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

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

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

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

[Simple elbow dislocations in children : Systematic review and meta-analysis]. / Einfache Ellenbogenluxationen beim Kind : Systematische Übersicht mit Metaanalyse.

BACKGROUND: Simple elbow dislocations in childhood are rare. Nevertheless, they have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed. AIM: The purpose of the study was to review the literature and to derive a recommendation for the best treatment concept. MATERIAL AND METHODS: A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified (initially nonspecific for age) and evaluated in a stepwise approach. Of these publications four met the inclusion criteria of the authors. The analysis was carried out descriptively and in a meta-analysis. RESULTS: The 4 publications included described simple elbow dislocations in 81 children (≤16 years). The weighted average age was 9.9 years with a gender ratio of 3.8 (boys:girls). The median follow-up was 49 months. Posterior and posterolateral dislocations were the most common with 73%. In 69 children the treatment was conservative and of these 66 were immobilized for longer than 2 weeks after closed reduction. The 12 children who had surgical treatment suffered dislocations that had not been reduced for longer than 3 weeks. The success rate of the conservatively treated immobilized group was 88%, of the conservatively treated non-immobilized group 70% and of the surgical group 42%. The differences between the success rates of the treatment methods was significant (p = 0.032). CONCLUSION: Simple elbow dislocations in children are rare. They most commonly occur in posterior and posterolateral directions. The prognosis is favorable; however a timely diagnosis and correct reduction are relevant for a good outcome.

[Primary fracture protheses and reverse shoulder arthroplasty in complex humeral head fractures : An alternative to joint-preserving osteosynthesis?] / Primäre Frakturprothese und inverse Schulterprothese bei komplexer Humeruskopffraktur : Eine Alternative zur gelenkerhaltenden Osteosynthese?

BACKGROUND: The surgical management of complex humeral head fractures has adapted dynamically over the course of the last decade. The primary use of reverse shoulder arthroplasty in elderly patients has gained in relevance due to promising short and middle-term results. Long-term results, however, are still pending. The appliance of anatomical hemiarthroplasty, on the other hand, has lost in significance in favour of osteosynthesis and reverse shoulder arthroplasty. INDICATIONS: This review article follows the question as to under which circumstances primary fracture arthroplasty reflects an alternative or even a preference to joint-preserving osteosynthesis in the treatment of complex proximal humeral fractures. It also specifies spectrums of indications for anatomical hemiarthroplasty and reverse shoulder arthroplasty.

The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis.

Chronic painful Achilles tendinopathy (AT) is a common disorder among athletes. Sclerotherapy (ST) and prolotherapy (PT) are two promising options among the numerous other conservative therapies. As their efficacy and potential adverse effects (AE) are still unclear, we systematically searched, analyzed, and synthesized the available literature on ST and PT for treating AT. Electronic databases, Google Scholar and articles' reference lists were searched according to PRISMA guidelines. Eligibility criteria were set up according to the PICOS-scheme including human and animal studies. Three authors independently reviewed the results and evaluated methodological quality (Coleman Methodology Score and Cochrane Risk of Bias Assessment). The initial search yielded 1104 entries. After screening, 18 articles were available for qualitative synthesis, six of which were subjected to meta-analysis. The mean Coleman Score of the 13 human studies was 50. Four RCTs were ranked as having a low risk of selection bias. Three of those reported a statistically significant drop in the visual analog scale (VAS) score, one a significant increase in the VISA-A Score. 12 of 13 human studies reported positive results in achieving pain relief and patient satisfaction, whereas only one study's finding differed. Meta-analysis revealed an unambiguous result in favor of the intervention (weighted mean difference D=-4.67 cm, 95% CI -5.56 to -3.76 cm [P<.001]). Only one serious AE and two minor AEs were reported in the entire literature. This systematic review suggests that ST and PT may be effective treatment options for AT and that they can be considered safe. Long-term studies and RCTs are still needed to support their recommendation.

Spinal Orthoses: The Crucial Role of Comfort on Compliance of Wearing - Monocentric Prospective Pilot Study of Randomized Cross-Over Design.

