Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients?

INTRODUCTION: Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing. MATERIALS AND METHODS: From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device. RESULTS: 212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%. CONCLUSION: The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus.

[Successful in-hospital clamshell thoracotomy in a young male patient with polytrauma (ISS 57) : A case report]. / Erfolgreiche innerklinische Clamshell-Thorakotomie bei einem jungen polytraumatisierten (ISS 57) Patienten : Ein Fallbericht.

Life-threatened injured patients who suffer a cardiovascular arrest after a trauma are still enormously challenging for both the paramedics and the trauma team in the clinic. This case illustrates the treatment of a 16-year-old boy who suffered a blunt abdominal trauma with a traumatic cardiac arrest followed by an open resuscitation after clamshell thoracotomy. Subsequently, the treatment after damage control is discussed regarding the current literature and recommendations for treatment.

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE: Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome. METHODS: The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°. RESULTS: A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups. CONCLUSION: According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years.

INTRODUCTION: Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes. METHODS: Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI). RESULTS: Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection). CONCLUSIONS: The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.

Cementless Titanium Mesh Fixation of Osteoporotic Burst Fractures of the Lumbar Spine Leads to Bony Healing: Results of an Experimental Sheep Model.

INTRODUCTION: Current treatment strategies for osteoporotic vertebral compression fractures (VCFs) focus on cement-associated solutions. Complications associated with cement application are leakage, embolism, adjacent fractures, and compromise in bony healing. This study comprises a validated VCF model in osteoporotic sheep in order to (1) evaluate a new cementless fracture fixation technique using titanium mesh implants (TMIs) and (2) demonstrate the healing capabilities in osteoporotic VCFs. METHODS: Twelve 5-year-old Merino sheep received ovariectomy, corticosteroid injections, and a calcium/phosphorus/vitamin D-deficient diet for osteoporosis induction. Standardized VCFs (type AO A3.1) were created, reduced, and fixed using intravertebral TMIs. Randomly additional autologous spongiosa grafting (G1) or no augmentation was performed (G2, n = 6 each). Two months postoperatively, macroscopic, micro-CT and biomechanical evaluation assessed bony consolidation. RESULTS: Fracture reduction succeeded in all cases without intraoperative complications. Bony consolidation was proven for all cases with increased amounts of callus development for G2 (58.3%). Micro-CT revealed cage integration. Neither group showed improved results with biomechanical testing. CONCLUSIONS: Fracture reduction/fixation using TMIs without cement in osteoporotic sheep lumbar VCF resulted in bony fracture healing. Intravertebral application of autologous spongiosa showed no beneficial effects. The technique is now available for clinical use; thus, it offers an opportunity to abandon cement-associated complications.

Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures.

BACKGROUND: Little is known about non-operative treatment of proximal humerus 4-part and severe displaced fractures as those are normally treated operatively. In this study, we present a historical collective of two level I trauma centers, where all humeral head fractures, despite displaced fractures, received non-operative treatment within a 10 years period. Functional and clinical results of 2-, 3- and 4-part fractures were compared to those after fixed angle intramedullary nailing by matched pair analysis. METHODS: Between 2000 and 2010, 167 patients with 2-, 3- and 4-part humeral head fractures were treated non-operatively in two level I trauma centers in Rostock. Complete clinical, functional and radiographic follow-up were available for 41 patients in the retrospective analysis. The results were compared by matched-pair analysis to a prospective series of 143 patients treated by antegrade intramedullary nailing using a proximal humeral nail. Of these 143 patients complete radiological and clinical 12 months' follow-up was available for 117 patients. Thus, it was possible to built 41 pairs according to age, gender, and fracture type. Statistical significant differences in constant score (CS), pain, activity of daily living (ADL), range of motion (ROM) and muscle strength were evaluated by Wilcoxon test. Furthermore, x-ray analysis of fracture healing and complications were recorded. RESULTS: Operative treatment was not superior to non operative treatment concerning functional results, even in displaced fractures. The only significant difference was found in 3-part-fractures, where better ROM was reached in the non-operative group (p = 0.05). In contrast, there was a tendency toward better activity of daily living (ADL) in intramedullary nailing, but this did not reach statistical significance. X-ray findings revealed better anatomical reconstruction with less valgus and varus displacements after surgery (15% versus 50%, p < 0.005). The complication rate of 37% was higher in the surgery group with a reoperation rate of 32%. CONCLUSION: In our study, surgical treatment by fixed angle intramedullary nailing (Targon PH) seems not to be superior to non-operative treatment, regardless of fracture type. In 2-, 3- and 4-part fractures functional and clinical results were similar.

