Arthrodesis of the Ankle.

About 90 % of all cases of painful posttraumatic ankle arthritis can be very successfully treated with a minor invasive ankle arthrodesis technique by using a small anterior approach and a fixation with four 6. 5 mm screws of which the posteromedial and transfibular one are inserted percutaneously. The results with this standardized procedure have been reported previously as excellent and good in a mid-term run of 6 years (34). This technique leads to a high union rate of 99% (92 of 93) with rapid bone healing within 8 ± 2 weeks, it causes a low minor complication rate of 8 % and enables a significant increase of the AOFAS ankle/hindfoot score (17) from 36 preoperatively to 85 postoperatively as well as a midtarsal movement of 24° ± 16°. In some cases of ankle arthritis due to chronic syndesmotic instability a 5th screw is additionally used to compress the reamed espace claire for regaining a stable ankle fork. A 5th screw is used also in case of necessary shortening of the fibula or in cases of idiopathic ankle arthritis with gross varus deformity when a transfibular approach becomes necessary instead of the anterior approach. About 10% of ankle arthrodesis need different procedures like in cases of malunited ankle or pilon fractures with low grade infection, larger bony defects due to resection of necrotic bone, due to primary bone loss in open fractures or due to secondary bone loss in failed ankle replacement cases. They need usually a two stage procedure with primary debridement and temporary joint transfixation and secondary anterior double plate fixation with autogenous bone grafting. In case of critical anterior soft tissues a posterolateral approach with a bladeplate-fixation is performed. In the very rare cases of severe ankle infection a three stage procedure is recommended with a radical necrectomy of infected soft tissues or dead bone and/or combined with taking biopsies, filling the defects with Gentamycin-PMMA- beads and stabilizing the reamed joint with a threaded compression Charnley fixator in the first stage. A re-debridement in the second stage might need additionally a permanent lavage with sensitive antibiotics according to the probes and in the third stage a third debridement with finally autogeneous bonegrafting is done. Key words: ankle arthrodesis, anterior, posterolateral, transfibular ankle approach, 4- to 5-screw fixation technique, double plate fixation, autogeneous bonegrafting, Charnley compression fixator.

[Internal circular arc osteosynthesis of tibiotalocalcaneal arthrodesis]. / Die innere Kreisbogen-Osteosynthese der tibio-talo-calcanealen Arthrodese.

Tibiotalocalcaneal arthrodesis has recently become more popular as a form of reconstructive surgery. The precise anatomical orientation and the functional extrinsic musculature of the hindfoot are essential for a satisfactory result. Fixation of the arthrodesis is a mechanical problem. Straight and angulated nails are not anatomically or mechanically ideal. A circular arc nail can fix the tibia, the talus and the calcaneus in anatomical alignment. This is a pure "bone nail", in contrast to the "intramedullary nail," which is driven through an existing opening in long bones. The nail is driven through a circular arc-shaped opening in the bone, which results in optimal form-fit between nail and bone. A corresponding aiming device permits the precise shaping of the bone tunnel, which follows the orientation of the bone trabeculae. The instrumentation was applied in 11 cases, with the following indications: post-traumatic conditions, congenital deformities, chronic polyarthritis and diabetic Charcot arthropathy. The desired alignment of the hindfoot is not affected while the nail is being introduced. The fixation achieves primary stability thus allowing for early functional treatment.

[Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]. / Rückfußarthrodese beim Charcot-Fuß mit retrogradem Nagel.

BACKGROUND: Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear. MATERIALS AND METHODS: Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion. RESULTS: Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation. CONCLUSION: Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.

[Elective and acute procedures in trauma surgery. Complications requiring revision]. / Elektive und akute Eingriffe in der Unfallchirurgie. Revisionspflichtige Komplikationen.

