[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]. / Management vorbestehender Antikoagulation zur zeitgerechten Versorgung von hüftnahen Frakturen.

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

[The new treatment procedure of the German statutory accident insurance: From the perspective of a community hospital]. / Die neuen Heilverfahren der DGUV: Aus der Sicht eines Städtischen Krankenhauses.

The requirements of the German statutory accident insurance (DGUV) for the new treatment procedure were presented on 1 January 2013 in a new catalogue. The implementation of the certification of hospitals for the very severe injury procedure (SAV) by the DGUV should have been completed by 2014. These requirements placed high demands on trauma-oriented hospitals because of the high structural and personnel prerequisites. The background to the new organization was the wish of the DGUV for quality improvement in patient treatment in hospitals for patients with very severe occupational and occupation-related trauma by placement in qualified centers with high case numbers. No increase in income was planned for the hospitals to cope with the necessary improvements in quality. After 2 years of experience with the SAV we can confirm for a community hospital that the structural requirements could be improved (e.g. establishment of departments of neurosurgery, plastic surgery and thoracic surgery) but the high requirements for qualification and attendance of physicians on duty are a continuous problem and are also costly. The numbers of severely injured trauma patients have greatly increased, particularly in 2015. The charges for the complex treatment are not adequately reflected in the German diagnosis-related groups system and no extra flat rate funding per case is explicitly planned in the DRG remuneration catalogue. The invoicing of a center surcharge in addition to the DRG charges has not been introduced.

[Medial femoral neck fractures: possible reasons for delayed surgery. Part 2: Results of data from external inpatient quality assurance within the framework of secondary data evaluation]. / Mediale Schenkelhalsfraktur: mögliche Gründe für eine verzögerte operative Versorgung. Teil 2: Ergebnisse der Daten der externen stationären Qualitätssicherung im Rahmen sekundärer Datennutzung.

PROBLEM: In Germany a disproportionate number of patients with a femoral neck fracture still experience a delay in surgery. In 2008 delays of more than 48 h after admission occurred for 15.4 % of patients. This leads to increases in surgical and general complications as well as pressure sores. OBJECTIVE: Possible reasons that lead to delayed operations were investigated in a nationwide study. DATA AND METHODS: Using nationwide data from the German inpatient external quality assurance program from the year 2008 the reasons for performing operations later than 48 h after hospital admission were examined both exploratory and analytically using a multiple logistic regression model considering combined effects. RESULTS: Surgery was more frequently delayed for patients who were admitted to hospital on Friday or Saturday, patients with a higher American Society of Anesthesiologists (ASA) classification, men, patients with malignant diseases, in the presence of infectious diseases and patients with heart disease. Operations carried out within the first 48 h were more frequent with displaced fractures and in the presence of hypertension or mental illness. The volume per hospital had no consistent effect on the time delay of surgery. During the week no significant differences between the departments were detected. On Friday or Saturday surgery was delayed more often when patients were admitted to a department of general surgery than to a department of trauma surgery or orthopedics. CONCLUSIONS: There are medical and non-medical reasons for delayed surgery of femoral neck fractures. Studies have confirmed that delayed surgery for femoral neck fracture harms the patients. Organizational reasons which prevent an immediate operation, e.g. admission on Friday or Saturday, should therefore be eliminated by improvements in hospital organization and staffing. These can be measures of individual hospitals or of several hospitals in cooperation. The target should be to ensure a comprehensive and timely provision of the highest quality care even at the weekend.

[Osteoporotic fractures of the proximal femur. What's new?]. / Osteoporotische Frakturen des proximalen Femurs. Was gibt es Neues?

