Incidence of postoperative complications in patellar fractures related to different methods of osteosynthesis procedures - a retrospective cohort study.

BACKGROUND: Patellar fractures have a comparatively low incidence compared to all fracture frequencies of the musculoskeletal system. However, surgical management is crucial to prevent postoperative complications that affect the knee joint. The purpose of the present study was to evaluate the incidence of postoperative complications and onset of postoperative osteoarthritis related to the chosen technique of patellar fracture management. METHODS: In a retrospective cohort study consecutive managed, isolated patella fractures were reviewed for demographic data, trauma mechanism, patella fracture type, fixation technique and postoperative complications. The results were documented radiographically and clinically and analysed statistically. The reporting followed the STROBE guidelines. RESULTS: A total of 112 patients were eligible for data evaluation. Surgical management of comminuted patellar fractures with small fragment screws showed significant fewer postoperative complications compared to other fixation techniques (8%, p < 0.043). The incidence of posttraumatic infection was significantly higher following the hybrid fixation technique with cannulated screws and tension wire than following the other analysed techniques (p = 0.024). No postoperative wound infection was observed after screw fixation or locking plate fixation. Symptomatic hardware was most frequently seen after tension-band fixation. Onset of posttraumatic osteoarthritis was most often found after the hybrid fixation technique (55%). CONCLUSION: Surgical management of patellar fractures remains crucial but fracture fixation using plating systems or small fragment screws is least associated with postoperative complications. TRIAL REGISTRATION: Trial registration number (DRKS):00027894.

Incisional negative pressure wound therapy to reduce surgical-site infections in major limb amputations: a meta-analysis.

Purpose: Incisional negative pressure wound therapy (iNPWT) has shown effectiveness in the treatment of high-risk surgical wounds. Especially patients with diabetes-induced peripheral arterial disease undergoing major limb amputation have a high intrinsic risk for post-surgical wound infections. While normal gauze wound dressings do not cause stimulation of microvasculature, iNPWT might improve wound healing and reduce wound complications. The purpose of this study was to systematically review the literature for rates of wound complications and readmissions, as well as post-surgical 30-day mortality. Methods: We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score >60, non-traumatic major limb amputation, and adult patients. Traumatic amputations and animal studies were excluded. Relevant articles were reviewed independently by referring to the title and abstract. In a meta-analysis, we compared 3 studies and 457 patients. Results: A significantly overall lower rate of postoperative complications is associated with usage of iNPWT (odds ratio (OR) = 0.52; 95% CI: 0.30-0.89; P = 0.02). There was no significant improvement for 30-day mortality, when iNPWT was used (OR= 081; 95% CI: 0.46 - 1.45; P = 0.48). Nevertheless, we did not note a significant difference in the readmission rate or revision surgery between the two groups. Conclusion: Overall, the usage of iNPWT may reduce the risk of postoperative wound complications in major lower limb amputations but does not improve 30-day mortality rates significantly. However, to anticipate surgical-site infection, iNPWT has shown effectiveness and thus should be used whenever applicable.

Fracture dislocation of the humerus with intrathoracic humeral head fragment - A case report and review of the literature.

We present a rare case of humeral fracture dislocation with intrathoracic humeral head fragment. A 74-year old female was transferred to a major trauma facility after falling on her arm while gardening. An intrathoracic humeral head fragment was diagnosed after initial imaging. In correspondence with the department of thoracic surgery, the decision was made to remove the intrathoracic fragment thoracoscopically and succeed with a reverse total shoulder arthroplasty.

Treatment, recurrence rates and follow-up of Tenosynovial Giant Cell Tumor (TGCT) of the foot and ankle-A systematic review and meta-analysis.