BACKGROUND: Using data between 2010 and 31 March 2012, a cohort study concerning complications of all discharged patients who had undergone surgery was performed. PATIENTS AND METHODS: In our detailed analysis, we defined two groups out of the 5,248 cases: an acute trauma patient group (n = 3,942) and an elective patient group (n = 1,306). Complications were divided into the following groups: (1) technical complications (failure of the implant, poor indication, instability or non-union), (2) local complication (hematoma or delayed wound healing), and (3) infection. RESULTS: In 4.4% of patients (n = 233), treatment was delayed because of a complication. In 2.3% (n = 123), a technical complication was observed, followed by local complications in 1.3% [e.g., hematoma 0.6%, other wound healing disturbance (0.6%)]. In the elective surgery group, the percentage of complications needing revision (3.1%) was significantly lower compared to the trauma surgery group (4.9%). The patient's age for the non-complicated surgery group was significantly lower (54 vs. 63 years) and length of hospital stay (6.7 days longer) was significantly higher in patients with complications. Risk factors such as smoking were significantly more frequent in patients with complications (9% vs. 18.5%). CONCLUSION: Recording and evaluating of complications in surgery plays a major role for quality control. Certain factors (e.g., comorbidity and the age of the patient) cannot be influenced, but complications caused by technical problems could theoretically be avoided. Especially these cases must be analyzed in detail to reduce the percentage of complications requiring revision.

[Reconstructions after inveterated fractures and dislocations of the foot]. / Rekonstruktionsmaßnahmen nach veralteten Frakturen und Luxationen des Fußes.

Inveterated fractures or dislocations of the foot which are defined as being more than 6-12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.

[Treatment of fractures of the ankle in the elderly]. / Frakturversorgung des oberen Sprunggelenks im hohen Lebensalter.

BACKGROUND: Osteoporotic fractures of the ankle were observed three times more often in the year 2000 than in the year 1970 and it is predicted that this will increase another three times by the year 2030. The most important predictive values for ankle fractures in the elderly are smoking, multipharmacy and poor mobility. INJURY PATTERNS: Conservative treatment only seems to be successful in stable ankle fractures with good surrounding soft tissue. Pronation-abduction (PA) fractures most commonly affect elderly females and 90% of the cases present as the very unstable type III. Unstable fractures, such as PA type III, supination-eversion (SE) and pronation-eversion (PE) fractures type IV can be treated better by 2-stage open reduction internal fixation (ORIF). Because the PA type III fracture is often associated with dorsal dislocation of the foot it is proposed that this type should be classified as type IV, which needs urgent surgery to prevent further soft tissue damage. THERAPY: Recommended techniques are the K-wire cage or fibula-pro-tibia technique. Locking plates are also preferred for stable fracture fixation. According to the recommended preoperative computed tomography (CT) scan a Volkmann's fracture should be fixed through a posterolateral approach. The additional tibiotarsal internal transfixation should remain for 6-8 weeks after ORIF until it is changed to a protective lower leg cast after wound healing. An underlying osteoporosis should be diagnosed and inpatient treatment of this entity should be initiated by trauma surgeons whereby coordination training is also important. CONCLUSION: Due to the increasing number of ankle fractures in the elderly particularly in postmenopausal women with osteoporosis, the insufficient diagnostics and therapy of osteoporosis and because the number of these difficult to treat fractures will increase by a factor of 3 by 2030, special surgical techniques and particularly implants are necessary for unstable ankle fractures types PA III, SE IV and PE.

[Joint-preserving correction of Chopart joint malunions]. / Gelenkerhaltende Korrekturen bei Fehlheilungen im Chopart-Gelenk.

BACKGROUND: Injuries to the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted and therefore, not adequately treated at initial presentation. Malunion results in a loss of essential joint function and a three-dimensional malalignment leading to considerable impairment of global foot function and a rapid development of painful posttraumatic arthritis. METHODS: If no symptomatic arthritis is present, joint displacement or non-union may be subject to secondary anatomical reconstruction and internal fixation. Bone grafting becomes necessary in cases of non-union or partial avascular necrosis (AVN) of the navicular bone. In most cases joint destruction will have lead to manifest posttraumatic arthritis requiring fusion of the affected joint. Arthrodesis is always combined with axial realignment. Rebalancing of the medial and lateral foot columns is of utmost importance. RESULTS: We have treated 16 patients with joint-preserving correction of the Chopart joint: 6 of the navicular bone, 3 of the talar head, 3 of the anterior calcaneal process, 2 of the cuboid and 2 with combined malunions. Two female patients aged 50 and 67 years developed AVN of the navicular bone and required talonavicular fusion and one patient with a nonunion of the anterior calcaneal process needed a second revision surgery to achieve union. The average American Orthopaedic Foot and Ankle Society (AOFAS) score of 12 patients increased from 37 preoperatively to 77 at follow-up after an average of 2 years. CONCLUSION: Joint-preserving corrections are generally possible for all four bony components of the Chopart joint in carefully selected cases of malunited fractures and fracture dislocations.

