[Special reduction instruments]. / Spezielle Repositionsinstrumente.

Special and specialized instruments help perform reduction more effectively and in a tissue-preserving manner. In addition to other articles, the application and advantages of the following instruments are presented: colinear reduction forceps, cerclage, cerclage passer, distal radius reduction clamp, modular external fixator, extension table, distraction frame, joystick, manipulators, distractor and assistance of reduction with elastic nails.

[Surgical Treatment of Acetabulum Fractures with a New Acetabulum Butterfly Plate]. / Operative Versorgung von Azetabulumfrakturen mit der neuen Azetabulumflügelplatte.

Introduction: There have been significant increases in the number of acetabular fractures in elderly patients with primarily ventral pathology and medial protrusion of the femoral head. We have developed the "acetabulum wing plate", which is designed to facilitate repositioning, with its anatomically precontoured structure, and which offers full support of the quadrilateral surface, thus counteracting the force of the femoral head pushing inwards. Conventional plate osteosynthesis only provides insufficient support to the medial surface. After a successful series of biomechanical tests, we now report a clinical case series. Material and Methods: Between April 2012 and August 2013, a total of twelve patients underwent plate osteosynthesis using the precontoured plate described above. The patients (ten male, two female) were aged between 45 and 87 years, the average age being 62.5 years. We were able to perform all osteosynthesis with the modified Stoppa approach, in combination with the first window of the ilioinguinal approach (according to Letournel). In most patients, the plate was applied without complications, In some patients, it even supported repositioning. In six patients, the fractures were of the anterior collum and six fractures were fractures of both colla. The mean time span of follow-up was 13.1 months, the minimum being 4.5 and the maximum 23 months. Results: In most patients, the intra- and postoperative computed tomographic scans showed anatomically correct placement of the plate, thus confirming the correct repositioning of the bone. Routine follow-ups are part of the hospital's postsurgical care system for acetabular fractures; these revealed no secondary dislocation or loosening of the plate. The radiological examination showed consolidation of the fractures after a mean period of twelve weeks. A full year after the initial procedure, no implant-specific complications were observed. Revision surgery was necessary in one patient due to bleeding five days after surgery. In another patient, necrosis of the femoral head necessitated total hip replacement ten weeks after the first surgical intervention. In summary, the concept of the plate proved to be successful in its first case series. Summary: In spite of increasing surgical expertise and the refinements of standard approaches, there is a recognisable shift in acetabular fractures from mainly posterior fracture patterns to fractures of the anterior column. The new acetabulum wing plate takes these factors into account and is an implant designed to address the anterior aspects of the acetabulum. The outcome of the first application is promising and the acetabulum wing plate produces satisfactory results in our patients.

[Augmentation with PMMA cement]. / Augmentation mit PMMA-Zement.

Cements based on polymethyl methacrylate (PMMA) can be used without any problem in a variety of clinical augmentations. Cement-related complications in surgical procedures involving PMMA cements, such as embolism, thermal necrosis, toxicity and hypersensitivity, are often due to other causes. Knowledge about the properties of the cement helps the user to safely employ PMMA cements in augmentations. High radio-opacity is required in vertebral body augmentations and this is provided in particular by zirconium dioxide. In vertebral body augmentations, a low benzoyl peroxide (BPO) content can considerably prolong the liquid dough phase. In augmentations with cement fillings in the region of a tumor, a high BPO content can specifically increase the peak temperature of the PMMA cement. In osteosynthetic augmentations with PMMA, necrosis is rare because heat development in the presence of metallic implants is low due to heat conduction via the implant. Larger cement fillings where there is no heat conduction via metal implants can exhibit substantially higher peak temperatures. The flow properties of PMMA cements are of particular importance for the user to allow optimum handling of PMMA cements. In patients with hypersensitivity to antibiotics, there is no need to avoid the use of PMMA as there are sufficient PMMA-based alternatives. The PMMA cements are local drug delivery systems and antibiotics, antiseptics, antimycotics and also cytostatics can be mixed with the cement. Attention must be paid to antagonistic and synergistic effects.

[Femoral nailing using a helical nail shape (LFN(®))]. / Marknagelung des Femurs mit einem helikalen Implantat (LFN(®)).