BACKGROUND: The tenosynovial giant cell tumor (TGCT) is a usually benign lesion which arises from the synovium. It affects joints, tendon sheaths and bursae. The clinical course is often unpredictable, and local recurrences frequently occur. The aim of this study was to describe different treatment options, surgical complications, and to develop a follow-up regime based on a systematic literature review and meta-analysis of foot and ankle lesions. METHODS AND RESULTS: 1284 studies published between 01/1966 and 06/2021 were identified. 25 met the inclusion criteria, with a total of 382 patients. Of these, 212 patients had a diffuse (dTGCT) and 170 a localized (lTGCT) TGCT. Patients with a dTGCT had a mean age of 36.6±8.2 years, and 55% were female. The overall complication rate was 24% in dTGCT, irrespective of the therapeutic procedure; the mean follow-up was 37.9±27.4 months with a recurrence rate of 21%, and recurrences occurred between 3 and 144 months, the vast majority (86%) within the first 5 years following intervention. Patients with a lTGCT had a mean age of 31.2±5.7 years, and 53% were female. Complications occurred in 12%. The mean follow-up was 51.1±24.6 months, the recurrence rate was 7%, and recurrence occurred between 1 and 244 months after intervention. CONCLUSION: Diffuse TGCTs of the foot and ankle region have a remarkable recurrence rate irrespective of therapeutic procedures, and most lesions reoccurred within 5, with more than half of these in the first 2 years. The lTGCTs are well treatable lesions, with a low recurrence and a moderate complication rate. Based on these findings, we propose a follow-up regime for the dTGCT including a clinical survey and MR imaging 3 months after surgical intervention (baseline), followed by twice-yearly intervals for the first 2 years, yearly intervals up to the fifth year, and further individual follow-up due to the fact that recurrences can even occur for years later. For the lTGCT a clinical survey and MRT is proposed after 3-6 months after intervention (baseline), followed by annual clinical examination for 3 years, and in case of symptoms MR-imaging. Larger prospective multi-center studies are necessary to confirm these results and recommendations.

Evaluation of the influence of platelet-rich plasma (PRP), platelet lysate (PL) and mechanical loading on chondrogenesis in vitro.

The aim of this work is to investigate the capability of PRP as an adjuvant therapy to autologous chondrocyte implantation (ACI) in combination with multi-axial load with respect to cartilage regeneration. Articular cartilage shows poor repair capacity and therapies for cartilage defects are still lacking. Well-established operative treatments include ACI, and growing evidence shows the beneficial effects of PRP. Platelets contain numerous growth factors, among them transforming growth factor beta (TGF-ß). Dynamic mechanical loading is known to be essential for tissue formation, improving extracellular matrix (ECM) production. For our ACI model monolayer expanded human chondrocytes were seeded into polyurethane scaffolds and embedded in fibrin (hChondro), in PRP-Gel (PRP), or in fibrin with platelet lysate (PL), which was added to the media once a week with a concentration of 50 vol%. The groups were either exposed to static conditions or multi-axial forces in a ball-joint bioreactor for 1 h per day over 2 weeks, mimicking ACI under physiological load. The culture medium was collected and analyzed for glycosaminoglycan (GAG), nitrite and transforming growth factor beta 1 (TGF-ß1) content. The cell-scaffold constructs were collected for DNA and GAG quantification; the expression of chondrogenic genes, TGF-ß and related receptors, as well as inflammatory genes, were analyzed using qPCR. Loading conditions showed superior chondrogenic differentiation (upregulation of COL2A1, ACAN, COMP and PRG4 expression) than static conditions. PRP and PL groups combined with mechanical loading showed upregulation of COL2A1, ACAN and COMP. The highest amount of total TGF-ß1 was quantified in the PL group. Latent TGF-ß1 was activated in all loaded groups, while the highest amount was found in the PL group. Load increased TGFBR1/TGFBR2 mRNA ratio, with further increases in response to supplements. In general, loading increased nitrite release into the media. However, over time, the media nitrite content was lower in the PL group compared to the control group. Based on these experiments, we conclude that chondrogenic differentiation is strongest when simulated ACI is performed in combination with dynamic mechanical loading and PRP-gel or PL supplementation. An inflammatory reaction was reduced by PRP and PL, which could be one of the major therapeutic effects. Loading presumably can enhance the action of TGF-ß1, which was predominantly activated in loaded PL groups. The combination of load and PRP represents an effective and promising synergy concerning chondrocyte-based cartilage repair.

Immunohistochemical analysis of sensory corpuscles in human transplants of the anterior cruciate ligament.