Fixation of intra-articular fractures of the distal radius using intramedullary nailing: a randomized trial versus palmar locking plates.

BACKGROUND: Proposed benefits of intramedullary techniques include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial was that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of intra-articular fractures of the distal radius. METHODS: We conducted a single-centre, prospective randomized matched-pairs trial. Patients with intraarticular distal radius fractures with metaphyseal comminution and a sagittal fracture line (AO 23 C2.1) were randomized to receive volar locking plate fixation (n = 14) or intramedullary nailing (n = 14). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks and 2 years after the operation. RESULTS: There were no significant differences between groups in terms of range of motion, grip strength or the level of pain at eight weeks. At the final follow up, patients in the nail group had regained more extension than in the plate group (98% of the unaffected side vs. 94%, this however, did not reach significance). Reduction was maintained in both groups; however volar tilt and ulnar variance were significantly better in the plate group. There was no significant difference in the complication rate between groups. CONCLUSION: The present study suggests that intramedullary nail fixation is a reasonable alternative to volar plate fixation for the treatment of intra-articular distal radius fractures and both techniques can yield reliably good results.

Results of geriatric distal radius fractures treated by intramedullary fixation.

INTRODUCTION: Distal radius fracture are common injuries but no gold standard for their therapy exists. The aim of this study was to evaluate the quality of fracture care in distal radius fractures using an intramedullary implant (Targon DR interlocking nail). The nail had been developed to minimize the surgical exposure, increase fixation strength, to prevent tendon irritations and to allow for a fast return to activity. PATIENTS AND METHODS: Prospective study reports the result of 43 patients with an age over 70 years (range 70-91 years) treated by closed reduction and intramedullary fixation. Inclusion criteria were displaced unilateral isolated AO A or C type fractures. The Targon DR interlocking nail was used for all patients. The minimum follow up was 12 months. RESULTS: All fractures united within 2 months. At one-year follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial abduction of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and a grip strength of 91.5 ± 4.3% compared to the contralateral wrist. Pain score measured by a Visual Analogue Scale scored 0.0 ± 0.0 at rest and in activity 0.3 ± 0.3. The mean Castaing Score was good (1.06 ± 0.30) and the Gartland & Werley Score was excellent (1.50 ± 0.57). The mean radial shortening was 0.2 ± 0.1 mm and radial inclination was 3.1 ± 1.1° (range +15° to 0°). No deep soft-tissue or chronic osseous infections were observed. One patient developed a carpal tunnel syndrome. Paraesthesia or dysaesthesia of the superficial radial nerve was registered in seven patients and fully recovered in four patients. There were two cases of single screw loosening. We also found two cases of screw overlength and consecutive contact with the ulnar head, one patient underwent implant removal. Another patient developed CRPS (2.3%). We did not observe any case of hardware failure, tendon irritation or tendon rupture. CONCLUSION: In geriatric patients intramedullary interlocking nailing of displaced extraarticular or intraarticular distal radius fracture with the Targon DR nail represents a viable treatment option and alternative to the use of volar interlocking plating in terms of fracture reduction, maintenance of reduction and functional outcome.

Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score.

BACKGROUND: All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course. METHODS: The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8-11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system. RESULTS: Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm(2), ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained. CONCLUSIONS: Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.

The standardized creation of a lumbar spine vertebral compression fracture in a sheep osteoporosis model induced by ovariectomy, corticosteroid therapy and calcium/phosphorus/vitamin D-deficient diet.