PURPOSE OF THE STUDY Various spine disorders are regularly treated by orthoses, and success of treatment depends on wearing these devices. In this study we examined the compliance, wear comfort, subjective stabilization and side effects associated with spinal orthoses using an individualized questionnaire and the Compact Short Form-12 Health Survey (SF-12). MATERIAL AND METHODS In this prospective pilot study of randomized cross-over design, twelve healthy volunteers with a mean age of 31.2 years wore three different types of orthoses, each for one week: A hyperextension brace (HB), a custom-made semirigid orthosis (SO) and a custom-made rigid orthosis (RO). The daily duration of wearing the orthosis was defined as primary endpoint; contentment was measured using an individualized questionnaire and the standardized SF-12. RESULTS In the study population calculated probability of wearing the HB and RO was between 0.2 und 38.5% (95% confidence interval). No volunteer wore the SO orthosis for the predefined time. The SO and RO each displayed high subjective stabilization, while the RO was more often associated with side effects like skin pressure marks than the SO. The need for rework due to discomfort was mainly necessary with the RO. We observed no substantial differences in feeling compression and sweating. Noteworthy, eight of 12 subjects complained of uncomfortable sternal pressure due to the upper pad of the HB. The SF-12: scores ranged from 52.1 to 48.6 on the physical (PCS), and from 53.7 to 50.8 on the mental component score (MCS), demonstrating an influence on QoL. DISCUSSION AND CONCLUSIONS The design as well as the orthosis itself influence the compliance of wearing and exert a moderate negative, but acceptable impact on QoL. The SO appeared to correlate with the best overall compromise between comfort and subjective stabilization. Further investigations are necessary in patients with spinal diseases, for whom the effect of orthosis wearing may surpass the potential discomfort. Key words: thoracolumbar spine, orthoses, SF-12 - Quality of Life - QoL, comfort, compliance.

Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports.

BACKGROUND: Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main goals of this systematic review with meta-analysis were to summarize the evidence on clinical outcome and determine the rate of return to sports after conservative versus operative treatment of avulsion fractures of the pelvis. METHODS: A systematic search of the Ovid database was performed in December 2016 to identify all published articles reporting outcome and return to preinjury sport-level after conservative or operative treatment of avulsion fractures of the pelvis in adolescent patients. Included studies were abstracted regarding study characteristics, patient demographics and outcome measures. The methodological quality of the studies was assessed with the Coleman Methodology Score (CMS). RESULTS: Fourteen studies with a total of 596 patients met the inclusion criteria. The mean patient age was 14.3 ± 0.6 years and 75.5% of patients were male. Affected were the anterior inferior iliac spine (33.2%), ischial tuberosity (29.7%), anterior superior iliac spine (27.9%), iliac crest (6.7%) lesser trochanter (1.8%) and superior corner of the pubic symphysis (1.2%). Mean follow-up was 12.4 ± 11.7 months and most of the patients underwent a conservative treatment (89.6%). The overall success rate was higher in the patients receiving surgery (88%) compared to the patients receiving conservative treatment (79%) (p = 0,09). The rate of return to sports was 80% in conservative and 92% in operative treated patients (p = 0,03). Overall, the methodological quality of the included studies was low, with a mean CMS of 41.2. CONCLUSION: On the basis of the present meta-analysis, the overall success and return to sports rate was higher in the patients receiving surgery. Especially in patients with fragment displacement greater 15 mm and high functional demands, surgical treatment should be considered.

Non-Union in Upper Limb Fractures - Clinical Evaluation and Treatment Options.

Although non-unions in the upper limb are rare different treatment options of this challenging situation are still affected with up to 20% of failure rate due to current literature. Risk factors for delayed and non-union of fractures are mainly the size of the fracture gap and bone loss of open fractures or in primary surgery followed by other relevant internal and external factors. In the upper limb non-unions of long bones are described with up to 30% after operative intervention. Especially in the upper limb range of motion is limited in non-union cases and disables adjacent joints like the shoulder, elbow and wrist hence reducing the total activity level of affected patients. Beside careful investigation of the causes leading to the non-union a comprehensive treatment plan should be defined to achieve successful results. Treatment can be non-operative in several, selected cases, but in the majority of cases revision surgery is necessary to achieve osseous healing. Our own experience showed that non-union in the upper limb are rare and account for only 1.7% of all surgical managed upper limb fractures. Non-union of upper limb fractures occur most frequently in clavicle fractures followed by humeral fractures. Atrophic non-union is the most frequent reason for osseous non-union (57%) and osseous healing after revision surgery in non-unions is completed after a mean of 6.45 months. This article will give a brief overview of the genesis, clinical evaluation, treatment options and recommendations in upper limb non-unions according to the current literature. Key words: fracture, upper-limb, non-union, osteosynthesis, cancellous bone-graft.

