Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population.

PURPOSE: Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated. METHODS: A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated. RESULTS: Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018). CONCLUSION: Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Unsaturated Long-Chain Fatty Acids Activate Resident Macrophages and Stem Cells in a Human Skeletal Muscle Tissue Model.

Phenotypically heterogeneous populations of tissue-resident macrophages and stem cells play important roles in the regeneration of the skeletal muscle tissue. Previous studies using animal and cell culture models implied a beneficial effect of fatty acid (FA) species on tissue regeneration. Here, we applied a human experimental model using excised muscle tissues from reconstructive surgeries to study the effects of FAs on resident macrophages and stem cells in the natural environment of human skeletal muscle tissue. Muscle tissue samples from 20 donors were included in this study. The expression of 34 cytokines/chemokines was determined, using multiplex protein analysis. The phenotypes of macrophages and stem cells were determined immunohistochemically. The numbers of CD80+ macrophages correlated with the expression levels of IL-1α, IL-1RA, IL-8, IL-17A, and MCP-1, while the PAX7+ and MyoD+ stem cell counts were positively correlated with the expression level of CXCL12α, a recognized chemoattractant for muscle stem cells. Treatment of additional tissue sections with FAs revealed that CD80+ or MARCO+ macrophages- and PAX7+ or MyoD+ stem cells were simultaneously increased by unsaturated long-chain FAs. Taken together, this is the first experimental demonstration of a coordinated activation of macrophages and stem cells in human skeletal muscle tissue.

Transosseous suture versus suture anchor fixation for inferior pole fractures of the patella in osteoporotic bone: a biomechanical study.

BACKGROUND: The surgical treatment of inferior patellar pole fractures can be a challenge, especially in geriatric patients, who are particularly frequently affected by osteoporosis. The objective of this biomechanical study was to compare the performance of suture anchor and transosseous suture fixation in fractures of the inferior patellar pole in context of bone mineral density. METHODS: Twelve fresh-frozen human cadaveric knees received a transverse osteotomy, simulating an AO/OTA 34C1.3 inferior pole fracture of the patella. These fractures were fixated with either suture anchors (SA; Corkscrew® FT 4.5 mm) or transosseous suture (TS; #2 FiberWire®). Cyclic loading tests were performed by pulling the quadriceps tendon against gravity from 90° flexion to almost full extension (5°) for 1000 cycles. Motion and fracture gap displacement were tracked until failure occurred. Subsequently, loading to failure tests followed. Differences between groups were compared using unpaired t-tests, and correlations were calculated with Pearson's correlation coefficient. RESULTS: The suture anchor group showed significantly fewer cycles to failure than the transosseous suture group (SA: 539.0 ± 465.6 cycles, TS: 1000 ± 0 cycles, P = 0.04). Bone mineral density correlated positively with cycles to failure in the suture anchor group (Pearson's r = 0.60, P = 0.02). No differences in fracture gap displacement could be proven after 100 cycles (SA: 4.1 ± 2.6 mm, TS: 6.5 ± 2.6 mm, P = 0.19); 500 cycles (SA: 6.4 ± 6.1 mm, TS: 9.6 ± 3.8 mm, P = 0.39); and 1000 cycles (SA: 4.0 ± 0.4 mm, TS: 11.0 ± 4.5 mm, P = 0.08). Furthermore, the mean destructive load to failure in the suture anchor group was also significantly lower than in the transosseous suture group (SA: 422.4 ± 212.2 N, TS: 825.7 ± 189.3 N, P = 0.04). CONCLUSIONS: Suture anchors may be a viable alternative to transosseous suture in younger patients for clinical advantages, but in osteoporotic bone, the more stable osteosynthesis with transosseous suture continues to prove superior. Therefore, trauma surgeons might consider the use of transosseous suture in elderly patients, especially in those presenting with low bone mineral density values.

L4/5 accessibility for extreme lateral interbody fusion (XLIF): a radiological study.

