Comparison of revision strategies for failed C2-posterior cervical pedicle screws: a biomechanical study.

STUDY PURPOSE: With increasing usage within challenging biomechanical constructs, failures of C2 posterior cervical pedicle screws (C2-pCPSs) will occur. The purpose of the study was therefore to investigate the biomechanical characteristics of two revision techniques after the failure of C2-pCPSs. MATERIALS AND METHODS: Twelve human C2 vertebrae were tested in vitro in a biomechanical study to compare two strategies for revision screws after failure of C2-pCPSs. C2 pedicles were instrumented using unicortical 3.5-mm CPS bilaterally (Synapse/Synthes, Switzerland). Insertion accuracy was verified by fluoroscopy. C2 vertebrae were potted and fixed in an electromechanical testing machine with the screw axis coaxial to the pullout direction. Pullout testing was conducted with load and displacement data taken continuously. The peak load to failure was measured in newtons (N) and is reported as the pullout resistance (POR). After pullout, two revision strategies were tested in each vertebra. In Group-1, revision was performed with 4.0-mm C2-pCPSs. In Group-2, revision was performed with C2-pedicle bone-plastic combined with the use of a 4-mm C2-pCPSs. For the statistical analysis, the POR between screws was compared using absolute values (N) and the POR of the revision techniques normalized to that of the primary procedures (%). RESULTS: The POR of primary 3.5-mm CPSs was 1,140.5 ± 539.6 N for Group-1 and 1,007.7 ± 362.5 N for Group-2; the difference was not significant. In the revision setting, the POR in Group-1 was 705.8 ± 449.1 N, representing a reduction of 38.1 ± 32.9 % compared with that of primary screw fixation. For Group-2, the POR was 875.3 ± 367.9 N, representing a reduction of 13.1 ± 23.4 %. A statistical analysis showed a significantly higher POR for Group-2 compared with Group-1 (p = 0.02). Although the statistics showed a significantly reduced POR for both revision strategies compared with primary fixation (p < 0.001/p = 0.001), the loss of POR (in %) in Group-1 was significantly higher compared with the loss in Group-2 (p = 0.04). CONCLUSIONS: Using a larger-diameter screw combined with the application of a pedicle bone-plastic, the POR can be significantly increased compared with the use of only an increased screw diameter.

Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting.

Injury of the extensor pollicis longus tendon is one of the commonest extensor tendon injuries after distal radius fracture. In 2003-2005 we performed extensor indicis transfer in 31 patients with loss of function of the EPL tendon and postoperative dynamic splinting. In 25 patients, a distal radius fracture managed surgically led to the EPL rupture (wire internal fixation in 23 patients, plate internal fixation in 2 patients). In 6 patients, the cause was a distal radius fracture treated conservatively. Out of our 25 followed-up patients, 9 (36%) had a very good and 15 (60%) a good result in the Geldmacher score. We did not identify any re-rupture. In injuries of the extensor pollicis tendon, transposition of the extensor indicis tendon is a simple and uncomplicated procedure. Considerable improvement of thumb extension can be achieved through this substitution repair.

First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions.

BACKGROUND: Plate osteosynthesis of the scaphoid, as reported earlier by Ender, has lost its importance in the past few years, after Herbert's introduction of the simple and successful technique of screw osteosynthesis. Only in rare cases does one encounter failed healing or instability of the fragments. Even with a vascularized bone chip, it is not always possible to achieve consolidation. Particularly in these situations, poor interfragmentary stability seems to be the reason for failed healing. METHODS: Between January 2007 and August 2009, we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis. All the patients had fractures of the waist of the scaphoid with established nonunion persisting for at least 6 months after the causative injury, with wrist pain, weakness, or both. All 11 patients had clinical and radiologic follow-up for at least 6 months. RESULTS: All the fractures united at a median time from operation of ∼4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 points. CONCLUSIONS: Scaphoid plate osteosynthesis should be regarded as a salvage procedure, and the indication for the procedure should be established accordingly. It is a simple procedure in terms of technique. The plate can be adjusted very well to the anatomic shape of the scaphoid, and one can achieve a high degree of stability, particularly rotational stability.

Multidirectional volar fixed-angle plating using cancellous locking screws for distal radius fractures--evaluation of three screw configurations in an extra-articular fracture model.