[Anatomical reconstruction of chronically instable Lisfranc's ligaments]. / Anatomische Wiederherstellung des chronisch instabilen Lisfranc-Ligaments.

BACKGROUND: From June 2001 to May 2013 four selected patients with an isolated and old Lisfranc's ligament rupture were treated at the Trauma Department of the University Hospital Carl Gustav Carus in Dresden with an anatomical repair of the ligament using half of the extensor hallucis longus tendon. This kind of graft 7 cm in length was used in three cases and in the fourth case the whole extensor hallucis brevis tendon was used. Of the four patients three were female with an average age of 28.6 years (range 15-39 years). The fourth patient was a 23-year-old male who was followed up for only 3 months due to emigration abroad. The three female patients were postoperatively followed up for a minimum of 1 year clinically and at the 1 year follow-up all three women had a stable Lisfranc's joint, two were absolutely pain free and one was relatively pain free. RESULTS: The youngest of the three females was 15 years old at the time of surgery and in preparation for the Olympic Games as a gymnast. This gave rise to the idea for an anatomical repair to avoid partial fusion of the Lisfranc's joint in this very young and extremely competitive sportswoman. The Lisfranc's joint was completely stable and pain free 2 years postoperatively and 10 years after surgery she qualified for the 2005 World Championships in Australia and the Olympic Games in Beijing in 2008.

[Secondary anatomical reconstruction of malunited central talus fractures]. / Sekundäre anatomische Rekonstruktion fehlverheilter zentraler Talusfrakturen.

BACKGROUND: Malunion or nonunion of central talar fractures lead to significant impairment, pain and decreased motion of the foot and ankle. In a 20-year period from 1994 to 2013 at the Trauma Department of the University Hospital Carl Gustav Carus of the Technical University of Dresden we treated a total of 25 patients with secondary anatomical reconstruction of the talus. METHOD: The mean age of the patients was 39.9 years (range 15-71 years) and only 4 out of the 25 patients were female. Of these patients 11 patients were treated conservatively, 3 minimally invasive with external fixation and were admitted on average 7.6 months (range 1.5-42 months) after the initial fracture. Of the patients 11 had previously been treated in another hospital by open surgery on average 8.4 months (range 1-24 months) months before. There were 9 malunions or nonunions of talar fractures of the shaft, 14 of the neck and 2 of the head. Only 3 cases were old fractures ≥ 6 weeks and 22 were malunions or nonunions ≥ 3 months. According to an in-house classification 12 malunions (type I), 5 nonunions (type II), and 8 malunions/nonunions with partial necrosis (type III) were treated. RESULTS: Of the patients 21 out of 25 needed a bilateral approach and 6 additionally an osteotomy of the medial malleolus.The mean follow-up of 22 out of 25 patients was 5.4 years (range 1.0-21.5 years). The preoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score increased on average from 36.6 to 86.7 points (p<0.001) at the time of follow-up.

[Joint-preserving osteotomy for calcanean malunions]. / Gelenkerhaltende Korrektur fehlverheilter Kalkaneusfrakturen.

BACKGROUND: Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis. METHODS: Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint. RESULTS: While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects. CONCLUSION: In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

[Anatomical reconstruction of malunited metatarsals and adjacent joints]. / Anatomische Wiederherstellung fehlverheilter Metatarsalia und deren angrenzender Gelenke.

