesic therapy.

Hydroxyapatite-coated pins versus titanium alloy pins in external fixation at the wrist: a controlled cohort study.

BACKGROUND: The purpose of this study was to analyze whether the prevalence of pin-related complications can be reduced by the use of hydroxyapatite (HA)-coated pins in external fixators applied for unstable wrist fractures. METHODS: Forty patients (160 pins) were randomized for standard uniplanar fixator treatment with the use of identically designed pins either composed of titanium-alloy (Ti6Al4V) (n = 20) or coated by HA (n = 20). Each pin site was clinically evaluated with regard to erythema, drainage, pain value, and radiologically assessed concerning loosening at T1 (mean, 9 days), T2 (mean, 43 days), and T3 (mean, 56 days). In case of pin-track complication, the patient was followed continuously. The need for antibiotics or additional surgery was documented. Bone mineral density was analyzed by Dual Energy X-ray Absorptiometry. At fixator removal (T2), the pin-extraction strength was measured by the use of a digital-torque-wrench. RESULTS: Two minor pin-track infections requiring oral antibiotics occurred in the HA-pin group (2.7%) (p > 0.05). The vast majority of clinical pin-site parameters were comparable in both groups. At the end of the fixator therapy, there were 16 loose pins (n(Ti6AL4V-group) = 10; n(HA-group) = 6). The rate of loose pins was correlated to patient's age (p < 0.05) but not to bone mineral density values or the occurrence of pin-site infection. Finally, no significant difference between the two groups was detected with regard to the prevalence of clinical relevant pin-site complications (p = 0.80). CONCLUSIONS: In external fixation of the wrist, the use of HA-coated pins yields no clinical advantages: there is a trend toward a superior pin-bone anchorage, but a tendency of increased susceptibility for minor pin-track infections.

Clinical benefit of hydroxyapatite-coated pins compared with stainless steel pins in external fixation at the wrist: a randomised prospective study.

BACKGROUND: The purpose of this study was to determine the clinical benefit of hydroxyapatite (HA)-coated pins compared with standard stainless steel pins in external fixators applied for unstable fractures of the distal radius. METHODS: A total of 40 patients (160 pins) with unstable wrist fractures were randomised for uniplanar fixator treatment with the use of identically designed, commercially available pins either composed of stainless steel (steel group) (n = 20) or coated by hydroxyapatite (HA group) (n = 20). Each pin site was clinically evaluated concerning erythema and grade of drainage as well as pain intensity (numeric rating scale (NRS) 0­10) and, additionally, radiological assessment was performed concerning pin-loosening/infection as well as fracture healing at T1 (Ø18 days), T2 (Ø44 days) and T3 (Ø65 days). In case of pintrack complication, the patient was followed continuously. The need for intensified pin-site care, oral or intravenous antibiotic medication, re-admission for additional surgery and premature fixator removal was documented. Bone mineral density (BMD) was determined by dual energy X-ray absorptiometry. At fixator removal (T2), the pin-extraction strength was measured by the use of an electronic torque wrench. RESULTS: Two pin-track infections requiring daily pin-site care and oral antibiotics occurred in the HA group (2.6%) compared with four in the steel group (5.3%) (p = 0.601) and although a trend towards a superior performance of HA pins was detectable, the majority of clinical pin-site-parameters were comparable in both groups. At the end of the fixator therapy, the HA group showed a non-significant lower rate of loose pins (n(steel group) = 9; n(HA group) = 6; p = 0.864) and both hydroxyapatite-coated pins showed at the radius a significantly stronger pin-bone bonding measured by the torque wrench (p(proximal radius pin) = 0.007; p(distal radius pin) = 0.031). Except for elderly patients of the steel group (p = 0.018), all demographic-, health- and injury-related data including BMD were not correlated to any type of pin-site complication in both groups (p > 0.05). Since all fracture healed uneventfully without any type of additional surgery, the number of patients suffering clinically relevant pin-related complications showed no significant difference between both groups (p = 0.707). CONCLUSIONS: The use of HA-coated pins compared with standard stainless-steel pins in external fixation for unstable wrist fractures yields only a trend towards a superior clinical outcome.