BACKGROUND: Sensory nerve endings in ligaments play an important role for the proprioceptive function. Clinical trials show that the sense of body position does not fully recover in the knee joint after reconstructive surgery of the ruptured anterior cruciate ligament. The aim of this study is to identify sensory corpuscles in autogenous and allogenous transplants of the ligament and to compare their quantity between the used allografts and autografts. METHODS: Thirty-three patients were included in this study. Three patellar tendon allografts, 14 patellar tendon autografts and 12 semitendinosus autografts were harvested during revision surgery after traumatic rerupture of the graft. The control consisted of 4 healthy anterior cruciate ligaments after fresh rupture. After haematoxylin staining, immunohistochemical analysis was performed using antibodies against S100, p75 and PGP9.5. Microscopical examination was carried out, and the number of mechanoreceptors was counted. Statistical analysis was performed using the Mann-Whitney U test. RESULTS: Two types of mechanoreceptors were identified in each graft: Ruffini corpuscles and free nerve endings. The number of Ruffini corpuscles per square centimeter was the highest in the control. Comparing the grafts, the highest number of receptors could be detected in the semitendinosus autograft. The amount of free nerve endings was higher in the semitendinosus and patellar tendon autografts than in the control; the allografts showed the lowest number of receptors. With increasing time after reconstruction, the number of both types of receptors showed a decrease in the semitendinosus graft, whereas it increased in the patellar tendon graft and allograft. The number of mechanoreceptors in the semitendinosus and patellar tendon graft decreased over time after graft-failure, whereas it increased slightly in the allograft. CONCLUSION: This study was the first to identify mechanoreceptors in human transplants of the anterior cruciate ligament. The partial increase in the number of receptors over time after reconstruction could indicate a reinnervation of the grafts.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment.

BACKGROUND: Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate. METHODS: Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d'Aubigne and the EQ. 5D-3 L scores. RESULTS: Over an 11-year period (2004-14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d'Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts. CONCLUSION: Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients. TRIAL REGISTRATION: DRKS, no. 00000488 . Registered 14th July 2010 - Retrospectively registered.

Evaluation of strategies for the treatment of type B and C pelvic fractures: results from the German Pelvic Injury Register.

Aims: The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods: The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results: Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion: Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973-83.

Current status of anti-inflammatory therapy for posttraumatic osteoarthritis.

Although there is ample evidence that intra-articular injuries are associated with the up-regulation of pro-inflammatory cytokines, the success of anti-inflammatory, disease-modifying treatments to prevent posttraumatic osteoarthritis (PTOA) remain uncertain. To summarize the current status of anti-inflammatory therapy for PTOA, we conducted a systematic review. 9 clinical studies in humans were identified applying anti-inflammatory agents to prevent or treat PTOA. A total of 347 patients aged an average 41 ±â€ˆ14 years were included in this review. 5 studies had comparable designs with randomized allocation. Those studies of course had a statistically significant higher Coleman Methodology Score (65 ±â€ˆ6) than the case-control studies (39 ±â€ˆ13, p = 0.013). The most frequently reported main outcome parameter was pain assessed by different scales (n = 7), the most examined joint the knee (n = 7). The majority of the analyses (n = 6) focused on the intra-articular (IA) application of hyaluronic acid (HA) reporting mainly positive effects. One study stated positive results following IA administration of Interleukin 1 receptor antagonist in -patients presenting rupture of the anterior cruciate ligament. Platelet-rich plasma was also used to relieve symptoms following acute injury, but the study quality was too low to conclude any effects. Although the initial data, especially regarding IA HA injection, are encouraging, study designs differ substantially. Therefore, current data does not allow us to conclude that anti-inflammatory therapy following acute injuries has beneficial effects on short- or long-term outcomes.

[Comparing effectivity of VAC therapy for treatment of infections following arthroplasty or soft-tissue surgery]. / Vergleich der Effektivität der VAC-Therapie bei der Behandlung von Prothesen- und Weichteilinfektionen.