BACKGROUND: Malunited fractures of the metatarsals seldom need correction because the adjacent joints proximally and distally are not axially loaded but they may cause significant pain when a subcapital fracture is malunited too far in a plantar direction. METHOD: Even if a metatarsal head is malunited too dorsally the neighboring head signals transfer metatarsalgia. Therefore, reorientation osteotomy with the intraoperative help of a minidistractor and stable fixation with a small locking plate is needed. Painful nonunion, especially of the proximal fifth metatarsal needs improvement of the biology (e.g. autogenous bone graft) and of the biomechanics (e.g. stable osteosynthesis) if for example pulsed ultrasound treatment fails. RESULTS: The importance of these small foot joints is illustrated by reopening the iatrogenically fused metatarso-cuboidal joint and making a new joint by interposition of crural fascia being crucial for a pain-free and fully functioning foot. The special biomechanics of the first ray is stressed by the secondary reconstruction of the first metatarsal showing a huge bony defect and poor surrounding soft tissues by performing callus distraction.

Fractures of the calcaneus: current treatment strategies.

Displaced, intra-articular fractures of the calcaneus represent a surgical challenge and the ideal choice of treatment remains a subject of continued debate. Open reduction and stable internal fixation without joint transfixation has been established as the standard treatment for most of these fractures with good to excellent results in more than two thirds of patients in larger clinical series. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints, but wound healing problems cannot be completely avoided despite meticulous soft tissue handling. Percuatneous and less invasive procedures have successfully lowered the rates of wound complications but exact anatomic reduction remains an important issue. Care must be taken not to overlook atypical fractures like sustentacular fractures and fracture-dislocations of the calcaneus that are treated with a small medial or curved epimalleolar lateral approach, respectively. The use of bone grafting or bone substitutes for defect filling appears not necessary in most cases. Prognostic factors that can be influenced by the surgeon are anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint which should both be controlled intraoperatively. Treatment results are adversely affected by severity of injury, open fractures, bilateral fractures, a high body mass index and smoking. Early, stable soft tissue coverage with pedicled or free flaps appears to lower infection rates and improve the functional results after open fractures. Calcaneal malunions and nonunions are disabling conditions resulting from either non-operative treatment or inadequate reduction and fixation of displaced fractures. Deformity correction is tailored to the type of deformity and individual patient needs. Treatment options include lateral wall decompression, in situ- or corrective subtalar arthrodesis and calcaneal osteotomies accompanied by soft tissue-balancing.

[Foot and ankle fractures in children]. / Frakturen des kindlichen Sprunggelenks und Fußes.

Ankle fractures are the most frequent factures of weight-bearing joints in children while fractures of the hindfoot and midfoot are rare. Metatarsal fractures make up the greatest portion of foot fractures in children and mostly heal uneventfully. Generally, the fracture severity increases with increasing age and the fracture patterns in adolescents resemble those in adults but transitional fractures of the distal tibial epiphysis in adolescents between 12 and 14 years of age are an exception. A subtle clinical and radiographic examination is necessary to detect the injury pattern and to discriminate fractures from accessory bones, juvenile avascular necrosis and apophyses. Computed tomography scanning is most useful to precisely evaluate the degree of injury, especially articular involvement and to allow precise planning of the operative approach. Except for the calcaneus and the metatarsals the bones of the foot and ankle do not display a significant potential for spontaneous correction during growth; therefore, open reduction and internal fixation is indicated in all displaced fractures if closed reduction does not yield a satisfying result in order to avoid relevant post-traumatic deformities.

[Joint-preserving osteotomy of malunited ankle and pilon fractures]. / Gelenkerhaltende Osteotomien fehlverheilter Sprunggelenk- und Pilonfrakturen.

Malunion and nonunion after ankle and pilon fractures regularly lead to the development of painful functional impairment even in cases of only mild axial deviation or residual joint incongruity. Involvement of the tibial pilon results in rapid progression of posttraumatic ankle arthritis. Corrective osteotomy with joint preservation aims at secondary anatomical reconstruction with functional rehabilitation. This requires a careful preoperative analysis and will be possible in carefully selected cases only. Prerequisites for successful reconstruction are intact cartilage, sufficient bone quality, residual joint function and good patient compliance. Since the works of B. G. Weber, joint-sparing osteotomy is an established treatment option for malunited malleolar fractures with reliable long-term results and low rates of complications and secondary fusions. Key to success is the re-establishment of the length of the distal fibula and repositioning into the tibial incisura in cases of syndesmotic instability. Corrections of the medial malleolus and posterior tibial fragment are less frequent. Corrective intra-articular osteotomies for malunited pilon fractures are rarely feasible because of manifest arthritis at the time of patient presentation in most cases. Besides case reports there is only one series of 14 patients available in the literature. At 5-year follow-up, a good to excellent result was seen in 10 cases and secondary ankle fusion was done in 2 patients with a poor result. Anatomical reconstruction of malunited tibial pilon fractures appears to be a viable treatment option besides arthroplasty and fusion in carefully selected patients.