Seniority of the first-treating doctor does not influence the outcome of acute whiplash injury: a prospective cohort study.

The aim of the prospective cohort study was to investigate the outcome of acute whiplash injury first treated either by junior doctors (JD) [≤3 postgraduate years (PGY)] or more experienced doctors (MED) (>3 PGY). At baseline, crash-related data and health parameters including the SF36 were evaluated in whiplash patients (WP), who fulfilled criteria for whiplash-associated disorders grade I-II and presented up to 48 h after motor vehicle accident to our Emergency Department. 81 WP were recruited and treated by either one of 14 JD (35 WP) or one of 22 MED (46 WP). The follow-up examination included the course of pain intensity [numeric rating scale (NRS) 0-10] by the use of a 28 days-pain-diary and the incidence of symptoms (standardized-telephone-interview at 1, 3, and 6 months post trauma) in terms of neck pain NRS > 2, analgesic medication, work-off, and utilization of further medical services as well as SF36 evaluated at the end of the study. Although the entry population seemed similar, all outcome parameters were comparable between the JD- and MED-group (p > 0.05). Therefore, we conclude that seniority of the first-treating physician does not influence the outcome of acute whiplash injury.

Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones.

BACKGROUND: Non-unions are severe complications in orthopaedic trauma care and occur in 10% of all fractures. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. However, there is morbidity associated with the bone-graft donor site and some patients offer limited quantity or quality of autologous-bone graft material. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM). METHODS AND RESULTS: From 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031). CONCLUSION: With the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 euro/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.

Titanium alloy pins versus stainless steel pins in external fixation at the wrist: a randomized prospective study.

BACKGROUND: Pin-track complications remain the most troublesome disadvantages of external fixation. The purpose of this study was to compare pin-related complications and pain levels after the use of external fixation for the stabilization of distal radial fractures with pins composed of two different materials. METHODS: In a prospective trail 80 patients (320 pins) with unstable distal radial fracture were randomized for standard small AO-external fixator treatment with the use of identical pin geometry either composed of stainless-steel (Ss) (n = 40) or titanium alloy (Ti6Al4V) (n = 40). The patients were followed at biweekly intervals until the external fixators were removed (44 days after surgery). The patients were evaluated with regard to erythema, drainage, cellulitis, occurrence of pain at each pin-site, clinical or radiographic evidence of pin-loosening, the need for antibiotics, and the need for pin removal before fracture-healing due to infection. RESULTS: The complication rate was 21%, and age was found to be significantly associated with an increased risk of pin-loosening (p = 0.003). There were no significant differences among the two groups with regard to the prevalence of pin-site complications. However, the rate of premature removal of fixator because of severe pin-track infection (5% vs. 0%) and the rate of pin-loosening (10% vs. 5%) was higher in the Ss-pin group. Furthermore, pain values were significantly reduced in the Ti6Al4V-pin group. CONCLUSIONS: The use of Ti6Al4V-pin external fixator in distal radial fractures yields a trend of reduced pin-related complications and significantly reduced pain levels than does the Ss-pin fixator.

Strategies for prevention and operative treatment of aortic lesions related to spinal interventions.

STUDY DESIGN: A retrospective analysis of a case series was performed. OBJECTIVE: To give recommendations for the prevention and operative treatment of thoracic and thoracoabdominal aortic lesions in association with spinal interventions. SUMMARY OF BACKGROUND DATA: Aortic lesions after spinal interventions for traumatic vertebral fractures, segmental spondylodiscitis, or vertebral metastasis are fortunately rare, but associated with a high perioperative mortality rate and absolute numbers are unknown. Therefore, preventive strategies to avoid perioperative major vessel injuries and recommendations for the operative treatment of aortic lesions related to spinal surgery are required. METHODS: The clinical course of 10 patients with an acute aortic hemorrhage or an increased intraoperative risk for aortic injuries in association with primary or secondary spinal interventions is reported. All patients were evaluated before surgery by orthopedic trauma surgeons, vascular surgeons, and diagnostic radiologists. RESULTS: Five patients had preventive vascular interventions to avoid major aortic injuries during spinal reinterventions, and 5 patients were treated as an emergency for acute intraoperative hemorrhage related to spinal interventions. The operative treatment was performed by direct aortic sutures (n = 3), segmental alloplastic reconstructions (n = 2), or endovascular stent graft implantations (n = 3). Prophylactic banding of the thoracic aorta during thoracotomy or a femoral access for possible aortic balloon blockade was performed in patients with an estimated lower risk for an aortic laceration caused by malpositioned pedicle screws. No perioperative mortality was observed in patients treated by this interdisciplinary concept, but 1 patient treated under emergency condition for spondylodiscitis with an initially unrecognized aortic lesion died. CONCLUSION: In patients with complex spinal trauma, spondylodiscitis or difficult vertebral reinterventions, and an increased risk of major vessel injury, a preoperative interdisciplinary evaluation is recommended, even under emergency conditions. Endovascular stent graft technique is an additional option for prevention and treatment of suspected or acute aortic injuries of thoracic and infrarenal aortic lesions, whereas injuries to the visceral aortic segment still require advanced vascular reconstructions.