INTRODUCTION: Vertebral compression fractures (VCFs) are one of the most common injuries in the aging population presenting with an annual incidence of 1.4 million new cases in Europe. Current treatment strategies focus on cement-associated solutions (kyphoplasty/vertebroplasty techniques). Specific cement-associated problems as leakage, embolism and the adjacent fracture disease are reported adding to open questions like general fracture healing properties of the osteoporotic spine. In order to analyze those queries animal models are of great interest; however, both technical difficulties in the induction of experimental osteoporosis in animal as well as the lack of a standardized fracture model impede current and future in vivo studies. This study introduces a standardized animal model of an osteoporotic VCF type A3.1 that may enable further in-depth analysis of the afore mentioned topics. MATERIAL AND METHODS: Twenty-four 5-year-old female Merino sheep (mean body weight: 67 kg; range 57-79) were ovariectomized (OP1) and underwent 5.5 months of weekly corticosteroid injections (dexamethasone and dexamethasone-sodium-phosphate), adding to a calcium/phosphorus/vitamin D-deficient diet. Osteoporosis induction was documented by pQCT and micro-CT BMD (bone mineral density) as well as 3D histomorphometric analysis postoperatively of the sheep distal radius and spine. Non osteoporotic sheep served as controls. Induction of a VCF of the second lumbar vertebra was performed via a mini-lumbotomy surgical approach with a standardized manual compression mode (OP2). RESULTS: PQCT analysis revealed osteoporosis of the distal radius with significantly reduced BMD values (0.19 g/cm(3), range 0.13-0.22 vs. 0.27 g/cm(3), range 0.23-0.32). Micro-CT documented significant lowering of BMD values for the second lumbar vertebrae (0.11 g/cm(3), range 0.10-0.12) in comparison to the control group (0.14 g/cm(3), range 0.12-0.17). An incomplete burst fracture type A3.1 was achieved in all cases and resulted in a significant decrease in body angle and vertebral height (KA 4.9°, range: 2-12; SI 4.5%, range: 2-12). With OP1, one minor complication (lesion of small bowel) occurred, while no complications occurred with OP2. CONCLUSIONS: A suitable spinal fracture model for creation of VCFs in osteoporotic sheep was developed. The technique may promote the development of improved surgical solutions for VCF treatment in the experimental and clinical setting.

Intrabody application of eptotermin alpha enhances bone formation in osteoporotic fractures of the lumbar spine; however, fails to increase biomechanical stability - results of an experimental sheep model.

This study analyses the effect of eptotermin α application into fractured vertebrae. It is hypothesized that eptotermin α is capable to enhance bony healing of the osteoporotic spine. In 10 Merino sheep osteoporosis induction was performed by ovariectomy, corticosteroid therapy and calcium/phosphorus/vitamin D-deficient diet; followed by standardized creation of lumbar vertebral compression fractures (VCFs) type A3.1 and consecutive fracture reduction/fixation using expandable mesh cages. Randomly, intravertebral eptotermin α (G1) or no augmentation was added (G2). Macroscopic, micro-CT, and biomechanical evaluation assessed bony consolidation two months postoperatively: Micro-CT data revealed bony consolidation for all cases with significant increased callus development for G2 (60%) and BV/TV (bone volume/total volume 73.45%, osteoporotic vertebrae 35.76%). Neither group showed improved biomechanical stability. Eptotermin α enhanced mineralisation in VCFs in an experimental setup with use of cementless augmentation via an expandable cage. However, higher bone mineral density did not lead to superior biomechanical properties.

Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates.

INTRODUCTION: Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates. MATERIALS/METHODS: 21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis. RESULTS: A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially. CONCLUSION: Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.

Bony healing of unstable thoracolumbar burst fractures in the elderly using percutaneously applied titanium mesh cages and a transpedicular fixation system with expandable screws.