BACKGROUND: Although vacuum-assisted wound closure (VAC) has been developed into a standard technique in septic surgery, reliable data about the efficacy of the treatment are still lacking. PATIENTS: Postoperative infections after arthroplasty or soft-tissue surgery were identified using a prospective database for complications (Critical Incidence Reporting System) which was retrospectively supplemented with items for evaluation of VAC therapy. Eradication success of infection was analysed considering epidemiological parameters, course of treatment, and characteristics of causing bacterial strains. Furthermore, serological C-reactive protein (CRP) concentrations were evaluated for diagnostic and prognostic reliability. RESULTS: 92 patients with an average age of 60 ± 4 years were included in the study. Patients with soft tissue infections (STI, n = 53) were statistically significant younger compared to patients with infections following arthroplasty (AI, n = 39) (53 ± 6 vs. 70 ± 4 years; p < 0.001), but the probability for eradication success was not dependent on age. Mortality was 9-fold higher in the AI group (p < 0.01). Patients with infected endoprostheses were longer treated on intensive care units (6.1 ± 8.4 vs. 3.5 ± 6.5 days; p < 0.01), but there was no statistically significant association to eradication success. Probability for eradication of infection was with 81 % statistically significant higher in the STI group compared to 38 % in the AI group (p < 0.001). Early infections in the AI group were associated with a better healing success when compared to chronic infections (p < 0.05). The same correlation could be shown for the removal of implant (p < 0.0001). Aerobic fermenting bacteria were less effectively eradicated than anaerobic germs following soft-tissue infections (p < 0.01). In cases of osteomyelitis following soft-tissue infection, the probability for eradication of infection was impaired (p < 0.001). Kind and quality of final wound closure in the STI group were statistically significantly associated with eradication success (p < 0.001). There was no critical value concerning the number of revisions until healing of infection was reached. CRP values were higher in the AI group and associated with the prognosis (p < 0.05). CONCLUSION: Probability of eradication success using VAC therapy is higher after soft-tissue infections compared to infections following arthroplasty. Accordingly, mortality is higher in this group. Chronic courses have worse chances for healing in both groups. For serological CRP values a prognostic relevance could be shown.

Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome.

INTRODUCTION: There is no consensus on optimal treatment strategy for Mason type II-IV fractures. Most recommendations are based upon experts' opinion. METHODS: An OVID-based literature search were performed to identify studies on surgical treatment of radial head and neck fracture. Specific focus was placed on extracting data describing clinical efficacy and outcome by using the Mason classification and including elbow function scores. A total of 841 clinical studies were identified describing in total the clinical follow-up of 1264 patients. RESULTS: For type II radial head and neck fractures the significant best treatment option seems to be ORIF with an overall success rate of 98% by using screws or biodegradable (polylactide) pins. ORIF with a success rate of 92% shows the best results in the treatment of type III fractures and seem to be better than resection and implantation of a prosthesis. For this fracture type the ORIF with screws (96%), biodegradable (polylactide) pins (88%) and plates (83%) showed the best results. In the treatment of type IV fractures similar results could be found with a tendency of the best results after ORIF followed by resection and implantation of a prosthesis. If a prosthesis was implanted, the primary implantation seems to be associated with a better outcome after type III (87%) and IV (82%) fractures compared to the results after a secondary implantation. DISCUSSION: Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence. LEVEL OF EVIDENCE: IV.

Autologous chondrocyte implantation in children and adolescents.

PURPOSE: Autologous chondrocyte implantation (ACI) is a well-established treatment method for cartilage defects in knees. Age-related grouping was based on expression data of cartilage-specific markers. Specificities of ACI in the different populations were analysed. METHODS: Two hundred and sixty-seven patients undergoing ACI in the knee between 2006 and 2010 were included in this analysis. Cell characteristics and expression data of cartilage-specific surface markers as CD44, aggrecan and collagen type II were statistically analysed for age association. Epidemiological data of the defined groups were compared. Course of treatment was evaluated using MRI. RESULTS: A correlation analysis showed statistically significant associations between age and aggrecan or collagen type II expression in all patients <30 years. A cluster analysis could predict age-dependent expression of these markers separating groups with an average age of 18.1 ± 2.3 and 23.6 ± 4.2 years, respectively (p < 0.02). Discriminance analysis suggested the age border between adults and juveniles at about 20 years. There was no influence of age on cell characteristics or CD44 expression. In the 19 of 267 patients with an age ≤18 years, gender distribution was not different compared to adults, but patella was significantly more affected. Cartilage lesions were mainly caused by osteochondritis dissecans (OCD) and trauma. The Knee Osteoarthritis Scoring System in MRI reached 4.8 ± 2.3 points before, declining to 3.3 ± 2.3 points 6 and 12 months after the operation. CONCLUSIONS: Age-related expression of cartilage-specific markers allows definition of adolescents in cartilage regenerating surgery. Chondromalacia in these patients is mainly caused by OCD or trauma. LEVEL OF EVIDENCE: Case series, Level IV.