[Open reconstruction of radius head fractures with and without accompanying ligament instability. Treatment results]. / Offene Rekonstruktion von Radiusköpfchenfrakturen mit und ohne begleitende Bandinstabilität. Behandlungsergebnisse.

BACKGROUND: The treatment of fractures of the radial head is commonly based on the Mason classification. Fractures of the radial head caused by a dislocation of the elbow are summarized as Mason type IV fractures. The purpose of this study was to investigate the outcome and the influence of additional ligamentous injuries after reconstruction of fractures of the radial head. PATIENTS AND METHODS: One hundred three patients with a fracture of the radial head were treated by open reduction and internal fixation between 2004 and 2009. Fifty-eight of them could be evaluated at an average of 3.6 years after surgery. Forty-one patients had no additional ligamentous injury and 17 had a fracture combined with complete dislocation of the elbow. At the final follow-up examination, all patients were assessed clinically, bilateral radiographs were taken, and the Broberg and Morrey and Kellgren & Lawrence scores were determined. RESULTS: Ten patients had a Mason type II, 31 a Mason type III and 17 a Mason type IV fracture. With regard to the Broberg and Morrey score, patients without ligamentous injury achieved a significantly better functional outcome, with good to excellent results in 97.5% of cases compared to 64.6% for patients with ligamentous injuries. Twelve percent of the patients without ligamentous injury and 47% of the patients with ligamentous injuries developed moderate or severe posttraumatic arthritis. Heterotopic ossification was found in 19.5% of the patients without and in 47% of those with ligamentous injury. CONCLUSION: Reconstruction of radial head fractures without ligamentous instability led to significantly superior functional results and lower rates of posttraumatic arthritis and heterotopic ossifications than osteosynthesis of fractures with additional ligamentous injury. In these cases primary endoprosthetic replacement might be considered.

[Bone substitute. Transplants and replacement materials--an update]. / Knochenersatz. Transplantate und Ersatzmaterialien--ein Update.

Due to the special characteristics, autologous bone for bone grafting remains the gold standard for defect filling. Besides allogenic bone transplants, as an alternative a set of bone substitutes has been established. An overview of the bone substitutes presently on the market is almost lost due to the abundance of products. The present paper gives a review of the materials available on the market. Different classification systems regarding origin, vitality, biological priority and chemical composition are described as well as the individual materials including the advantages and disadvantages. Finally, a description of tissue engineering and gene therapy gives a view of future prospective.

[Long-term results after Kirschner wire pinning of distal radius fractures]. / Langzeitergebnisse nach Kirschner-Draht-Osteosynthese distaler Radiusfrakturen.

BACKGROUND: The purpose of this study was to investigate the outcome after K-wire pinning of distal radius fractures with a minimum follow-up period of 5 years. PATIENTS AND METHODS: A total of 189 patients with an isolated fracture of the distal radius were treated between 1998 and 2002 and 100 were evaluated at an average of 5.6 years after the surgery. At the final follow-up examination all patients were assessed clinically and bilateral radiographs were taken. RESULTS: Of the patients 37 had an A type fracture, 8 a B type and 55 a C type according to the AO classification and 86% achieved good to excellent results based on the Gartland and Werley and Disability of Arm, Shoulder, Hand (DASH) scores. Patients were divided in to two groups. Group A included patients with fractures with a primary palmar inclination greater than -20° (range -20° to 10°) and group B with fractures with a primary palmar inclination less than -20° (range -45° to -20°). Secondary loss of reduction was significant higher in group B compared to group A (group B: 8.3°, group A: 1.6°, p <0.05). In 8 out of 11 patients of group B an osteoporosis was found. Functionally no difference was detected between the two groups. Radial shortening of over 4 mm resulted in a significant reduction (36%) of prosupination and supination. No other influence of the radiological results on the functional or subjective outcome was found. Superficial infection of the K-wire occurred in 6 cases, whereas early K-wire removal was performed in 2 cases, 8 patients complained of dysesthesia in the area of the superficial radial nerve and 5 patients developed an early stage of the complex regional pain syndrome. CONCLUSION: K-wire pinning cannot be routinely recommended. However, in cases of A2, A3 and C1 fractures, a primary dorsal dislocation of less than -20° and in patients without low bone mineral density, K-wire pinning leads to a high rate of radiological, functional good results.