INTRODUCTION: There is a high incidence of vertebral burst fractures following low velocity trauma in the elderly. Treatment of unstable vertebral burst fractures using the same principles like in stable vertebral burst fractures may show less favourable results in terms of fracture reduction, maintenance of reduction and cement leakage. In order to address these shortcomings this study introduces cementless fixation of unstable vertebral burst fractures using internal fixators and expandable intravertebral titanium mesh cages in a one-stage procedure via minimum-invasive techniques. MATERIAL AND METHODS: A total of 16 consecutive patients (median age 76 years, range 58-94) with unstable thoracolumbar burst fractures and concomitant osteoporosis were treated by an internal fixator inserted via minimum invasive technique one level above and below the fractured vertebra. Fracture reduction was achieved and maintained by transpedicular placement of two titanium mesh cages into the fractured vertebral body during the same procedure. Intra- and postoperative safety of the procedure as well as analysis of reduction quality was analysed by 3D C-arm imaging or CT, respectively. Clinical and radiographic follow-up averaged 10.4 months (range 4.5-24.5). RESULTS: Stabilization of the collapsed vertebral body was achieved in all 16 cases without any intraoperative complication. Surgical time averaged 102 ± 6.6 minutes (71-194). The postoperative kyphotic angle (KA) and Cobb angle revealed significant improvements (KA 13.7° to 7.4°, p < 0.001; Cobb 9.6° to 6.0°, p < 0.002) with partial loss of reduction at final follow-up (KA 8.3°, Cobb 8.7°). VAS (Visual Analogue Scale) improved from 7.6 to 2.6 (p < 0.001). Adjacent fractures were not observed. One minor (malposition of pedicle screw) complication was encountered. CONCLUSION: Cementless fixation of osteoporotic burst fractures revealed substantial pain relief, adequate maintenance of reduction and a low complication rate. Bony healing after unstable osteoporotic burst fractures is possible. TRIAL REGISTRATION: www.germanctr.de DRKS00005657.

Cementless fixation of osteoporotic VCFs using titanium mesh implants (OsseoFix): preliminary results.

INTRODUCTION: Vertebral compression fractures (VCFs) affect 20% of people over the age of 70 with increasing incidence. Kypho-/vertebroplasty as standard operative procedures are associated with limitations like cement leakage, limited reduction capabilities, and risk for adjacent fractures. To address these shortcomings, we introduce a new minimal invasive cementless VCF fixation technique. METHODS: Four patients (72.3 years, range 70-76) with VCFs type AO/Müller A1.3 and concomitant osteoporosis were treated by minimal invasive transpedicular placement of two intervertebral mesh cages for fracture reduction and maintenance. Follow-up included functional/radiological assessment and clinical scores and averaged 27.7 months (24-28). RESULTS: Endplate reduction was achieved in all cases (mean surgery time: 28.5 minutes). Kyphotic (KA) and Cobb angle revealed considerable improvements postoperatively (KA 14.5° to 10.7°/Cobb 10.1° to 8.3°). Slight loss of vertebral reduction (KA: 12.6°) and segment rekyphosis (Cobb: 10.7°) were observed for final follow-up. Pain improved from 8.8 to 2.8 (visual analogue scale). All cases showed signs of bony healing. No perioperative complications and no adjacent fractures occurred. CONCLUSION: Preliminary results in a small, selected patient collective indicate the ability of bony healing for osteoporotic VCFs. Cementless fixation using intravertebral titanium mesh cages revealed substantial pain relief, adequate reduction, and reduction maintenance without complications. Trial registration number is DRKS00005657, German Clinical Trials Register (DKRS).

Acromioclavicular joint dislocations: radiological correlation between Rockwood classification system and injury patterns in human cadaver species.