INTRODUCTION: Potential advantages of the Extreme Lateral Interbody Fusion (XLIF) approach are smaller incisions, preserving anterior and posterior longitudinal ligaments, lower blood loss, shorter operative time, avoiding vascular and visceral complications, and shorter length of stay. We hypothesize that not every patient can be safely treated at the L4/5 level using the XLIF approach. The objective of this study was to radiographically (CT-scan) evaluate the accessibility of the L4/5 level using a lateral approach, considering defined safe working zones and taking into account the anatomy of the superior iliac crest. METHODS: Hundred CT examinations of 34 female and 66 male patients were retrospectively evaluated. Disc height, lower vertebral endplate (sagittal and transversal), and psoas muscle diameter were quantified. Accessibility to intervertebral space L4/5 was investigated by simulating instrumentation in the transverse and sagittal planes using defined safe zones. RESULTS: The endplate L5 in the frontal plane considering defined safe zones in the sagittal and transverse plane (Zone IV) could be reached in 85 patients from the right and in 83 from the left side. Through psoas split, the safe zone could be reached through psoas zone II in 82 patients from the right and 91 patients from the left side. Access through psoas zone III could be performed in 28 patients from the right and 32 patients from the left side. Safe access and sufficient instrumentation of L4/5 through an extreme lateral approach could be performed in 76 patients of patients from the right and 70 patients from the left side. CONCLUSION: XLIF is not possible and safe in every patient at the L4/5 level. The angle of access for instrumentation, access of the intervertebral disc space, and accessibility of the safe zone should be taken into account. Preoperative imaging planning is important to identify patients who are not suitable for this procedure.

In Vitro Model of Human Skeletal Muscle Tissue for the Study of Resident Macrophages and Stem Cells.

Findings from studies of muscle regeneration can significantly contribute to the treatment of age-related loss of skeletal muscle mass, which may predispose older adults to severe morbidities. We established a human experimental model using excised skeletal muscle tissues from reconstructive surgeries in eight older adults. Muscle samples from each participant were preserved immediately or maintained in agarose medium for the following 5, 9, or 11 days. Immunofluorescence analyses of the structural proteins, actin and desmin, confirmed the integrity of muscle fibers over 11 days of maintenance. Similarly, the numbers of CD80-positive M1 and CD163-positive M2 macrophages were stable over 11 days in vitro. However, the numbers of PAX7-positive satellite cells and MYOD-positive myoblasts changed in opposite ways, suggesting that satellite cells partially differentiated in vitro. Further experiments revealed that stimulation with unsaturated fatty acid C18[2]c (linoleic acid) increased resident M1 macrophages and satellite cells specifically. Thus, the use of human skeletal muscle tissue in vitro provides a direct experimental approach to study the regulation of muscle tissue regeneration by macrophages and stem cells and their responses to therapeutic compounds.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures.

BACKGROUND: Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls. METHODS: In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF. RESULTS: Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses. CONCLUSION: Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Internal fixation versus hip arthroplasty in patients with nondisplaced femoral neck fractures: short-term results from a geriatric trauma registry.

PURPOSE: To determine whether internal fixation (IF) or hip arthroplasty (HA) is associated with superior outcomes in geriatric nondisplaced femoral neck fracture (FNF) patients. METHODS: Data from the Registry for Geriatric Trauma of the German Trauma Society (ATR-DGU) were analyzed (IF Group 449 and HA Group 1278 patients). In-hospital care and a 120-day postoperative follow-up were conducted. Primary outcomes, including mobility, residential status, reoperation rate, and a generic health status measure (EQ-5D score), and the secondary outcome of mortality were compared between groups. Multivariable analyses were performed to assess independent treatment group associations (odds ratios, ORs) with the primary and secondary end points. RESULTS: Patients in the HA group were older (83 vs. 81 years, p < 0.001) and scored higher on the Identification of Seniors at Risk screening (3 vs. 2, p < 0.001). We observed no differences in residential status, reoperation rate, EQ-5D score, or mortality between groups. After adjusting for key covariates, including prefracture ambulatory capacity, the mobility of patients in the HA group was more frequently impaired at the 120-day follow-up (OR 2.28, 95% confidence interval = 1.11-4.74). CONCLUSION: Treatment with HA compared to treatment with IF led to a more than twofold increase in the adjusted odds of impaired ambulation at the short-term follow-up, while no significant associations with residential status, reoperation rate, EQ-5D index score, or mortality were observed. Thus, IF for geriatric nondisplaced FNFs was associated with superior mobility 120 days after surgery. However, before definitive treatment recommendations can be made, prospective, randomized, long-term studies must be performed to confirm our findings.

Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons.

PURPOSE: Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons. METHODS: Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss' kappa (κ) statistics. RESULTS: We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%. CONCLUSION: We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.

Biomechanical Performance of BoneHelix® Compared with Elastic Stable Intramedullary Nailing (ESIN) in a Pediatric Tibia Fracture Model.