OBJECTIVE: Antegrade femoral nailing through a greater trochanteric entry portal avoids damage to the proximal external rotators and to the ramus profundus of the medial femoral circumflex artery, furthermore eases insertion in adipose subjects. However a helical nail shape is necessary for this pathway because bending in two perpendicular planes has to be passed by the nail. INDICATIONS: All femoral shaft fractures suitable for antegrade nailing (type 32-A/B/C). Additional femoral neck fractures (type 31-B) by using proximal Recon-interlocking screws. CONTRAINDICATIONS: The common contraindications for femoral nailing. In certain subtrochanteric fractures (Type 32-A/B) the proximal femoral nail may be favorable. SURGICAL TECHNIQUE: General or spinal anesthesia. Supine position with flexion/abduction of the contralateral leg in order to facilitate fluoroscopy of the proximal femur in a true lateral view. Closed reduction of length and axis. Measurement of length and diameter of the nail using a radiolucent ruler. Dorsolateral approach to the greater trochanter. Insertion of the guide wire 10 mm lateral to the trochanteric tip (anteroposterior view) and in the middle third of the trochanter (lateral view). Reaming of the insertion point using a flexible reamer. If reaming of the entire medullary canal is desired, this should be done using a long intramedullary guide wire in combination with a long flexible reamer. Insertion of the nail starts in an anterior position and ends in a lateral position of the insertion instrument, so a 90° external rotation of the nail occurs during insertion. Proximal interlocking is performed using the guide of the insertion instrument. Check interfragmentary rotation. Distal interlocking using a radiolucent drill device. POSTOPERATIVE MANAGEMENT: Depends on the fracture shape: stable interfragmentary support may allow early full weight bearing. Otherwise, reduced weight bearing is recommended for at least 6 weeks. RESULTS: In a prospective mulicentric study, 227 helical femoral nails were used for antegrade femoral nailing. Follow-up after 12 month was available in 74 %. Surgeons' rating for ease of identifying entry site was excellent or good in 89 %. Functional and radiological results after 12 months do not prove significant benefits over conventional antegrade femoral nails.

[Dynamic locking screw 5.0--first clinical experience]. / Dynamic Locking Screw 5.0--erste klinische Anwendung.

The principle of "biological" plate osteosynthesis describes the optimum interaction between mechanics and biology with the aim to achieve an uneventful consolidation of the fracture by secondary bone healing. The preservation of soft tissue and blood supply are central points in this context. Empirical values show that a too rigid internal fixation can suppress callus formation. The dynamic locking screw - DLS - allows for a decrease of the rigidity of a plate osteosynthesis. The fracture motion is positively affected. The advantages of the angular stability are not affected. In the Trauma Centre Tuebingen 35 patients were treated with the DLS5.0 in the time between November 2011 and October 2012. These first clinical cases with the use of the large fragment DLS showed good results. Handling the DLS5.0 is comparable to the conventional locking screw - LS5.0. Complications were not caused by the DLS and their application.

[Experiences with a helical femoral nail (LFN®). A multicenter study]. / Erfahrungen mit einem helikalen Femurmarknagel (LFN®). Eine multizentrische Studie.

INTRODUCTION: Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant. MATERIAL AND METHODS: Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167). RESULTS: The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%. CONCLUSION: The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.

[Removal of plates and screws. Tips and tricks for problematic cases]. / Implantatentfernung von Platten und Schrauben. Tipps und Tricks für die problematische Metallentfernung.

BACKGROUND: This overview article addresses the different ways of explanting plates and screws. Once the decision has been taken to remove plates and screws, the situation is resolved by skilled performance of surgical procedures. METHOD: In particular, tips and tricks are offered on how to deal with difficult explantations. In general, implant removal is straightforward and without complications. Special techniques, instruments, tips and tricks are important when implant removal becomes problematic due to screw damage, immovable implants, instrument breakage and suchlike. CONCLUSION: This article describes procedures that will put the surgeon on a direct route to implant removal. Keeping strictly to the pathway will inevitably turn problematic implant removal into a straightforward procedure.

A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN).

INTRODUCTION: The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct. PATIENTS AND METHODS: 180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12 weeks and 1 year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation. RESULTS: The 1-year follow-up rate was 81 %. At 1 year, the prevalence of delayed union was 12.2 % and higher for open fractures (18.2 %) compared to closed fractures (9.7 %). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5 % in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment >5° in any plane 1 year after surgery was 5.5 %. Proximal third fractures were at a higher risk of postoperative malalignment (17.6 %). The rate of secondary malalignment was 1.4 %. The risk of unplanned reoperation was 9.2 %. CONCLUSION: Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.

[Angle-stable fixation of intramedullary nails using the Angular Stable Locking System® (ASLS)]. / Winkelstabile Verriegelung von Marknägeln mit dem Angular Stable Locking System® (ASLS).