Comminuted Fracture of Elbow - Ostheosynthesis vs. Total Joint Replacement.

Comminuted fractures of the elbow are very rare and in most cases very complex and the successful treatment can be a challenge for the treating surgeon. Due to the elbow joint's complex functional anatomy, the multi-fragmentary nature of many fractures and concomitant destabilizing associated injuries, comminuted fractures of the elbow still present a serious challenge for the orthopedic surgeon. Especially in more severe communicated injuries an osteosynthesis or endoprosthesis must be discussed with the patient. There is a lack of clear treatment recommendations based on solid evidence. An overview of the literature including a treatment algorithm to guide decision making for the distal humeral fracture in the adults is presented and own results are analyzed. Key words: comminuted fracture of elbow, total joint replacement of the elbow, elbow prosthesis, elbow arthroplasty, distal humeral fracture.

Long-Term Function following Periprosthetic Fractures.

PURPOSE OF THE STUDY Clinical results of long-term follow-up after traumatic periprosthetic femur fractures and different therapies (ORIF vs. revision arthroplasty) MATERIAL AND METHODS The Visual Analog Scale (VAS), Harris-Hip-Score (HHS), Oxford-Hip-Score (OHS), Oxford-Knee-Score (OKS), Knee-Society-Score (KSS), SF-36 Questionnaire and Funktionsfragebogen Hannover (FFH) were used to evaluate outcome and functionality. Radiological examinations were performed and the Vancouver (THA) and Lewis and Rorabeck (TKA) classifications used. RESULTS 70 patients suffered a periprosthetic hip fracture (29× revision prosthesis, 41x ORIF), 23 patients underwent an ORIF due to periprosthetic fracture of a TKA (total mean age 75.2 years). 47 patients (follow-up rate 51%) were examined 40 months after surgery (mean age 72 years) (THA: 16× revision, 23× ORIF, TKA: 8× ORIF). The VAS revealed significant less pain in the group that had undergone revision hip arthroplasty than in the ORIF group: 3.9±1 vs. 5.1±1.7 (p<0.05), respectively. 5/16 patients with revision arthroplasty had excellent or good results in the HSS compared to 3/23 patients after ORIF. The OHS yielded excellent or good results in 12/16 patients after revision arthroplasty vs. 10/23 after ORIF. The VAS after ORIF in patients who suffered periprosthetic knee fractures was 4.9±2.1. 3/8 patients achieved excellent or good results according to the OKS. CONCLUSION Every functional score (HSS, OHS, FFH, SF-36) of those patients who had undergone revision arthroplasty was slightly higher and their VAS significantly lower than the scores of the patients after ORIF. Key words: periprosthetic fractures, trauma, open reduction and internal fixation, revision arthroplasty.

Outcome and predictors for successful resuscitation in the emergency room of adult patients in traumatic cardiorespiratory arrest.