Fixation strength of a novel bioabsorbable expansion bolt for patellar tendon bone graft fixation: an experimental study in calf tibial bone.

This biomechanical study compares the initial fixation strength of a novel bioabsorbable two-shell expansion bolt (EB) with that of a well-established interference-screw technique in bone-patellar tendon-bone (BPTB) reconstruction in a calf model. Thirty tibia plateaus (age 5-6 months) were assigned to three groups: In groups I and II, trapezoidal bone plugs of BPTB grafts were fixed with bioabsorbable poly-L-lactide interference screws (8 x 23 mm) or titanium interference screws (8 x 25 mm) respectively. In group III, semicircular grafts were fixed using bioabsorbable poly-D, L-lactide expansion bolts (5.8/8.7 x 10 x 35 mm). The tensile axis was parallel to the bone tunnel, and the construction was loaded until failure applying a displacement rate of 1 mm per second. In group II the mean ultimate loads to failure (713 N+/-218 N) were found to be significantly higher than those of groups I (487 N+/-205 N) and III (510 N+/-133 N). Measurement of stiffness showed 45 N/mm+/-13.3 in group I, 58 N/mm+/-17.4 in group II and 46 N/mm+/-6.9 in group III, and did not demonstrate significant differences. We found a correlation between insertion torque and wedge insertion force and ultimate loads to failure in all groups (r=0.53 in group I, r =0.54 in group II, and r =0.57 in group III). Cross-section planes of bone tunnel increased by 51%, 30% and 31% respectively, following insertion of screws or expansion of bolts (p<0.05). We conclude that ACL graft fixation by means of the presented expansion bolt demonstrates a fixation strength similar to the established bioabsorbable screw fixation, and is a reasonable alternative fixation method, especially since some of the specific pitfalls of screw fixation can be avoided.

Long-term results after pulmonary resection of renal cell carcinoma metastases.

BACKGROUND: Until now no conclusive data exist regarding the factors influencing long-term survival after pulmonary resection of renal cell carcinoma metastases. The aim of the present study, therefore, was to discover definitive prognostic factors for survival using a large and homogeneous single center patient cohort. METHODS: Between 1980 and 2000, 105 patients, after curative resection of lung metastases from renal cell carcinoma, were followed in this long-term study. These patients underwent a total of 150 surgical procedures. Survival analysis was done using the Kaplan-Meier method and the log-rank test. Multivariate analysis of prognostic factors was performed using the Cox multivariate proportional hazard model. RESULTS: Median survival after curative resection reached 43 months (range, 1 to 218 months). Survival at 3, 5, and 10 years was 54%, 40%, and 33%, respectively. Univariate analysis revealed that a complete resection, a less than 4-cm diameter of the metastases and tumor-free lymph nodes at the time of primary operation, were highly significant dependent prognostic factors (p < 0.001). These factors were also shown to be independent prognostic factors as suggested by multivariate analysis (p < 0.05). CONCLUSIONS: The size of the metastatic nodule, the completeness of pulmonary resection, and the lymph node status at the time of nephrectomy are the most important prognostic factors that influence survival after resection of pulmonary metastases. Recurrence of resectable pulmonary metastases does not impair survival, thus favoring repeated resection in patients with recurrent disease.