Proximal femoral fractures in the elderly are still increasing and are almost always associated with osteoporosis. Especially the over 80-year-olds are increasing and at risk in this respect. In the treatment of these patients new knowledge has been achieved over the last years. An interdisciplinary, multimodal approach with early involvement of internists, geriatricians, anesthetists, osteologists, social workers, care facilities and outpatient trauma and orthopedic surgeons seems to generate a better outcome with fewer complications. In cases of suspected proximal femoral fracture diagnostic imaging should include a computed tomography scan of the posterior pelvic ring to detect commonly occurring fragility fractures of the lateral mass of the sacrum. Early surgery within the first 48 h has a significant positive effect with respect to general and local complications and early mortality. Medical and organizational barriers to an early operation, such as anticoagulant medication, limited capability of communication due to mental dysfunction and lack of operation capacity are continuously declining and subsequently complication rates are decreasing annually in Germany. Endoprosthetics are still associated with higher perioperative mortality than osteosynthesis (4.4 % versus 5.8 %). The innovations in the field of implants and surgical technique also contribute to these lower complication rates. While endoprosthetic treatment is still the gold standard for severely dislocated femoral neck fractures, non-dislocated or slightly dislocated fractures should be fixed with a stable extramedullary implant. For pertrochanteric fractures extramedullary stabilization can only be recommended for stable types of fractures. Every instable trochanteric fracture should be fixed with an intramedullary implant. The use of third generation nails has implicated a significant reduction of complication rates regarding cut-out and reoperations. Rotational fixing of the head-neck fragment with angular stable blade systems and the option of polymethyl-methacrylate (PMMA) cement augmentation are promising advantages that still remain to be clinically tested. Endoprosthetic treatment of pertrochanteric femoral fractures still has 3 times higher complication rate and is implemented only in exceptional situations.

[Traumatic dissection of the internal carotid artery following whiplash injury. Diagnostic workup and therapy of an often overlooked but potentially dangerous additional vascular lesion]. / Traumatische Dissektion der A. carotis interna nach HWS-Beschleunigungstrauma. Diagnostik und Therapie einer häufig übersehenen aber potenziell gefährlichen Begleitverletzung.

We report on the case of a 33-year-old male patient who was brought to the emergency room of our hospital after suffering a high-energy trauma due to an automobile accident. Besides a scaphoid fracture there were no signs of any neurological deficits. After several hours without clinical symptoms the patient developed dysarthria as the first manifestation of local cerebral ischemia based on a traumatic dissection of the internal carotid artery. Under systemic high-dose heparin therapy, fast and complete remission of all neurological disorders could be achieved. In the course of time a dissecting aneurysm developed. Temporary anticoagulation with phenprocoumon was started in the meantime and no further complications have appeared up to now. Besides presenting this absorbing case, this article highlights the diagnostic and therapeutic regime in cases of a traumatic dissection of supra-aortal arteries for rapid and adequate management of this rare but potentially dangerous complication.

[CT-findings in penetrating captive bolt injuries to the head and brain: analysis of the trauma-related CT-findings and review of the literature]. / CT-Befunde bei penetrierenden Kopfverletzungen durch Bolzenschussgeräte--Analyse der verletzungsspezifischen CT-Befunde und eine Übersicht über die relevante Literatur.

Penetrating gunshot injuries to the head and brain are rare in Germany and the rest of Western Europe. Due to the small number of cases over here no consistent diagnostic and therapeutic standards exist in this respect. Thus these kinds of injuries present a great challenge to the attending physicians. Most of these violations are a result of a suicidal attempt or an accident. Beside violations by firearms also penetrating injuries to the head and brain due to captive bolt devices, as used in slaughtery business for the "humane" killing of animals, occur from time to time. The impact on the head differs from that caused by firearms because no projectile is leaving the barrel and the used bolt, as a fix part of the device, does not remain in the affected tissue. That implies characteristic results within the radiological imaging that might be pathbreaking for the further treatment, because the origin of such a head injury is often unknown during primary care. Consequently the knowledge of these specific findings is central to the radiologist to make the appropriate diagnosis. Based on some clinical examples the trauma-related CT-findings are introduced and a short overview of the relevant literature is also given.

[Trochanteric femoral fractures: anatomy, biomechanics and choice of implants]. / Pertrochantäre Femurfrakturen: Anatomie, Biomechanik und Wahl der Implantate.