BACKGROUND: Data of the TraumaRegister DGU® were analyzed to derive survival rates, neurological outcome and prognostic factors of patients who had suffered traumatic cardiac arrest in the early treatment phase. METHODS: The database of the TraumaRegister DGU® from 2002 to 2013 was analyzed. The main focus of this survey was on different time points of performed resuscitation. Descriptive and multivariate analyses (logistic regression) were performed with the neurological outcome (Glasgow Outcome Scale) and survival rate as the target variable. Patients were classified according to CPR in the prehospital phase and/or in the emergency room (ER). Patients without CA served as a control group. The database does not include patients who required prehospital CPR but did not achieve ROSC. RESULTS: A total of 3052 patients from a total of 38,499 cases had cardiac arrest during the early post-trauma phase and required CPR in the prehospital phase and/or in the ER. After only prehospital resuscitation (n = 944) survival rate was 31.7 %, and 14.7 % had a good/moderate outcome. If CPR was required in the ER only (n = 1197), survival rate was 25.6 %, with a good/moderate outcome in 19.2 % of cases. A total of 4.8 % in the group with preclinical and ER resuscitation survived, and just 2.7 % had a good or moderate outcome. Multivariate logistic regression analysis revealed the following prognostic factors for survival after traumatic cardiac arrest: prehospital CPR, shock, coagulopathy, thorax drainage, preclinical catecholamines, unconsciousness, and injury severity (Injury Severity Score). CONCLUSIONS: With the knowledge that prehospital resuscitated patients who not reached the hospital could not be included, CPR after severe trauma seems to yield a better outcome than most studies have reported, and appears to be more justified than the current guidelines would imply. Preclinical resuscitation is associated with a higher survival rate and better neurological outcome compared with resuscitation in the ER. If resuscitation in the ER is necessary after a preclinical performed resuscitation the survival rate is marginal, even though 56 % of these patients had a good and moderate outcome. The data we present may support algorithms for resuscitation in the future.

Interobserver Variability in the Differential Diagnosis of Benign Bone Tumors and Tumor-like Lesions.

PURPOSE: The interobserver-variability of radiological diagnosis of benign bone tumors (BBT) and tumor-like lesions (TLL) was examined in order to identify difficult-to-diagnose entities, to examine the frequency of advanced diagnostics and to describe the number of interdisciplinary tumor center diagnoses (IDT) in comparison with diagnoses upon referral (ED) and radiologists´ diagnoses (RD). MATERIALS AND METHODS: We retrospectively reviewed 413 patients with 272 BBT and 141 TLL, classified either histologically or through interdisciplinary consultation. Discrepancies between groups were analyzed and rates of additional imaging and biopsy to establish diagnosis were assessed. RESULTS: In BBT the number of identical radiological diagnoses was 56 (ED) and 81 % (RD) compared to the IDT, while in the latter additional imaging were obtained in 30 % cases. In 21 % (12 % to establish diagnosis) BBT were biopsied, the ED matching the histology 40 %, the RD 60 % and the IDT 76 % of the time. For TLL diagnosed through radiology, ED and RD matched IDT 31 % and 61 % of the time, with additional imaging being obtained in 21 % of cases (IDT). In 36 % (27 % to establish diagnosis) biopsy was performed, with histological diagnosis matching the IDT, RD and ED in 51, 27 and 20 %. Diagnostic challenges were apparent in enchondromas, non-ossifying fibromas (NOF), solitary (SBC) and aneurysmal bone cysts (ABC). Ganglia can be misinterpreted as a tumor. CONCLUSIONS: Establishing a definitive diagnosis for BBT and TLL can be challenging with the latter posing greater difficulties. An interdisciplinary approach involving radiologists, orthopedics and pathologists was found to improve diagnostic accuracy. KEY POINTS: • Benign bone tumors (BBT) and tumor-like lesions (TLL) present a diagnostic challenge, while enchondroma, NOF, SBC and ABC were difficult to diagnose, and ganglia can be misinterpreted as a tumor• Additional imaging studies were required for diagnosis in 29 % and 21 % of cases for BBT and TLL, respectively, biopsies in 12 % of cases for BBT and 27 % for TLL• Sound diagnoses can be made through interdisciplinary case discussion, while reducing the risk of overtreatment Citation Format: • Scheitza P, Uhl M, Hauschild O et al. Interobserver Variability in the Differential Diagnosis of Benign Bone Tumors and Tumor-like Lesions. Fortschr Röntgenstr 2016; 188: 479 - 487.

Radial head prosthesis after radial head and neck fractures - current literature and quality of evidence.