OBJECTIVE: Greater stability in intramedullary osteosynthesis using angle-stable fixation with intramedullary nails and proximal locking screws. A novel screw-and-sleeve system (ASLS®, Synthes GmbH, Oberdorf, Switzerland) is applied using normal cannulated nails. Decisions can be made intraoperatively. INDICATIONS: This technology widens the range of indications for intramedullary nailing: The smaller and less stable the fragment requiring fixation, the greater the indication for angular stable fixation of the proximal and/or distal fragment. Femoral, tibial and humeral fractures, intramedullary osteosynthesis in osteoporotic bone and ante- and retrograde nailing. Particularly in the case of retrograde nailing, sustained prevention of nail toggling is achieved. CONTRAINDICATIONS: None. SURGICAL TECHNIQUE: Drill with the first drill bit, which has the same core diameter as the screw shaft. Drill the cortex to the external diameter of the sleeve. Place the sleeve on the tip of the screw. The screw-sleeve combination is then advanced through the larger near hole until the sleeve-covered screw tip sits in the locking hole of the intramedullary fixation nail. Advance the screw. As the screw diameter becomes larger, the sleeve expands resulting in an angular stable locking effect. The screw is then advanced until the head of the screw sits on the exposed surface of the cortex. The hole is filled with the expanded part of the screw shaft beneath the screw head. The necessary 1-3 turns are cut by the self-tapping flute on the screw. POSTOPERATIVE MANAGEMENT: According to experience to date, this form of angle-stable fixation enables earlier and/or greater partial mobilization or earlier full mobilization. In all other respects, the guidelines for aftercare in intramedullary nailing apply. RESULTS: A multi-center pilot study has shown the technique to be reproducible and simple. There have been no complications using this technique to date. Biomechanical laboratory studies have demonstrated that stability with respect to axial and torsional loading is statically and dynamically higher than with conventional nailing. Device failure occurs later. Further applications as well as results of a prospective randomised study currently under way will show how great the clinical advantages ultimately prove to be.

[External fixation osteosynthesis]. / Fixateur-externe-Osteosynthese.

External fixation is one of the mainstays of surgical fracture treatment. This method of osteosynthesis facilitates local damage control surgery for fractures with extensive soft tissue injury and in polytraumatized patients. In addition, correction of deformities and bone segment transport are possible. Arthrodesis and septic surgery also benefit from external fixation.An extensive range of fixators and methods are available to meet these various needs. An external fixator consists of three elements: securing the bone fragments (pins and/or wires with extracorporeal ends), longitudinal rods and rings, and the connectors. The main features of external fixation can be described in terms of a few design and assembly principles. It is important that "form follows function", i.e. design and assembly are modified to function. If these principles are observed, external fixation can be successfully applied.

[Humerus shaft fractures]. / Humerusschaftfrakturen.

Fractures of the humerus shaft are a common injury, mainly in younger patients and often coming with other injuries. The strategies of treatment are the conservative therapy, which was favoured till the late 1970s, and the operative therapy, including intramedullary nailing, plate osteosynthesis and external fixation. The initial procedure should be chosen according to the primary soft tissue damage and the existence of radial nerve palsy. The aim of treatment must be a usable extremity with anatomical axis, length and rotation.

Angle stable interlocking screws improve construct stability of intramedullary nailing of distal tibia fractures: a biomechanical study.

INTRODUCTION: Intramedullary nailing is the treatment of choice for most displaced tibial shaft fractures. The ability to maintain a mechanically stable fixation becomes more difficult the further the fracture extends distally or proximally or when unreamed tibial nails are used. We assumed that a new angular stable locking option would provide improved stability and reduced interfragmentary movements in a distal tibia in vitro fracture model. MATERIALS AND METHODS: Left and right bones of 8 pairs of human cadaveric tibiae were randomly assigned to either a group with conventional locked or a group with angular stable locked intramedullary nails. Nails of 10-mm-diameter were used after reaming up to 11 mm. A transverse distal osteotomy was performed and the specimens were tested mechanically under eccentric axial load. A video optical measurement system was used to determine the angular displacement of the osteotomy gap during loading. RESULTS: Construct stiffness, maximum load of the bone-nail construct and gap angle at 0.5 kN load were measured. The group with the angular stable locking option showed significantly higher stiffness values and reduced fracture gap motion compared to the group with conventional locked nails. DISCUSSION: A new angular stable locking option of intramedullary nails provides higher stability in terms of construct stiffness and reduced interfragmentary movements in a distal tibia in vitro fracture model.

Fractures of the distal tibia treated with closed reduction and minimally invasive plating.