The objective of any surgical care of a trochanteric femoral fracture should be the achievement of a stable osteosynthesis that allows early full weight-bearing mobilisation of the patient, because long-term immobilisation soon becomes a vital threat to the affected patients who are usually elderly with correlating comorbidities. The anatomical references of the proximal femur and the structure of the hip joint contain some specifics that play an essential role in the incurrence of a trochanteric femoral fracture and the planning of the osteosynthesis as well. With reposition and fracture stabilisation particular importance must be attached to the collo-diaphyseal and the antetorsion angle so that they do not interfere with the functional interaction of the hip and knee joint. Uncomplex trochanteric fractures ordinarily stabilise sufficiently after reposition so that even an extramedullary implant can ensure full weight-bearing stability. With evermore distal fracture course and intertrochanteric comminution zone, rotational instability and pivot transfer of the fracture area to lateral and caudal are followed by an increase of the dislocating forces. These kinds of fractures (A2 and A3 according to the AO/ASIF classification) profit from an intramedullary and rotationally stable osteosynthesis. Basically primary total hip arthroplasty is a potential option for surgical care of a trochanteric fracture in elderly patients with relevant coxarthrosis. However this procedure can only be recommended in cases of a stable uncomplex fracture. The more the medial interlocking of the proximal femur is destroyed the more difficult it will be to primarily implant a total hip prosthesis with good offset and without a varus and rotational failure in the fracture zone.The current studies in the main show disadvantages due to increased complications in these patients, so that in cases of an unstable trochanteric fracture a primary osteosynthesis should be performed followed by total hip arthroplasty after fracture consolidation has occurred.

Fractures of the femoral neck.

The ideal treatment of the intracapsular fracture of the femoral neck still is subject of discussion. The demographic development of the population in Europe with fractures of the neck of femur being typical in the older patient, requires conclusive and stringent concepts of treatment. Adequate and patient oriented therapy should be promoted, regional differences and provisional deficiencies need to be adjusted in order to minimize the rate of complications. The guideline "Schenkelhalsfraktur" of the German board of trauma surgeons, the 'Deutsche Gesellschaft für Unfallchirurgie', and the article at hand are meant to serve as a manual for the trauma surgeon. Based on evaluated data it simplifies rational decision-making for treatment of fractures of the proximal femur. Moreover, secondary prophylaxis as well as the subsequent outpatient treatment and the social reintegration of the patients recovering from fractures of the femoral neck remains vital- ly important. After all, even with ideal treatment of the fracture more than half of the patients are impaired for a long time and one out of four permanently depends on nursing assistance.

[Balloon kyphoplasty in the treatment of osteoporotic vertebral fractures: indications - treatment strategy - complications]. / Ballonkyphoplastie zur Behandlung osteoporotischer Wirbelfrakturen: Indikationen - Behandlungsstrategie - Komplikationen.