Due to the elbow joint's complex functional anatomy, the multifragmentary nature of many fractures and concomitant destabilizing associated injuries, dislocated fractures of the radial head and neck still present a serious challenge for the orthopedic surgeon. Thorough knowledge of the elbow's anatomy and biomechanics is essential to analyze and understand the injury and plan its treatment. The aim of a differentiated therapy approach is to restore the joint's anatomy and kinetics, stable and painless joint function, and to avoid or at least delay posttraumatic joint changes. The degree of dislocation, stability of fragments, size and number of fractured joint surfaces and associated bony and ligamentous injuries (and the instability they incur) must be addressed in the therapy regimen. There are various treatment options depending on the injury's classification, i.e. a Mason I fracture is treated conservatively, while more severe injuries may require osteosynthesis and endoprosthesis. There is a lack of clear therapy recommendations based on solid evidence regarding Mason classification types III-IV. In particular expert opinions diverge and study results are inconsistent. Especially the value of radial head arthroplasty is still hotly debated. Key words: radial head fracture, radial head prosthesis, radial neck fracture, Mason classification, radial head arthroplasty, elbow injury.

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

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

[German trauma centers: level-dependent differences in polytrauma care regarding resources and diagnostic concepts]. / Polytraumaversorgung in Deutschland: Klinikabhängige Unterschiede in der Ressourcenvorhaltung und bei diagnostischen Konzepten.

BACKGROUND: The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system. MATERIAL AND METHODS: A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study. RESULTS: A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p < 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p < 0.05). CONCLUSIONS: Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

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

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

Percutaneous iliosacral screw insertion: malpositioning and revision rate of screws with regards to application technique (navigated vs. Conventional).

BACKGROUND: Conventional percutaneous iliosacral screw placement in pelvic surgery is considered to be a highly demanding operative technique with a high rate of screw malpositions, which may be associated with the risk of neurologic damage or inefficient stability. In the conventional technique, the correct entry point for the screw and the small target corridor for the iliosacral screw may be difficult to visualize using an image intensifier. We tried to find out in this study whether the positioning of percutaneous screw implantations could be optimized by evaluating the rate and grade of malpositions and whether the needed revisions could be reduced by using computer navigation and three-dimensional (3D) image intensifier. METHODS: A group of 54 patients with 63 screws implanted using computer navigation was compared with 87 patients with 131 screws implanted using the conventional fluoroscopic technique. The exact screw position was controlled in a postoperative computed tomography scan, and the grade of malposition of every screw was investigated and compared. RESULTS: A complete intraosseous screw position was found in 42% of cases using the conventional technique and was significantly less compared with 81% using a 3D image intensifier in combination with a navigation system. Moreover, the revision rate of 1.6% was significantly less in the navigated group compared with 19% in the conventional group. CONCLUSIONS: The results indicate that 3D-computer navigation of the percutaneous iliosacral screw insertion can facilitate surgical performance in respect to reducing screw malposition and revision rates.

[Variability of the screw position after 3D-navigated sacroiliac screw fixation. Influence of the surgeon's experience with the navigation technique]. / Variabilität der Schraubenlage bei 3D-navigierter Sakrumverschraubung. Einfluss der operateurspezifischen Navigationserfahrung.

BACKGROUND: The precision of sacroiliac screw placement can be improved with the use of navigation techniques. The purpose of this study was to evaluate the accuracy of 3D-navigated sacroiliac screw positioning in relation to the surgeon's experience with the navigation technique. PATIENTS AND METHODS: A consecutive series of 3D-navigated sacroiliac screw placements were prospectively evaluated between December 2005 and February 2008. Postoperatively the precision of screw placement was analyzed in relation to the surgeon's navigation experience with a CT-scan using the criteria of Smith. RESULTS: A total of 37 screws were implanted by 7 surgeons in 33 patients. In the group of surgeons with less experience in navigation techniques two cases of malpositioning led to revision of the screws. No screws which were implanted or assisted by surgeons experienced in navigation needed to be revised. There was no significant difference in the malposition rate. CONCLUSION: In the clinical setup a malpositioning of sacroiliac screws is possible even with the use of 3D navigation. One reason may be a low level of navigation experience of the surgeon in combination with low experience in the conventional technique. Therefore even in navigation-based placement of sacroiliac screws the malpositioning rate is dependent on the surgeon's experience with the navigation technique. The correct placement of the screws should be controlled intraoperatively using the 3D image intensifier.