INTRODUCTION: The classification system of Rockwood and Young is a commonly used classification for acromioclavicular joint separations subdividing types I-VI. This classification hypothesizes specific lesions to anatomical structures (acromioclavicular and coracoclavicular ligaments, capsule, attached muscles) leading to the injury. In recent literature, our understanding for anatomical correlates leading to the radiological-based Rockwood classification is questioned. The goal of this experimental-based investigation was to approve the correlation between the anatomical injury pattern and the Rockwood classification. MATERIALS AND METHODS: In four human cadavers (seven shoulders), the acromioclavicular and coracoclavicular ligaments were transected stepwise. Radiological correlates were recorded (Zanca view) with 15-kg longitudinal tension applied at the wrist. The resulting acromio- and coracoclavicular distances were measured. RESULTS: Radiographs after acromioclavicular ligament transection showed joint space enlargement (8.6 ± 0.3 vs. 3.1 ± 0.5 mm, p < 0.05) and no significant change in coracoclavicular distance (10.4 ± 0.9 vs. 10.0 ± 0.8 mm). According to the Rockwood classification only type I and II lesions occurred. After additional coracoclavicular ligament cut, the acromioclavicular joint space width increased to 16.7 ± 2.7 vs. 8.6 ± 0.3 mm, p < 0.05. The mean coracoclavicular distance increased to 20.6 ± 2.1 mm resulting in type III-V lesions concerning the Rockwood classification. CONCLUSIONS: Trauma with intact coracoclavicular ligaments did not result in acromioclavicular joint lesions higher than Rockwood type I and II. The clinical consequence for reconstruction of low-grade injuries might be a solely surgical approach for the acromioclavicular ligaments or conservative treatment. High-grade injuries were always based on additional structural damage to the coracoclavicular ligaments. Rockwood type V lesions occurred while muscle attachments were intact.

Finding the needle in the haystack: differentiating "identical" twins in paternity testing and forensics by ultra-deep next generation sequencing.

Monozygotic (MZ) twins are considered being genetically identical, therefore they cannot be differentiated using standard forensic DNA testing. Here we describe how identification of extremely rare mutations by ultra-deep next generation sequencing can solve such cases. We sequenced DNA from sperm samples of two twins and from a blood sample of the child of one twin. Bioinformatics analysis revealed five single nucleotide polymorphisms (SNPs) present in the twin father and the child, but not in the twin uncle. The SNPs were confirmed by classical Sanger sequencing. Our results give experimental evidence for the hypothesis that rare mutations will occur early after the human blastocyst has split into two, the origin of twins, and that such mutations will be carried on into somatic tissue and the germline. The method provides a solution to solve paternity and forensic cases involving monozygotic twins as alleged fathers or originators of DNA traces.

Intramedullary medial column support with the Midfoot Fusion Bolt (MFB) is not sufficient for osseous healing of arthrodesis in neuroosteoarthropathic feet.

INTRODUCTION: To address midfoot instability of Charcot disease a promising intramedullary implant has recently been developed to allow for an arthrodesis of the bones of the medial foot column in an anatomic position. We report on a group of patients with Charcot arthropathy and instability at the midfoot where the Midfoot Fusion Bolt had been employed as an implant for the reconstruction of the collapsed medial foot column. MATERIAL AND METHODS: A total of 7 patients (median age 56.3 years, range 47-68) were enrolled with severe Charcot deformation at Eichenholtz stages I-II (Sanders and Frykberg types II and III). The medial column was stabilised primarily with an intramedullary rod (Midfoot Fusion Bolt) in stand-alone technique in order to reconstruct the osseous foot geometry. The bolt was inserted in a retrograde mode via the head of MTI and forwarded into the talus. Follow-up time averaged 27 months (range 9-30). RESULTS: Intraoperative plantigrade reconstruction and restoration of the anatomic foot axes of the medial column was achieved in all cases with the need for revision surgery in 6 out of 7 patients due to soft tissue problems (2 impaired wound healing, 1 postoperative haematoma, 3 early infection). Implant-associated problems were seen in one case intra-operatively with fracture of the first metatarsal shaft and two cases with implant loosening of the MFB and need for implant removal during long time follow-up. Two patients underwent lower leg amputation due to a progressive deep soft tissue infection. One patient healed uneventfully without need for revision surgery. Except for one case recurrent ulcerations were not observed, so far. CONCLUSION: Medial column support in midfoot instability of Charcot arthropathy with a single intramedullary rod does not provide enough stability to achieve osseous fusion. MFB loosening was associated with deep infection in a majority of our cases. To prevent early loosening of the intramedullary rod and to increase rotational stability, additional implants as angular stable plates are needed at the medial column and eventually an additional stabilisation of the lateral foot column where manifest instability exists at the time of primary surgical intervention.