BACKGROUND: Considering the demographic changes in the populations of Germany and Europe as a whole, the field of geriatric traumatology is gaining more and more importance within the specialty of orthopedic and trauma surgery. The high prevalence of osteoporosis in this specific group of patients poses a special challenge, with vertebral compression fractures being the by far most common osteoporosis-related fractures. These fractures present with acute as well as chronic back pain leading to severe consequences for the affected patients. Mobility and quality of life are often heavily impaired. Furthermore, higher morbidity and mortality as well as higher risk for further fractures have been proven in these patients. METHOD: Balloon kyphoplasty has become a more frequently used therapy and is now offered broadly. This treatment addresses stable fractures not involving the posterior margin of the vertebrae. With increasing application of this surgical procedure the number of complication reports is also rising. The following article gives an overview of the technique, indications and the possible complications by giving several examples from the daily practice and reviewing the relevant literature. RESULTS: Cement leakage of the treated vertebrae is the most common complication associated with balloon kyphoplasty. In almost all cases this occurs due to too early application of the cement, not having reached its optimum in viscosity. Literature research shows a percentage rate of about 9% for cement leakage. Thus, balloon kyphoplasty provides more safety for the patient than vertebroplasty, for which cement leakage rates of up to 41% are reported. Other studies report cement leakage ratios of 4-10% for kyphoplasty versus 20-70% for vertebroplasty. Overall the percentage of cement leakage is clearly increased in osteoporotic fractures compared to non-osteoporotic fractures, with the cement leaking mainly into the spinal disc space. So far, valid data in order to further explore the consequences of intradiscal cements are lacking. Most relevant for everyday practice are cement leakages that have become symptomatic. Depending on the localisation they present with dysaesthesia culminating in radicular pain or even paraplegia. Cement leakage into vessels can, depending on the amount of cement, lead to embolism of pulmonary arteries. Complications due to the surgical technique, postoperative infections, bleeding or cardiovascular complications are rare with less than 1%. The probability for symptomatic cement leakage averages about 1.3% for balloon kyphoplasty. Another discussion, for which at present there is no evidence-based verification, is concerned with the higher risk for adjacent vertebral fractures after cement augmentation of an osteoporotic vertebral compression fracture. At present the degree of osteoporosis and more important the number of osteoporosis-related fractures must be the relevant predictor for adjacent fractures of neighbouring vertebrae. CONCLUSION: Balloon kyphoplasty is a highly standardised and widely used minimally invasive procedure for stabilising and augmenting painful osteoporotic fractures of the vertebral body. When surgery is indicated carefully and is carried out subtly, the risk of complications is reasonable and the outcome is promising. Viscosity of the used cement has to be adequate and it must not be inserted with too high a pressure. A causal connection between cement viscosity and risk of cement leakage has been proven in experimental studies. During application of PMMA cement a thorough fluoroscopic monitoring must take place in order to detect cement leakage at an early stage and if necessary stop application. These procedures should be reserved for clinical centres and surgeons who are able to surgically handle possible complications such as compression of the spinal cord. On the basis of our own experience we also recommend treatment in a hospital with an integrated osteoporosis centre and consecutive treatment in specialised outpatient care. Standards in primary care as well as after treatment can be introduced thereby. Also communication with practitioner concerned with outpatient care is simplified, which leads to enduring therapeutic outcome.

[How to become a trauma surgeon: analysis of the current situation and concepts for career development in the new common field of orthopaedics and trauma surgery--part I]. / Der Weg zum Unfallchirurgen : Situationsanalyse und Konzepte zur Nachwuchsförderung in der Unfallchirurgie im Umfeld des neuen gemeinsamen Fachs Orthopädie/Unfallchirurgie - Teil I.

The lack of clinical residents especially in the surgical domains, including orthopaedics and trauma surgery, is not only omnipresent but also a topic of lively discussions. This lack originates from sociopolitical and healthcare policy issues as well as from a loss of attractiveness of all surgical disciplines. The loss is caused by the high workload and disadvantageous working hours especially in those disciplines with a high rate of emergencies, e.g. trauma surgery. Moreover, it is caused by the poorly structured and unpredictable period of residency. In order to anticipate the bottleneck in supply due to the lack of trainees, a number of structural and contextual measures have to be taken to improve both undergraduate und postgraduate surgical training. Due to the numerous facets of the topic the first part of this analysis refers to the period until the trainee decides on the field of training.A basic insight into the field of orthopaedics and trauma surgery can already be offered far before the period of medical studies itself. During undergraduate medical education the existing structures should be modified, the characteristics of the discipline should be emphasized and the charm of combining theory and practical skills should be highlighted in order to enhance student's perception of the discipline. This might begin during preclinical training and should be continued throughout clinical training and elective courses (basic wound care, TEAM approach, AO course for students and seminars for M.D. candidates). Contextual and structural improvements of the practical year are indispensable to arouse students' interest in our discipline. These options conjoined with the actual offers for students provided by our scientific society, such as guided tours during the annual congress, travelling grants and the recently inaugurated summer school, might provide the basis for clearly structured information and offer a distinct stimulus to apply for residency in our field.

[How to become a trauma surgeon: analysis of the current situation and concepts for career development in the new common field of orthopaedics and trauma surgery--part II]. / Der Weg zum Unfallchirurgen: Situationsanalyse und Konzepte zur Nachwuchsförderung in der Unfallchirurgie im Umfeld des neuen gemeinsamen Faches Orthopädie/Unfallchirurgie--Teil II.