Tibial shaft fractures are common injuries in the pediatric and adolescent populations. Elastic stable intramedullary nailing (ESIN) is the treatment of choice for cases that require surgical stabilization. A new intramedullary device, BoneHelix® (BH), may be an alternative for use with fractures that cannot be satisfactorily stabilized with ESIN. This study aimed to assess the biomechanical performance of BH compared with ESIN in a porcine tibia fracture model, observing cyclic fatigue and load to failure. Computed tomography was used to monitor the implant position and to rule out unintended damage. No implant or bone failure occurred during the fatigue testing. An increase in the cumulative plastic displacement was observed in both test groups over the loading cycles applied. Both implant-bone constructs displayed a trend toward closure of the osteotomy gap. During the load-to-failure test, the average loads at failure in specimens instrumented with ESIN and BH were 5364 N (±723) and 4350 N (±893), respectively, which were not statistically significant (p = 0.11). The values of both groups were two to three times higher than the estimated maximal load (2000 N) during physiological weight bearing. The biomechanical results thus indicate equivalent performance and stability by the implants tested.

In-Hospital Clinical Outcomes in Patients with Fragility Fractures of the Lumbar Spine, Thoracic Spine, and Pelvic Ring: A Comparison of Data before and after Certification as a DGU® Geriatric Trauma Centre.

Background and Objectives: The implementation of orthogeriatric co-management (OGCM) reflects the demand for interdisciplinary collaborations due to the increasing comorbidities of geriatric trauma patients. This study aimed to assess clinical in-hospital outcomes in lumbar spine, thoracic spine, and pelvic ring fragility fracture patients before and after the implementation of a Geriatric Trauma Centre (GTC) certified by the German Trauma Society (DGU®). Materials and Methods: In this observational, retrospective cohort study, geriatric trauma patients (>70 years of age) were stratified into either a pre-GTC group (hospital admission between 1 January 2012 and 31 December 2013) or a post-GTC group (hospital admission between 1 January 2017 and 31 December 2018). Patients' pre-injury medical complexity was measured by ASA class (American Society of Anaesthesiologists classification), the use of anticoagulant medication, and the ACCI (Age-adjusted Charlson Comorbidity Index). Outcome parameters were patients' in-hospital length of stay (LOS) and mortality rates, as well as new in-hospital findings and diagnoses. Further, the necessity of deviation from initial management plans due to complications was assessed using the Adapted Clavien-Dindo Scoring System in Trauma (ACDiT score of ≥1). Results: Patients in the post-GTC group (n = 111) were older (median age 82.0 years) compared to the pre-GTC group (n = 108, median age 80.0 years, p = 0.016). No differences were found in sex, body mass index, ASA class, or ACCI (all p > 0.05). Patients in the post-GTC group used vitamin K antagonists or direct oral anticoagulants more frequently (21.3% versus 10.8%). The incidence of non-surgical treatment and mortality was comparable between groups, while LOS tended to be shorter in the post-GTC group (7.0 days versus 9.0 days, p = 0.076). In the post-GTC group, the detection of urinary tract infections (UTI) increased (35.2% versus 16.2%, p = 0.001), and the delirium diagnoses tended to increase (13.0% versus 6.3%, p = 0.094), while an ACDiT score of ≥1 was comparable between groups (p = 0.169). Conclusions: In this study including lumbar spine, thoracic spine, and pelvic ring geriatric fragility fractures, patients in the post-GTC group were more medically complex. More UTIs and the tendency for increased delirium detection was observed in the post-GTC group, likely due to improved diagnostic testing. Nonetheless, the necessity of deviation from initial management plans (ACDiT score of ≥1) was comparable between groups, potentially a positive result of OGCM.

Care of Geriatric Patients with Lumbar Spine, Pelvic, and Acetabular Fractures before and after Certification as a Geriatric Trauma Center DGU®: A Retrospective Cohort Study.