INTRODUCTION: The treatment of fractures of the distal tibia can be problematical because of the thin soft-tissue covering. Bridging slide-insertion plate osteosynthesis is performed by indirect, axially correct reduction of the fracture and stabilization without opening the soft tissue at the fracture site. Stripping of the periosteum is thus avoided, the fragments remain integrated into the soft tissue, and healing occurs spontaneously by way of callus formation. MATERIALS AND METHODS: Seventy-one patients treated by slide-insertion plate osteosynthesis were followed up over at least 2 years. As would be expected in this anatomical region, the proportion of C fractures and fractures with concomitant soft-tissue damage was high. The majority of patients were treated by application of an external fixator on the day of the accident; the definitive osteosynthesis with the slide-insertion plate was performed at a later date after healing of the soft tissues. RESULTS: In 68 patients, fracture healing was achieved within 2 years. In 80% of the cases, the final X-ray follow-up showed no or tolerable axis deviations (<5 degrees) in the varus/valgus plane or in the recurvation/antecurvation plane. A deviation >10 degrees requiring a correcting osteotomy was found in only 1 patient. Postoperative complications were rare occurrences. Five patients required an additional cancellous bone graft to deal with inadequate bone healing. System-related complications (instability, malalignment) due to intraoperative technical errors only had to be corrected in revision operations in 2 patients. CONCLUSION: Closed reduction and minimally invasive plating offers the combined advantages of minimal soft-tissue damage with stable fracture fixation.

Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases.

The LISS-DF (Less invasive stabilization system-distal femur) is a new type of implant system for the treatment of distal femoral fractures according to the principles of "Minimally Invasive Surgery". A plate, pre-contoured to the anatomy, is inserted through a minimally invasive incision into the epiperiosteal space by means of an aiming device after indirect, closed fracture reduction. The implant is stabilized by insertion of screws which lock into the plate holes and prevent tilting. This is performed with the aid of an aiming device and through stab incisions. It is not necessary for a large area to be exposed at the fracture site. As part of an AO prospective multicenter study, the new system was applied to 112 patients with 116 fractures. The time to follow-up was on average 13.7 months (minimum 7 months, maximum 33 months). Fractures treated were distal femoral shaft and supracondylar femoral fractures. Eight patients died during the study of causes unrelated to the implant. Of the remaining 104 patients with 107 fractures, 96 patients with 99 fractures were available for complete follow-up (93% follow-up rate). In 90% of all cases treated and followed up, the fracture had consolidated during the period of observation. Twenty-three revision operations were necessary in 21 patients. In two cases, implant failure occurred as the result of a pseudarthrosis. The complications can be attributed in nearly all cases to the severity of the trauma and/or a lack of experience when applying the new style implant to a wider range of indications. The results of the study show that with a sound knowledge of the operative technique and careful preoperative planning this system represents an excellent, safe procedure for the treatment of almost all distal femoral fracture types including periprosthetic fractures of the distal femur. There is generally no need for primary cancellous bone grafting.

[Distal femoral fracture--technical possibilities]. / Distale Femurfraktur--Technische Möglichkeiten.

The fractures of the distal femur are classified as extra-articular fractures (type A), partial articular fractures (type B), and complete articular fractures (type C). The aims of operative treatment are anatomical reconstruction of the articular surfaces, restoration of rotational and axial alignment, stable fixation of the condyles to the shaft of the femur and early functional aftercare. Techniques and implants for treating intra-articular fractures lies in the reduction of the joint fragments and fixation with lag screws. For the treatment of the extra-articular fractures different approaches, techniques and implants have proven to be reliable and effective: direct-indirect reduction, open-minimal invasive approaches, open-slipped techniques. Implants: condylar plate, dynamic condylar screw (DCS), condylar buttress plate, anterograde nailing, retrograde nailing, internal fixators (Low Invasive Stabilisation System--LISS) and external fixation.

[Computer-assisted performance documentation. Effects in orthopedics and trauma surgery on budgets and reimbursement]. / Rechnergestützte Leistungsdokumentation. Auswirkungen in Orthopädie und Unfallchirurgie auf Budget und Entgeltformen.

Since 1995 German health maintenance laws require hospitals to document and code all referrals, admissions and discharges using the 4-digit ICD. Operative procedures are documented and coded using the ICPM. Beginning in January 1996, reimbursement for health services requires a diagnosis-related billing and payment for special procedures. The decision for billing is based on documented diagnosis and therapy. This extended request for documentation makes an online access to diagnosis and therapy with a computer-assisted coding system advisable. In 1996 in our hospital each diagnosis and operation was manually documented and coded on a form. Since the beginning of 1997, documentation and coding has been exclusively computer-assisted. On the basis of documented diagnosis and therapy the computer provides the route of reimbursement. Retrospectively we evaluated the number of charged diagnosis-related billings and payments for special procedures from January to April of 1996 and 1997. It became evident that with computer-assisted documentation and coding the number of detected and charged diagnosis-related billings and payments for special procedures was significantly increased in comparison with the previous year.