An increasing lack of young fellowship trainees in operative medicine, particularly in orthopaedics and traumatology and the various options to counteract this problem during the phases until the individual decision for residency and the fellowship program is made, were the focus of part I. The present part concentrates on residency and the fellowship phase including the individual perspectives after successful training. With respect to an attractive and highly qualified training in orthopaedics and traumatology, three essential points are to be made: a timely general framework, the establishment of a clinic-specific management of training and a general evaluation of training in the sense of a benchmarking system. A flexible work schedule including structural entities, such as an in-hospital day care facility for children, a structured and reliable curriculum of training according to a model curriculum to be adapted to the corresponding training unit including options of rotation to other facilities of training and the integration of nationwide education and mentoring programs represent further elements of an attractive training program. Thus the quality of training will become a decisive criterion of selection. The fellowship program for specialized traumatology inevitably leads to limitations of the whole spectrum of the field with an increasing specialization. In the future the contents of fellowship training will need a well-considered adaptation to the clinical needs and realities in the light of the emerging national trauma network program. A wide field of activity will open up to specialists in orthopaedics and traumatology with a focus on special traumatology considering the rapid changing field of hospital and outpatient care. Thus a systematic and creative reorganization of the residency and fellowship phases will overcome any problem of attractiveness.

[Medial hip neck fracture: influence of pre-operative delay on the quality of outcome. Results of data from the external in-hospital quality assurance within the framework of secondary data analysis]. / Mediale Schenkelhalsfraktur: Einfluss des Versorgungszeitpunkts auf die Ergebnisqualität. Ergebnisse der Daten der externen stationären Qualitätssicherung im Rahmen sekundärer Datennutzung.

PROBLEM: According to international and national studies and clinical guidelines, patients with medial hip neck fracture should receive surgery as soon as medically reasonable after hospitalization, preferably within 48 h. Analysis of the German quality registry data of 2006 showed, however, that in 13 out of the 16 federal states less than 85% of patients were operated on within 48. Delayed surgery was found especially during the weekend. OBJECTIVE: The objective of the study was to examine whether German data confirm that a short preoperative waiting time after hip fracture improves the outcome. The study was commissioned by the Federal Joint Committee (G-BA) and was jointly performed by the German Society for Accident Surgery (DGU) and the National Institute for Quality in Healthcare (BQS). DATA AND METHODS: The analysis is based on the data of the nationwide quality registry of the years 2004-2006. Out of a total of 129,075 patients with a medial hip neck fracture 22,171 received operative treatment later than 48 h after hospital admission. Comparable study groups were constructed with the help of a propensity score (1-to-1 matching). Study and control groups only differed in terms of delay of surgery. The comparison concerning the outcomes was made with the Fisher exact test (bilateral). RESULTS: In the group of patients with a delay of surgery longer than 48 h significantly higher rates of surgical complications (OR 1.10), general complications (OR 1.09) and pressure ulcers (1.27) were observed (all p<0.001). The in-hospital mortality showed no significant difference (OR 0.96, p=0.302). CONCLUSIONS: Patients with medial hip neck fracture should receive operative treatment without delay, if no medical contra-indications for immediate surgery. In particular appropriate organizational measures should be taken to ensure an early surgical treatment even during weekends.

[Marjolin's ulcer: malignant transformation of a crural ulcer due to posttraumatic chronic osteomyelitis]. / Das Marjolin-Ulkus : Maligne Transformation eines Ulcus cruris auf dem Boden einer posttraumatischen chronischen Osteomyelitis.

We report on the case of an 81-year-old female patient who developed a squamous cell carcinoma in a long-lasting therapy-resistant crural ulcer of the lower leg due to posttraumatic chronic osteomyelitis. Eventually the lower leg had to be amputated because of massive destruction of soft tissue and the tibia bone. Based on the desolate wound conditions plastic reconstruction by a pivoted muscle flap and surgical covering with mesh graft plastic was also necessary.The amputation stump had completely healed 6 months after surgery and the patient is fitted with an artificial limb ensuring independent mobility even outside the home. Up to the present there is no evidence of any tumor recurrence or progression.