Background: More than 750,000 fragility fractures occur in Germany every year, with an expected increase in the following years. Interdisciplinary care pathways for geriatric patients are increasingly established to improve the treatment process and outcome, but there has been only limited evaluation of their use. Objectives: This study aimed to compare patient care before and after the implementation of a geriatric trauma center (GTC) in conformity with the German Society for Trauma Surgery (DGU®). Patients and Methods: We performed a retrospective single-center cohort study, including 361 patients >70 years old with lumbar spine, pelvic, and acetabular fractures, admitted between January 2012 and September 2019. Patients were divided into a usual care cohort (UC, n = 137) before implementation and an ortho-geriatric care cohort (OGC, n = 224) after implementation of the GTC DGU®. We recorded and compared demographic data, fracture type, geriatric assessment and management, therapy, complications, and various clinical parameters, e.g., length of stay, time to surgery, hours admitted to ICU, and change in walking ability. Results: The geriatric assessment revealed significant geriatric co-morbidities and a need for geriatric intervention in 75% of the patients. With orthogeriatric co-management, a significant increase in the detection of urological complications (UC: 25.5% vs. OGC: 37.5%; p = 0.021), earlier postoperative mobilization (UC: 57.1% vs. OGC: 86.3%; p < 0.001), an increased prescription of anti-osteoporotic treatment at discharge (UC: 13.1% vs. OGC: 46.8%; p < 0.001), and lower rates of revision surgery (UC: 5.8% vs. OGC: 3.1%; p = 0.012) could be seen. Conclusions: Our results emphasize the improvement in patient care and clinical outcome by implementing a GTC DGU® and provide opportunities for future improvement in ortho-geriatric patient care.

Influence of endplate size and implant positioning of vertebral body replacements on biomechanics and outcome.

BACKGROUND: Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes. METHOD: Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence. FINDING: Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes. INTERPRETATION: Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence.

Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit?

BACKGROUND: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured patients both in general and in respect to spinal injury severity. METHODS: A retrospective analysis of multiple-injured patients with an associated spinal trauma within the thoracic or lumbar spine (injury severity score (ISS) >16, age >16 years) was performed from January 2012 to December 2016 in two Level I trauma centres. Demographic data, circumstances of the accident, and ISS, as well as time to spinal surgery were documented. The evaluated outcome parameters were length of stay in the intensive care unit (ICU) (iLOS) and length of stay (LOS) in the hospital, duration of mechanical ventilation, onset of sepsis, and multiple organ dysfunction syndrome (MODS), as well as mortality. Statistical analysis was performed using SPSS. RESULTS: A total of 113 multiple-injured patients with spinal stabilization and a complete dataset were included in the study. Of these, 71 multiple-injured patients (63%) presented with an AOSpine A-type spinal injury, whereas 42 (37%) had an AOSpine B-/C-type spinal injury. Forty-nine multiple-injured patients (43.4%) were surgically treated for their spinal injury within 24 h after trauma, and showed a significantly reduced length of stay in the ICU (7.31 vs. 14.56 days; p < 0.001) and hospital stay (23.85 vs. 33.95 days; p = 0.048), as well as a significantly reduced prevalence of sepsis compared to those surgically treated later than 24 h (3 vs. 7; p = 0.023). These adverse effects were even more pronounced in the case where cutoffs were increased to either 72 h or 96 h. Independent risk factors for a delay in spinal surgery were a higher ISS (p = 0.036), a thoracic spine injury (p = 0.001), an AOSpine A-type spinal injury (p = 0.048), and an intact neurological status (p < 0.001). In multiple-injured patients with AOSpine A-type spinal injuries, an increased time to spinal surgery was only an independent risk factor for an increased LOS; however, in multiple-injured patients with B-/C-type spinal injuries, an increased time to spinal surgery was an independent risk factor for increased iLOS, LOS, and the development of sepsis. CONCLUSION: Our data support the concept of early spinal stabilization in multiple-injured patients with AOSpine B-/C-type injuries, especially of the thoracic spine. However, in multiple-injured patients with AOSpine A-type injuries, the beneficial impact of early spinal stabilization has been overemphasized in former studies, and the benefit should be weighed out against the risk of patients' deterioration during early spinal stabilization.

[Posttraumatic deformity of the thoracolumbar spine]. / Posttraumatische Fehlstellungen der Brust- und Lendenwirbelsäule.

Posttraumatic kyphotic deformities of the thoracolumbar spine may result in significant clinical complaints. If conservative treatment is not successful, surgical correction of the kyphosis becomes an option. In contrast to degenerative deformities, posttraumatic kyphotic deformities are usual limited to few segments and can be treated with shorter constructs. The surgical strategy depends on the rigidity and the localization of the posttraumatic kyphotic deformity. In this respect purely posterior approaches and combined posteroanterior surgical approaches are available each with different advantages and disadvantages.

[Traumatic periprosthetic fractures in patients with total hip replacement]. / Traumatische periprothetische Frakturen bei einliegender Hüftprothese.