[Prevention of road accidents involving non-motorized traffic participants (pedestrians and cyclists) in Germany]. / Prävention von Verkehrsunfällen äußerer Verkehrsteilnehmer (Fußgänger und Fahrradfahrer) in Deutschland.

During a 1-day workshop organized by the German Society of Orthopaedics and Traumatology (DGOU) 15 German accident researchers used different approaches to improve the effectiveness of accident prevention for pedestrians and bicyclists on German roads. The main results of this analysis show: Fatal injuries of pedestrians have been significantly reduced by 82% between 1970 (n=6.056) and 2007 (n=695). Similarly, fatalities of bicyclists have been reduced during the same time period from 1,835 to 425 which amount to almost 80%. However, the total number of injured cyclists increased almost twice, i.e. from 40,531 (in 1979) to 78,579 (in 2007) a fact that needs to be analyzed in more detail. Although scientifically proven to provide protection against severe head injuries, helmets are worn less frequently by adolescents and women as compared to younger children and men. Fatalities of bicyclists might be reduced by using Dobli mirrors which allow the truck driver to see the bicyclist when turning right. Recently developed sensors are able to detect pedestrians walking closely (<2.5 m) and warn the truck driver acoustically. Bicycle lanes should be planned for one direction only, separated from the pedestrian way and large enough (2.0 m are safer than 1.6 m). Traffic education for school beginners and younger children should be repeated to be effective. Training for elderly bicyclists in cities with heavy traffic would also be reasonable. Active security systems in cars like ESP (electronic stability program), BAS (brake assist system), special light systems for curves, and night vision utilities are most effective to prevent collision with pedestrians and bicyclists. TV spots for bicyclists could help to point out dangerous situations and the proven benefits of wearing a helmet in the same way as previous campaigns, e.g."The 7th Sense" for car drivers.

[Problems and controversies in the treatment of ankle fractures]. / Probleme und Kontroversen in der Behandlung von Sprunggelenkfrakturen.

Ankle fractures are the most frequent injuries of a load-bearing joint. Their treatment belongs to the daily routine in trauma surgery. However, despite an increased understanding of the mechanism of injury and relatively straightforward fixation techniques, the medium- to long-term results are often less than satisfactory. The following article therefore explicitly focusses on unsolved problems and controversies in the treatment of ankle fractures in the light of the current literature. These include the therapeutic and prognostic relevance of frequently used classification systems, criteria for the indication for surgery, frequent hazards in internal fixation, the question of whether and how to fix the posterior malleolus, and the detection and treatment of syndesmotic instability. Furthermore, trauma surgeons face the increasing incidence of ankle fractures in the elderly. The presence of osteoporosis, diabetes mellitus and neuropathic osteoarthropathy represents a special challenge.

[Control of diffuse bleeding in unstable pelvic fractures with compression plate packing: presentation of the surgical technique]. / Kontrolle diffuser Blutungen bei instabiler Beckenfraktur mittels Kompressionsplattentamponade: Vorstellung der chirurgischen Technik.

Current recommendations on surgical management of unstable pelvic fracture with hemorrhagic shock include reduction and fixation, i.e., with a C-clamp and external fixator, angiographic embolization of injured pelvic arteries, and preferably extraperitoneal packing to control diffuse bleeding from the venous plexus and fracture site. However, the recently reported lethality at 40-60% remains seriously high. One possible reason could be the unsatisfactory efficiency of extraperitoneal packing in the case of a traumatically or surgically opened retroperitoneal compartment. In this paper, a new approach, so-called compression plate packing, is proposed to control diffuse bleeding. In this technique, the essential pressure of the packing on the bleeding site is set up with small fragment plates with screw fixation to the pelvic ring. In two first clinical cases of severe pelvic trauma the hemorrhage could be controlled reliably.