Humerus shaft fractures - where are we today?

Humeral shaft fractures account for about 1-3% of all fractures. These fractures are regarded as the domain of non-surgical management. This is certainly still the contemporary view but there is an obvious trend towards surgical stabilization. Surgical treatment of humeral shaft fractures has nonetheless been greatly facilitated by the development of new implants. In particular, a new generation of nails that general permit immediate mobilization have become available for improved management of longitudinal and multi-segmental fractures. Retrograde and antegrade nails have advantages and disadvantages and selection procedure is often based on the distal or proximal location of the fracture. Plates also offer an alternative for certain indications and have advantages at the proximal and distal shaft in particular. If there is primary lesion of the radial nerve, exploration is not very advisable, but in the absence of remission exploration can be conducted after several months with the same degree of success. Since the published literature offers no comparative studies with a high level of evidence, our statement can only be regarded as an up-to-date recommendation in the hope that future prospective randomized studies will address this issue.

Clinical outcome after surgical treatment of transitional fractures of the distal tibia in children.

PURPOSE OF THE STUDY: Fractures affecting a partially closed physis are described as transitional fractures. The distal tibia is one of the most common locations for transitional fractures second only to the distal radius. Aim of this retrospective study was to evaluate the clinical and radiological results after surgical treatment of transitional fractures of the distal tibia. PATIENTS AND METHODS: From May 2003 to March 2009 24 children (median age 14 years) received surgical treatment for transitional fractures of the distal tibia. 89% (21/24) of patients were followed up after 27.5 (range 6 to 72) months to assess functional out come (using the AO Foot and Ankle Score). RESULTS: Nine girls and 15 boys were included in the study with the girls being younger on average (12.4 ± 0.9 vs. 14.3 ± 1.1 years, p = 0.00013). Two-plane fractures were present in 4 cases, 15 and 5 children sustained tri-plane I and II fractures, respectively. Median preoperative fracture displacement was measured at 4 mm (range 3 to 11 mm). Traumatic supination of the ankle joint during sports activities was the predominant injury mechanism (18/24 cases) followed by bicycle or motorbike accidents (6/24). A satisfactory reduction (1 mm or less) was achieved in all but one patient. In this case revision surgery was necessary to restore anatomical reduction. No perioperative complications occurred in the remaining 23 cases. Metal implants were removed upon fracture consolidation after 8.2 ± 6.7 months. At the time of follow-up none of the children were impaired in activities of daily living and there were no restrictions in sporting activity. All patients sco- red good or excellent results on the AO Foot and Ankle Score. DISCUSSION: Surgical stabilization can be recommended as a safe and effective treatment strategy in displaced transitional fractures of the distal tibia and will lead to good or excellent mid term results.

Surgical treatment of supracondylar humerus fractures in children.

PURPOSE OF THE STUDY: Surgical techniques for the treatment of supracondylar fractures in children are repeatedly the subject of discussion. The aim of the present study was to compare experience with the technique of crossed Kirschner wires at our own hospital with current literature. PATIENTS AND METHODS: In the period from 2000-2006 a total of 86 children aged 1.7 to 12.7 years were treated by means of crossed K-wire osteosynthesis. Follow up was conducted at an average of 32 months. Outcomes were evaluated based on von Laer's criteria. RESULTS: Reported complications were migration of the K-wires in 7% of cases and secondary dislocation and re-operation in 4% of cases. Lesion of the radial nerve was diagnosed postoperatively in two cases. Hospital stay was 1.5 days on average. Postoperative immobilization in an upper arm splint and implant removal after 6 weeks on average. 57% of the children received physiotherapy during the course of treatment. Slight varization was found in 11% of children and an unsatisfactory range of motion in 13%. Satisfactory outcomes were recorded for 83% of patients. CONCLUSION: K-wire osteosynthesis is associated with a low complication rate and continues to be a safe standard procedure for the stabilization of supracondylar humerus fractures. Key words: supracondylar humerus fracture, Kirschner wires, paediatric fractures.