INTRODUCTION: Volar fixed-angle plating is a popular treatment for unstable distal radius fractures. Despite the availability of plating systems for treating distal radius fractures, little is known about the mechanical properties of multidirectional fixed-angle plates. The aim of this study was to compare the primary fixation stability of three possible screw configurations in a distal extra-articular fracture model using a multidirectional fixed-angle plate with metaphyseal cancellous screws distally. MATERIAL AND METHODS: Eighteen Sawbones radii (Sawbones, Sweden, model# 1027) were used to simulate an extra-articular distal radius fracture according to AO/OTA 23 A3. Plates were fixed to the shaft with one non-locking screw in the oval hole and two locking screws as recommended by the manufacturer. Three groups (n = 6) were defined by screw configuration in the distal metaphyseal fragment: Group 1: distal row of screws only; Group 2: 2 rows of screws, parallel insertion; Group 3: 2 rows of screws, proximal screws inserted with 30° of inclination. Specimens underwent mechanical testing under axial compression within the elastic range and load controlled between 20 N and 200 N at a rate of 40 N/s. Axial stiffness and type of construct failure were recorded. RESULTS: There was no difference regarding axial stiffness between the three groups. In every specimen, failure of the Sawbone-implant-construct occurred as plastic bending of the volar titanium plate when the dorsal wedge was closed. DISCUSSION: Considering the limitations of the study, the recommendation to use two rows of screws or to place screws in the proximal metaphyseal row with inclination cannot be supported by our mechanical data.

Results of dynamic treatment of fractures of the proximal phalanx of the hand.

BACKGROUND: The treatment of fractures of the proximal phalanx in three-phalanx fingers has for a long time been the domain of conservative static treatment in a plaster cast. After removal of the plaster, there was usually limitation of mobility of the interphalangeal joints. Fractures of the proximal phalanx are managed with conservative functional treatment in our clinic. The aim of this method is to achieve bony healing and free mobility at the same time and not in succession. We evaluated our treatment outcomes in a follow-up study. METHODS: The dressing consists of a dorsopalmar plaster splint and a so-called finger splint. The wrist and metacarpophalangeal joints are immobilized with the plaster cast. The wrist is dorsiflexed 30 degrees, and the metacarpophalangeal joints are flexed 70 degrees to 90 degrees. In this intrinsic plus position, the extensor aponeurosis is taut and covers two-thirds of the proximal phalanx, thus leading to firm splinting of the fracture. RESULTS: Sixty-five patients (46 men and 19 women) with 78 proximal phalanx fractures were followed up after an average of 23 months (12-69 months). The average age of the patients was 41 years (18-93 years). Among our patients, the ring finger was affected most often, with transverse fractures predominating. As regards the location, fractures in the proximal third were most frequent (51%). All fractures consolidated. Delayed fracture healing or pseudarthrosis was not observed. Sixty-seven fingers (86%) showed full range of motion at follow-up. In 11 cases (14%), there was limitation of finger joint movements, with inhibition of extension of the proximal interphalangeal joint in nine patients up to a maximum of 20 degrees. Two patients had limitation of flexion with a fingertip-palm distance of 1.1 cm. CONCLUSION: The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility at the same time and not in succession. Active exercises in the proximal and distal interphalangeal joints prevent limitations of mobility and the subsequent occurrence of rotational and axial deformities.

Predictive factors influencing the outcome after gunshot injuries to the head-a retrospective cohort study.

BACKGROUND: Civilian gunshot injuries to the head are relatively rare in the irenical European Union, and studies of treatment and outcomes are seldom for this region in the current literature. METHODS: A cohort of 85 patients with civilian head gunshot injuries, who were admitted to our University hospital over a period of 16 years, was reviewed retrospectively. Clinical manifestation, computed tomography scan findings, and surgical treatment were described, with special regard to prognostic factors and outcome. RESULTS: The mean age was 48 years (range, 17.8-98.4 years), and 87% were men. Sixty patients sustained penetrating craniocerebral injuries (P-group) and 25, nonpenetrating gunshot wounds (NP-group). The overall mortality was 87% in the P-group and 4% in the NP-group. The Glasgow Coma Scale (GCS) score at admission was recorded to be 3 to 5 in 58 patients (96%) and 7 patients (28%) in the P-group and NP-group, respectively. Only 8 patients (13%) survived in the P-group compared with 24 patients (96%) in the NP-group. Excluding wound debridement, there were 16 surgical procedures in the P-group and 8 in the NP-group, with a mortality rate of 63% and 13%, respectively. CONCLUSIONS: Glasgow Coma Score at admission and the status of pupils and hemodynamic situation seem to be the most significant predictors of outcome in penetrating craniocerebral gunshot wounds. Computed tomography scans, bi- or multilobar injury, and intraventricular hemorrhage were correlated with poor outcome. Patients with a GCS score >8, normal pupil reaction, and single lobe of brain injury may benefit from early aggressive management.