[Quality of care after distal radius fracture in Germany. Results of a fracture register of 1,201 elderly patients]. / Die stationäre Behandlungsqualität der distalen Radiusfraktur in Deutschland: Ergebnisse eines Frakturregisters mit 1201 älteren Patienten.

BACKGROUND: This study is the first to document the quality of inpatient care provided to elderly patients with distal radius fracture in Germany. PATIENTS AND METHODS: Inpatient care provided to 1,201 patients age 65 or older with isolated distal radius fracture was documented in a prospective cohort study conducted at 242 acute care clinics in Germany between January 2002 and September 2003. RESULTS: The median patient age was 75, and nearly 90% of patients were female. Approximately 71% of patients were classified as ASA I or II, and 28% were ASA III. The most common comorbidity was arterial hypertension (60%). Seventy-five percent of patients were admitted on the day of the accident; of these, 63% had surgery on the same day, and 20% on the following day. The primary form of anaesthesia was general anaesthesia (55%). The predominant fracture management procedure was percutaneous K-wire osteosynthesis (56% of cases), followed by plate osteosynthesis (44%). The length of hospital stay after plate osteosynthesis (median 8.5 days) was more than twice as long as after K-wire osteosynthesis (median 4 days). The rate of postoperative complications typical of each procedure was around 10%. Roughly 90% of patients were discharged to home. Although evidence of osteoporosis was observed in 62% of women and 50% of men, only 7.9% of patients were prescribed osteoporosis-specific medication. CONCLUSIONS: Unexpected findings were the predominance of general anaesthesia and percutaneous K-wire osteosynthesis. Osteoporosis, affecting a majority of elderly women, is neglected in clinical practice. Good quality of care is reflected by the low rate of complications.

[Treatment of femoral neck fractures]. / Behandlung der Schenkelhalsfrakturen.

Due to the high incidence (600-900 patients/year >65 years old), the expected increase in frequency by a factor of five by 2050, and the proportionately shrinking capacity in trauma centers, femoral neck fractures are relevant to health care both economically and politically. Surgical treatment within 6 h improves results of osteosynthesis, within 24 h reduces general complications, and within 48 h reduces mortality. The literature displays great regional differences in methods and results. There is however general agreement that the hip joint should be preserved in young, active patients, regardless of fracture type and dislocation and that endoprosthesis is desirable for elderly patients with severe dislocation. The controversies begin with compressed fracture, determination of the degree of dislocation, and age and physical condition of patients who would profit from endoprosthesis. Total endoprostheses show better results in more active patients than do hemiarthroconstructions. Cemented endoprostheses are preferable in older patients due to their better function and lower postoperative pain. The DGU recommends prophylactic osteosynthesis for impacted fracture and osteosynthesis for nondislocated fracture or when closely following slightly dislocated fracture.

Intramedullary osteosynthesis in the treatment of lower extremity fractures.

AO Principles are described today as follows: * appropriate reduction * appropriate stabilization * preservation of vascularity * painless early mobilization These requirements can all be met by intramedullary osteosynthesis for suitable indications. The modern generation of nails is highly user-friendly and application of the systems is very safe. Outcome predictions favor reamed locked nailing for suitable fractures, whereby reaming should be moderate. The need to activate the dynamization option should be evaluated six to eight weeks postoperatively.

["Cutting out" in pertrochanteric fractures--problem of osteoporosis?]. / "Cutting out" bei pertrochantären Frakturen -- ein Problem der Osteoporose?