Injury patterns in polytraumatized children and consequences for the emergency room management.

INTRODUCTION: The effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of com- mon injury patterns, incidence, mortality, and consequences. The needed initial radiological imaging remains controversial and should be adapted to the expected injury pattern. PATIENTS AND METHODS: In this retrospective study, the injury patterns of 56 polytraumatized paediatric patients (age ≤ 16 years) in the period from December 2001 to May 2009 were evaluated. All children were initially diagnosed with a whole body CT scan. The cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. The AIS (Abbreviated Injury Scale) and ISS (Injury Severity Score) were used to classify the severity of injuries in different body regions. Moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. RESULTS: The mean ISS was 30 ± 13 in 38 boys and 18 girls with a mean age of 10 years. The lethality was 13% and 4% in the first 24 hours. The most severe and most frequent injury was craniocerebral trauma in 89% with an AIS ≥ 3 in 80%. Surgical intervention of the head was done in 41%. Thorax injuries were found in 63% with 57% with an AIS ≥ 3 and in 11% a thoracic drainage was needed. Abdominal trauma was found in 34% (surgery 4%) with an AIS ≥ 3 in 32%. Fractures of the spine occurred in 14% (surgery 5%) with an AIS ≥ 3 in 4% and pelvic injuries were diagnosed in 16% (surgery 4%) with an AIS ≥ 3 in 14%. Injuries of the upper extremity were found in 23% (surgery 11%) with an AIS ? 3 in 5% and of the lower extremity in 32% (surge- ry 16%) with an AIS ≥ 3 in 13%. CONCLUSION: The authors recommend a whole body CT scan in children who are potentially polytraumatized because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery. The quickest imaging with a high sensitivity is the whole body CT scan which provides the clinicians with relevant information to initiate life-saving therapy.

[Graft integration in the lumbar spine of bovine cancellous bone compared to autologous iliac crest in a sheep model]. / Das Einwachsverhalten von trikortikalen Beckenkammspänen und lösungsmittelkonservierter, boviner Spongiosa bei ventraler Spondylodese der Lendenwirbelsäule im Schafsmodell.

BACKGROUND: Spinal injuries are common and a standard procedure for the stabilisation of spinal injuries is ventral spondylodesis with an autograft from the iliac crest. Because of the high incidence of harvesting complications there is a need to search for alternative materials. The aim of our study was to evaluate graft integration in the lumbar spine of bovine cancellous bone compared to autologous iliac crest material. MATERIAL AND METHODS: Two groups of eight female adult sheep (median age 3 years, range 2.4-3.8 years) received surgical treatment in the form of anterior monosegmental spondylodesis. The spondylodesis was performed in all animals in the motion segment L3/4 through a lateral approach with the animals lying on their right sides. To produce serial sections, the explanted vertebral segments were implanted in methyl methacrylate. On one side the histological preparation was examined qualitatively and in addition we analysed the quantity of the bone structure with special software. RESULTS: The bone structure in both groups did not differ significantly and demonstrated integration of the grafts in the adjacent vertebral bodies. Fractures and lysis occurred in the region of the intervertebral disc and were more frequent in the group with the bovine graft. CONCLUSION: The bony integration of the grafts of both groups was not significantly different and showed good results. Almost all of the bovine grafts fractured or presented regions of lysis. In our opinion bovine cancellous bone graft is not a good alternative to autologous iliac crest.

[Monteggia lesions in children--a clinical trial]. / Monteggia-Verletzungen im Kindesalter.