Unstable distal radius fractures in the elderly patient--volar fixed-angle plate osteosynthesis prevents secondary loss of reduction.

BACKGROUND: Because of demographic changes in industrialized countries, signifying a growing population of the aged and a markedly increased life expectancy, the incidence of the distal radius fracture is expected to increase by a further 50% until the year 2030. Osteoporosis characterizes the radius fracture in elderly patients. Primarily weakening metaphyseal bone, osteoporosis renders simple fractures unstable and makes distal bone fixation a challenge. The introduction of fixed-angle plate systems for extension fractures of the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new plating system. The focus of our interest was whether a secondary loss of reduction can be prevented by this plating system in the elderly patient. METHODS: We reviewed 58 patients aged 75 years or older treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, wrist splint used for 4 weeks, and physiotherapy. At the time of follow-up, after a mean period of 13 months (range, 12-15 months), standard radiographic and clinical fracture parameters were measured and final functional results were assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up. On X-rays taken at the time of follow-up, 53 patients (91%) had no radial shortening, 5 patients (9%) had a mean radial shortening occurred during follow-up of only 1.3 mm (range, 1-2 mm) compared with the contralateral side. Comparing the first postoperative X-rays with those taken at final evaluation showed no measurable loss of reduction in the volar tilt or radial inclination. Castaing's score yielded a perfect outcome in 25 cases, a good outcome in 30 cases, and an adequate outcome in 3 cases. On an average, the range of motion was reduced by 19% during extension/flexion, by 13% during radial/ulnar deviation, and by 9% in pronation/supination compared with the contralateral side. Grip strength was 55% higher than that of the contralateral side. Eleven patients (19%) reported pain at rest with a mean Visual Analog Pain Scale score of 3.1 (range, 1-6), whereas 30 patients (52%) had pain on load-bearing with a mean Visual Analog Pain Scale score of 3.4 (range, 1-8). The mean disabilities of the arm, shoulder, and hand (DASH) score (Jester A, Harth A, Germann G. J Hand Surg Am. 2005;30:1074.e1-1074.e10) was 28 points. A carpal tunnel syndrome with abnormal nerve conduction velocity was diagnosed in three patients, a rupture of the flexor pollicis longus tendon was seen in one patient. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius in the elderly patient signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist associated with a low complication rate. This technique with its simple palmar access, allows exact anatomic reduction of the fracture, allows early return to function, and minimizes morbidity in the elderly patient. Secondary correction loss can be prevented by this procedure.

Urine toxicology screening in Austrian trauma patients: a prospective study.

INTRODUCTION: The question as to whether the patient consumed drugs prior to the trauma and which drugs were consumed, is of prime importance for the anesthesia required during surgery. However, many patients are unwilling or unable (including those with multiple trauma or impaired consciousness, or unconscious patients) to answer this question. The purpose of our prospective multicenter study was to collect data about drug consumption in Austria to determine whether drugs are identifiable in the urine of recently injured individuals and to establish the types of drugs consumed. MATERIALS AND METHODS: This prospective study included severely and moderately injured patients admitted to the Lorenz Boehler Trauma Hospital (Vienna, Austria), the Trauma Hospital Linz (Linz, Austria) and the Department of Trauma Surgery of the General Hospital Horn (Horn, Austria) during an 18-month period (October 2003-March 2005). All patients were suffering from injuries urgently requiring surgery. Urine samples were gained from all patients immediately after admission. Urinary samples were tested by Immuno-Assay (Triage 8 Immuno-Assay, Biosite, San Diego, USA). Urine samples were screened simultaneously for opiates, methadone, cocaine, barbiturates, amphetamines, cannabinoids, benzodiazepines and tricyclic antidepressants. RESULTS: Our prospective study included a total of 664 patients (320 from Vienna, 193 from the city of Linz, and 151 from Horn). Six hundred and forty-two patients were moderately injured (ISS < 16), suffering mostly from injuries to the extremities (504 patients) and 22 patients were severely injured (ISS > 16). Of the 664 patients, 178 (26.8%) tested positive for one or more drugs. The drugs most commonly detected were benzodiazepines (111 patients, 16.7%), cannabinoides (39 patients, 6%), tricyclic antidepressants (28, 4.2%) and opiates (26, 3.9%). CONCLUSION: Drug use is widespread in patients presenting to urban trauma centers in Austria. Physicians should maintain a high index of suspicion that their patients may be intoxicated and should perform drug testing routinely.

Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results.

BACKGROUND: With an incidence of about 2-4 per 1,000 residents per year, the distal radial fracture is the most common fracture in the human skeleton. The introduction of fixed-angle plate systems for extension fractures at the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new system. The focus of our interest was whether a secondary loss of reduction can be avoided by this plating system. METHODS: We reviewed 80 patients treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, a wrist splint used for 4 weeks and physiotherapy. Standard radiographic and clinical fracture parameters after 12 months (range 12-14 months) were measured and final functional results where assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up after 1 year. On X-rays taken at the time of follow-up 60 patients (75%) had no radial shortening, 20 patients (25%) had a mean radial shortening of only 1.8 mm (range 1-3 mm) compared to the contralateral side. The radial tilt was on average 22 degrees (range 14 degrees-36 degrees); the volar tilt was on average 6 degrees (range 0 degrees-18 degrees). Comparing the first postoperative X-rays with those taken at final evaluation showed no measureable loss of reduction in the volar or radial tilt. Castaing's score, which includes the radiographic results, yielded a perfect outcome in 30 cases, a good outcome in 49 cases and an adequate outcome in one case. The range of motion was on average reduced by 21% during extension/flexion, by 11% during radial/ulnar deviation and by 7% in pronation and supination compared to the contralateral side. Grip strength was 65% that of the contralateral side. The mean DASH score was 25 points. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist. The technically simple palmar access, with a low rate of complications, allows exact anatomical reduction of the fracture. The multidirectional fixed-angle system we used provides solid support for the joint surface even in osteoporotic bone and allows simple subchondral placement of screws with sustained retention of the outcome of reduction. Secondary correction loss can be avoided by this procedure. Early mobilisation can be achieved and is recommended.

Retrospective review of outcome after surgical treatment of enchondromas in the hand.

BACKGROUND: Tumours of the skeleton of the hand are rare. While the majority of bone tumours are benign (89.4%), a small number show signs of malignancy (4.4%). Among the benign bone tumours of the skeleton of the hand, enchondromas are the most common, at 35-65%. METHODS: In the period from 1998 to 2005, a total of 35 enchondromas on the hand were diagnosed at the Trauma Center Lorenz Boehler. These were 16 women and 19 men with an average age of 36 years (age range 16-66). The most common site of an enchondroma was the proximal phalanx in 17 cases, followed by the metacarpal bone in 8 cases and the middle phalanx in 5 cases. In five patients, an enchondroma was found in the carpal bones. Twenty-nine patients underwent surgery. RESULTS: The follow-up findings (average follow-up time, 47 months) were assessed in accordance with the formula outlined by Wilhelm and Feldmaier. Twenty-five of 27 patients who underwent follow-up examination showed an excellent result. In two patients, the result was assessed as good on account of restricted mobility caused by increased scar formation. No recurrence was detected in X-ray controls. CONCLUSION: Enchondromas of the hand are usually detected after a bagatelle trauma. For accurate diagnosis, conventional X-ray examination and if necessary, a contrast medium MRI should be performed. Histological investigation is compulsory due to the risk of malignancy. Depending on its spread, the defect in the extirpation cavity should be filled with autogenous spongy bone.

Gelatin thrombin granules for hemostasis in a severe traumatic liver and spleen rupture model in swine.

BACKGROUND: Treatment of traumatic liver and spleen rupture is a major challenge for the surgeon. Because of their excellent blood supply and tissue structure, rupture of the liver and spleen is often associated with massive abdominal hemorrhage. Frequently the surgeon's only feasible option is partial or total resection of the organ. The purpose of this study was to test the hemostatic efficacy of gelatin thrombin granules (FloSeal) in a standardized severe traumatic liver and spleen rupture model in swine (representing a grade IV-V rupture) during severe hemorrhagic shock and coagulation disorder. METHODS: Standardized combined penetrating liver and spleen rupture was inflicted in 10 anesthetized swine. Hemorrhagic shock was induced after heparinization. Gelatin thrombin granules were used to treat both the ruptured liver and the ruptured spleen. Blood loss, hemostasis, and 48 hours survival rate were quantified. Cardiorespiratory parameters, activated clotting time, and plasma fibrinogen level were monitored. After 1 hour and 48 hours a second look evaluation was performed to detect any postoperative hemorrhage. Ruptures were then examined macroscopically and histologically. RESULTS: Hemostasis was achieved with FloSeal in all swine. The mean amount of FloSeal used was 14 mL +/- 2.5 mL. Macroscopic and histologic findings after 48 hours showed excellent clot integration into the surrounding tissue without any adverse effects. CONCLUSION: Gelatin thrombin granules (FloSeal) are effective in treating severe penetrating rupture of the liver and spleen even during hemorrhagic shock, retransfusion conditions, and coagulation disorder.

Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center.

BACKGROUND: The early clinical management of patients with major trauma still represents a challenge. To clinically evaluate the full extent of a patient's injuries is difficult, especially when the patient is unconscious. Before December 2002, trauma patients admitted to our emergency room (ER) underwent a diagnostic protocol including physical examination, conventional radiography (CR), sonography and further procedures if necessary. After the installation of a MSCT scanner, all trauma patients underwent the "MSCT protocol" immediately after admission. The aim of the study was to compare the "MSCT-protocol" as it is performed at our institution, with the "Pre-MSCT-protocol". METHODS: We compared 185 patients undergoing the "Pre MSCT-protocol" with 185 patients undergoing "MSCT protocol". We evaluated the efficacy, speed and accuracy of the "MSCT protocol" using several variables. Time periods from admission to the ER to admission to the intensive care unit were compared as well as outcome parameters such as length of ICU stay, ventilation period and rates of organ. Dichotomous data were analyzed by Chi-square analysis; continuous data were analyzed by Student's t test. Any values of p < 0.05 were considered significant for any test. RESULTS: No significant differences were found regarding demographic data. The full extent of injuries was definitively diagnosed after 12 +/- 9 minutes in 92.4% of the "MSCT protocol" cohort. In only 76.2% of "Pre-MSCT protocol" cohort definitive diagnosis was possible after 41 +/- 27 minutes. Total ER time was 104 +/- 21 minutes with the "Pre-MSCT protocol" and 70 +/- 17 minutes with "MSCT protocol" (p < 0.05). "Pre-MSCT protocol" patients had a significantly longer ICU stay than "MSCT protocol" patients (p < 0.05). "MSCT protocol" patients had significantly fewer ventilation days (14.3 vs. 10.9 days). Furthermore, rates of organ failure were lower in patients undergoing the "MSCT protocol". CONCLUSION: We could demonstrate that immediate MSCT in patients with blunt major trauma leads to more accurate and faster diagnosis, and reduction of early clinical time intervals. We also observed a reduction in ventilation, ICU, and hospital days, and in organ failure rates, though this might have been partly due to small differences in case mix. The "MSCT protocol" algorithm seems to be safe and effective.

Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma.

BACKGROUND: The timing of fixation of femoral fractures in multiply injured patients with severe thoracic trauma is discussed controversially. Some authors recommend damage control surgery, whereas other authors prefer early definitive treatment. The aim of our study was to investigate the effect of early definitive fixation of femoral fractures on outcomes in multiply injured patients with severe thoracic trauma. METHODS: Between May 1, 1998 and December 31, 2004, 578 severely injured patients were admitted to our institution. Forty-five patients met the inclusion criteria for the study cohort (severe thoracic trauma and femoral fracture stabilized with unreamed intramedullary nailing [IMN] within the first 24 hours) and 107 patients were selected for the control cohort (severe thoracic trauma without any lower extremity fracture). Inclusion criteria for both cohorts were age 15 to 55 years with blunt trauma (e.g. motor vehicle collisions, falls) including severe thoracic trauma (Abbreviated Injury Scale [AIS] score >or=3) and Injury Severity Score (ISS) >or=18. For comparison between the cohorts data on patients status (Glasgow Coma Scale score at arrival, Revised Trauma Score, Trauma and Injury Severity Score survival prognosis, Simplified Acute Physiology Score II score), treatment (intubation rate, thoracic drainage, surgery), and outcomes (duration of intensive care unit stay and ventilation, rate of adult respiratory distress syndrome [ARDS], multiple organ failure syndrome [MOFS], and mortality) were selected from hospital databases. Dichotomous data were analyzed by chi test; continuous data were analyzed by Student's t test. Any values of p < 0.05 were considered significant for any test. RESULTS: Both cohorts were comparable with regard to demographic data, ISS, AIS score in the thoracic region, and incidence and severity of brain injury. There was no difference in dependent parameters in both cohorts. Rates of ARDS, MOFS, and mortality were not negatively influenced by early unreamed IMN. CONCLUSION: Early unreamed IMN of femoral fractures in multiply injured patients with severe thoracic trauma is a safe procedure and seems to be justified to achieve early definitive care.