BACKGROUND: Despite the use of intramedullary fixation devices for the stabilisation of intertrochanteric fractures, the rate of complications is still high. One of the main reasons for burdensome reinterventions in 9-15% of cases is the cutting out of the fixation device through both the spongious bone and the cortical bone at the apex of the femoral head. This phenomenon is strongly connected to the reduction of the fractures achieved, the technical performance of the operation with optimal implant positioning and the resistance of the trabecular bone in the femoral head against deformation by the fixation device. The latter is very low in cases of severe osteoporosis. To prevent the complication of cutting out, it seems sensible to find the limits of load-bearing capacity of individual osteoporosis-associated features (i.e. bone mineral density) at which special additional measures or other techniques for the treatment of these patients are desired. METHODS: In a first step a new biomechanical standard test for implants stabilizing unstable trochanteric fractures was developed, which would provide predictable results depending on bone mineral density. In a second step a cut-off limit was sought for the bone density in the proximal femur that would afford stable fixation as measured by QCT (quantitative computed tomography) and DEXA (dual-energy X-ray absorptiometry). RESULTS: The developed test is realistic; it can be used to study typical cutting out phenomena on cadaver femora. In an unstable fracture model (type A 2.3 of the AO classification), the implants DHS with TSP, PFN and TGN showed a stable long-term load-bearing capacity at a bone mineral density of >0.6 g/cm3. In 5 of 32 specimens a cutting out phenomenon could be demonstrated, in 4 cases if the bone mineral density of the proximal femur was below 0.6 g/cm3 as measured by DEXA, and in one case poor performance of the implant (short screw in the femoral head) was evident. CONCLUSIONS: In cases of bone density of >0.6 g/cm3 in the proximal femur (DEXA), the standard implants for the fixation of unstable trochanteric fractures could guarantee fixation without cutting out. The critical value of sufficient bone density in our few cases seems to be around 0.6 g/cm3 as measured by DEXA. Further investigation is needed to define the limits of bone mineral density for a successful osteosynthesis. An appropriate augmentation of the trabecular bone of the femoral head or a new design of the central loading device could increase the load-bearing capacity and thus help to reduce the cutting out phenomenon. Another alternative could be the primary implantation of an endoprosthesis in the treatment of these patients.

[Morel-Lavallée lesion. A grave soft tissue injury]. / Die Morel-Lavallée-Läsion. Eine schwerwiegende Weichteilverletzung.

The Morel-Lavallée lesion is a rare condition that was first described by the French physician Maurice Morel-Lavallée in 1853. The lesion is caused by forces of pressure and shear stress at the borders of subcutaneous tissue to the muscle fascia or bone as they are seen in run-over accidents. It leads to a shear of skin and subcutaneous tissue from the neighboring fascia followed by the development of a blood-filled hollow space at predestined regions of the body. If therapy is insufficient, large areas of necrosis can form, which will negatively influence operative measures. We report about three patients with the diagnosis of a Morel-Lavallée lesion. The history and the impressive clinical findings are demonstrated as well as the differential operative therapy performed, partially with osteosynthesis of accompanying bone injuries. According to the recommendations of the literature known to us, an adjusted therapeutic regime suited to the particular findings was carried out and in all three cases uncomplicated healing can be reported. Our results are in line with the existing recommendations, which are to relieve the soft tissue hematoma in time and sufficiently, and secondly to carry out débridements initially as well as planned second-look operations.

[Prosthetic care of proximal femur fractures]. / Prothetische Versorgung der proximalen Femurfrakturen.

The endoprosthetic replacement of the hip joint or its components in fractures of the proximal femur is a standard method. Indications for replacement are strongly dislocated intracapsular femoral neck fractures in elderly patients, fractures with an existing arthritis of the hip joint, and profound osteoporosis. Improved perioperative management and more gentle anesthetic techniques have helped to reduce perioperative mortality from nearly 50% to 11.5% over the last 40 years. As routine treatment options, the bipolar endoprosthesis without replacement of the acetabular joint surface and total hip replacement in case of degenerative arthritis of the acetabular joint surface are commonly used. The mere replacement of the femoral head with a simple femoral head prosthesis should be reserved for exceptional cases. For the implantation of a hip joint prosthesis and its uncomplicated post-treatment and long-term durability, careful preoperative planning is essential together with the selection of a suitable implant, its optimal bony fixation, avoidance of intra-operative complications and restoration of the anatomical landmarks such as the centre of rotation of the hip joint, the offset of the prosthetic shaft as well as leg length. Despite the high standard of endoprosthetics in Germany, the results are still improvable in comparison to other countries. Measures which preserve the joint as well as the bone will be increasingly important in prophylaxis of further complications. In addition, more attention should be paid to the prophylaxis of falls and a sufficiently guide-lined therapy of osteoporosis for the prophylaxis of fractures of the elderly.