BACKGROUND: The Monteggia lesion is a rare injury of the elbow in children. This lesion is defined as a shaft fracture of the ulna combined with a luxation of the radial head. The primary problem in this injury is the proper diagnosis because the misalignment of the radial head is often missed. The purpose of this study was to retrospectively analyse the results after Monteggia lesions in children. PATIENTS AND METHODS: Ten children between two and nine years of age (six boys and four girls) were clinically assessed using the Morrey score. They were treated in our department between December 1999 and October 2004. RESULTS: The Morrey score after 54 months (min.: 26/max.: 84) had a median value of 100 points with 100 being the maximum (min.: 95/max.: 100). We found two complications, a combined lesion of the radial and ulnar nerves which completely recovered after six months. In one case a k-wire dislocated, which was removed earlier. DISCUSSION: If the Monteggia lesion in children is correctly diagnosed and treated early enough, only good and very good results may be expected. After delayed diagnosis and treatment, the clinical results are not as good or even very poor.

[The reversed locked internal plate fixator as an alternative internal fixation of problematic proximal femur fractures]. / Der umgedrehte Plattenfixateur zur osteosynthetischen Stabilisierung bei erschwerter Frakturheilung am proximalen Femur.

AIM: The aim of the study was to evaluate the application of a locked internal fixator in complex fractures of the proximal femur, in which the internal fixation with standard implants was not possible due to poor quality of bone or already failed internal fixation in the past. METHOD: Ten patients suffering from a pertrochanteric (n = 5), periprosthetic (n = 1) or subtrochanteric (n = 4) femural fracture between 2003 and 2008 were prospectively registered, underwent open reduction and internal fixation with an "upside-down" femur LISS (less invasive stabilisation system) and were followed up. In all these patients a primary internal fixation had failed or the local bone situation and circulation were poor. The mean follow-up was 14 +/- 25 months. X-ray images and a clinical examination were performed at each appointment. RESULTS: All fractures reached a primarily stable fixation with the locked internal plate fixator. Seven patients showed a complete bone healing after 3 months of follow-up and could bear full body weight afterwards. Three patients with preoperatively existing vascular disease or chronic osteomyelitis showed a deep wound infection postoperatively, which led to the explantation of the implant. CONCLUSIONS: The "reversed" locked internal fixator could be a successful alternative implant for stabilisation of proximal femur fractures which could not be fixated by standard implants due to poor bone quality and circulation. It can also be used as a salvage procedure after internal failed fixation in proximal femur fractures.

[Clinical evaluation of evidence-based criteria for CT diagnostics in the treatment of mild traumatic brain injury]. / Klinische Evaluation evidenzbasierter Kriterien für die CT-Diagnostik bei der Behandlung der Commotio cerebri.

AIM: The mild traumatic brain injury (MTBI) is one of the most frequent diseases treated in emergency departments. Extensive studies addressing evidence-based treatment criteria have been published, the indication for CT scans depending on clinical symptoms appeared to be one of the critical issues. In this study, the question was raised whether or not the developed evidence-based criteria may be transferred to the patients of a German level 1 trauma centre. PATIENTS AND METHODS: Within 2 years (2004/05) 1841 patients with a traumatic brain injury were treated, 1042 patients with a mild traumatic brain injury and with an age over 14 years were included in the study. The indication for a head CT scan was checked by criteria of a phase 3 study (New Orleans Criteria - NOC). Furthermore, the length of hospitalisation, number and character of secondary aggravation, and kind of inpatient care were analysed. RESULTS: 69.5 % of our patients were diagnosed with the help of a CT scan, according to the evidence criteria 98.8 % of the patients should have been scanned (p > 0.001). A secondary aggravation caused by a cerebral lesion was found in 3 patients without a CT scan, all of these patients would have been scanned according to the NOC (n. s.). The fraction of patients with alcohol intoxication reached 44 %, a rate that is significantly higher compared to other international studies. These patients were not as often scanned (p < 0.001) and had a shorter hospital stay (p < 0.001) compared to other patients. Duration of hospital stay was prolonged depending on the severity of the brain injury and occurrence of secondary aggravation (p < 0.001). CONCLUSION: Summarising, the high sensitivity of the investigated evidence-based criteria (NOC) could be confirmed, but the application would not have led to a reduction of CT scans within our population.