The incidence of periprosthetic hip fractures is increasing due to the increase in endoprosthetic hip replacements. These fractures require a staged and individual treatment concept with the aim of mobilization of the patient as early as possible. The special challenge in the diagnostics is to identify pre-existing signs of loosening of the prosthesis. When the prosthesis is still firmly fixed femoral fractures can be treated with angular stable osteosynthesis. Loosened stems usually have to be revised, mostly in combination with osteosynthesis. Fractures around the acetabulum with a fixed cup can be treated nonoperatively or with osteosynthesis, while loosened cups have to be revised. In revision surgery the stabilization of the dorsal column is crucial for a successful outcome.

Influence of additional cement augmentation on endplate stability in circumferential stabilisation of osteoporotic spine fractures.

BACKGROUND: Anterior stabilisation of osteoporotic spine fractures is uncommon but necessary in the case of complex vertebral body comminution. The purpose of this study was to investigate the effect of additional cement-augmentation on the endplate stability. METHODS: Twelve human cadaveric lumbar spines were divided in two groups: (A) posterior cement-augmented pedicle screw/rod-based instrumentation of L3 to L5, posterior decompression of L4/5 and partial corpectomy of L4 and (B) same experimental setup with additional cement-augmentation of the adjacent endplates. A cyclic loading test was performed at a frequency of 3 Hz, starting with a peak of 500 N for the first 2.000 cycles, up to 950 N for 100.000 cycles under a general preload with 50 N. All specimens were evaluated with regard to a potential collapse of the adjacent endplates. Subsequently, the maximum zero-time failure load of all specimens was determined using a universal testing machine. FINDINGS: The median T-score of bone density was -4.32 (range -2.97 to -5.59), distributed equally in the two groups (average age 83 years). The specimen of the endplate-augmented group showed a significant higher failure load compared to non-endplate-augmented cadavers (group A: 2038 N, group B: 2990 N, p = 0.03). All specimens passed the full cyclic loading protocol with 100.000 cycles. No significant difference was observable regarding the adjacent endplate subsidence. INTERPRETATION: Additional cement augmentation in circumferential stabilisation resulted in a significant enhancement of the endplate stability regarding the maximum axial load, while the cyclic loading did not significantly enhance the fatigue endurance of the vertebral endplates over the 100,000 cycles tested.

Predictors for Pediatric Blunt Cerebrovascular Injury (BCVI): An International Multicenter Analysis.

INTRODUCTION: Practice guidelines for adult BCVI patients have been implemented recently, but data for this devastating injury pattern in children are still limited. An international multicenter analysis was performed to characterize BCVI in the pediatric population. METHODS: The TraumaRegister DGU®, a prospectively maintained database, was analyzed (01/2002-12/2015). Pediatric patients (0-17 years) with major injuries [Injury Severity Score (ISS) ≥ 9 points] were included. BCVI was divided into carotid artery injury and vertebral artery injury (VAI). Data of demographics, injury, imaging, therapy, and outcome characteristics were analyzed with SPSS (Version 25, IBM Inc., Armonk, NY). RESULTS: The study cohort included 8128 pediatric trauma patients. We identified 48 BCVIs in 42 children, resulting in an overall prevalence of 0.5%. Carotid injuries were diagnosed more frequently (n = 30; 0.4%) when compared to VAIs (n = 12; 0.1%). The coincidence of head (p = 0.028), facial (p ≤ 0.001), chest (p ≤ 0.001), and spinal injuries (p ≤ 0.001) was higher in BCVI patients. The risk for thromboembolic complications (8.3% vs. 1%, p = 0.026) and in-hospital mortality (38.1% vs. 7.7%, p ≤ 0.001) was excessive in children with BCVI. We identified various predictors for pediatric BCVI and quantified the cumulative impact of these risk factors. CONCLUSION: BCVI is more uncommon in pediatric than in adult trauma patients. Due to the considerable relevance of this injury for both children and adults, special attention should be paid to this entity and associated complications in the early treatment phase after severe pediatric trauma, especially in high-risk children.

[Percutaneous screw techniques for the pelvic ring and acetabulum]. / Perkutane Schraubentechniken an Beckenring und Acetabulum.

In the treatment of pelvic ring and acetabular fractures percutaneous screw osteosynthesis provides the advantage of minimal soft tissue damage. The techniques are frequently used in combination with open osteosynthesis and less frequently as stand-alone procedures. A preoperative planning with the aid of computed tomography (CT) and knowledge of the intraoperative radiological fluoroscopy adjustment are prerequisites for an accurate placement of the screws. This article describes the indications and techniques for frequently used percutaneous screws.