[In vitro study on the influence of fibrin in cartilage constructs based on PGA fleece materials]. / In-vitro-Studie zum Einfluss von Fibrin in Knorpelkonstrukten auf der Basis von PGA-Vliesstoffen.

BACKGROUND: The matrix component in autologous chondrocyte implantation plays an important role. In this study the influence of an additional fibrin component in cartilage constructs based on polyglycolide polymers (PGA) was investigated. METHODS: Human chondrocytes of femoral heads were isolated and cultured using a serum-free technique. The cells were seeded on PGA-91 scaffolds with and without an additional fibrin component; the constructs were cultured for 2 weeks in vitro. Besides cell viability, DNA content, pH, aggrecan production, mRNA expression of aggrecan, and collagen types I and II were determined by real-time PCR. Furthermore, cartilage grafts were histologically analyzed. RESULTS: All constructs contained viable, metabolically active cells in the investigated time period. There was no cell proliferation within the graft, and the DNA content was decreased over time. The pH level constantly remained within a physiologic range. The Alcian blue staining of the constructs showed the homogeneous cell distribution and a cell-associated proteoglycan production. Aggrecan concentration in the supernatants of fibrin-containing constructs was significantly lower compared to fibrin-free grafts (-24%), a result that correlated with diminished aggrecan mRNA expression (-80%). mRNA expression of collagen type II increased in the fibrin-free constructs over time and was 57% higher than in the fibrin-containing grafts. The immunohistochemical detection of collagen type II was possible in all constructs. CONCLUSION: Cartilage constructs based on carbohydrate matrices are suitable for matrix-associated chondrocyte implantation. The results of this study suggest a partially inhibitory effect of an additional fibrin component in PGA constructs for chondrogenic differentiation.

[Injury severity and localisations seen in polytraumatised children compared to adults and the relevance for emergency room management]. / Verletzungsschwere und -lokalisationen polytraumatisierter Kinder im Vergleich zu Erwachsenen und deren Bedeutung für das Schockraummanagement.

PURPOSE: The treatment of paediatric polytrauma patients in the emergency room is not common. The knowledge of specific injuries in consideration of the age-specific characteristics is of particular importance for precise diagnostics and therapy. The goal of this study is the aquisition of the frequency, the localisation and the severity of paediatric polytrauma (age: 0-16 years) in comparison with adults. PATIENTS AND METHODS: In the period 7 / 01 to 5 / 04 the localisation and injury severity of 23 paediatric polytrauma patients (age: 2-16 years) were compared retrospectivly with those of 324 adults (age: 17-88 years). In the paediatric group (ISS: 31) the lethality was 17 % and so much higher than that in the grown-up population (ISS: 33) with 10 % at comparable injury severity. The cause of accident and the injury severity of the affected body region were analysed. The severity of the diffferent body regions were classified by the Abbreviated Injury Severity Score (AIS). The results were discussed with regard to the current literature. RESULTS: With 65 %, more than every second child suffered from severe head injuries (AIS > 2), whereas only 37 % of the adults were affected in this way. The different types of intracranial bleedings were analysed and compared. Heavy injuries of the thorax (AIS > 2) were the result of an accident in 61 % of the children and in 54 % of the adults. The incidence of children with injuries to the abdomen was 30 % compared to 31 % in the grown-up collective. Lesions of the spleen and liver had a frequency of 13 to 16 %. Injuries of the spine could be only found in 4 % of the children compared to 40 % of the adult group. The frequencies of pelvic injuries were similar at 22 % for children and 28 % for adults. With 13 % for the upper extremities and 17 % for the lower extremities, children were much less injured in these body regions. In the group of adults 43 % had injuries to the upper extremities and 33 % injuries to the lower extremities. CONCLUSIONS: Taking the results into account with consdieration of the literature data, the authors recommend that the emergency room management for adults and, especially, the radiolgical diagnostic chain with CT scans should also be applied to polytraumatised children. The main reasons for this are the extremely high incidence of intracranial injuries and the high sensitivity of CT scans also for abdominal trauma and pelvic injuries.