Conservative or operative therapy in patients with a fragility fracture of the pelvis: study protocol for a prospective, randomized controlled trial.

BACKGROUND: The incidence of fragility fractures of the pelvis is rising. Whereas the treatment for FFP type I, III, and IV is clear, the optimal treatment for FFP type II remains a topic of discussion. Traditionally these fractures have been treated conservatively. However, there is a shift toward early surgical stabilization with percutaneous screw fixation to reduce pain and promote mobility in an already frail patient population. High-quality evidence, however, is lacking. Therefore, a randomized clinical trial was designed to compare conservative management to early percutaneous screw fixation in patients with type II fragility fractures. METHODS: This is a monocenter randomized controlled trial. All patients with a FFP type II are screened for inclusion. After obtaining informed consent, patients are randomized between conservative management and surgical stabilization. Conservative management consists of early mobilization under guidance of physiotherapy and analgesics. Patients randomized for surgical treatment are operated on within 72 h using percutaneous screw fixation. The primary endpoint is mobility measured by the DEMMI score. Secondary endpoints are other dimensions of mobility, pain levels, quality of life, mortality, and morbidity. The total follow-up is 1 year. The required sample size is 68. DISCUSSION: The present study aims to give certainty on the potential benefit of surgical treatment. Current literature on this topic remains unclear. According to the volume of FFP at the study hospital, we assume that the number of patients needed for this study is gathered within 2 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT04744350. Registered on February 8, 2021.

Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques.

OBJECTIVE: Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques. METHODS: All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation. RESULTS: In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications. CONCLUSION: Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

Long-term follow-up of patients with displaced scapular fractures managed surgically and non-operatively.

INTRODUCTION: Controversy remains on which patients with displaced scapula fractures benefit from surgery. This retrospective cohort study aims to compare and describe long-term patient-reported outcomes of patients with displaced scapula fractures treated both surgically and conservatively. METHODS: This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion. RESULTS: Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation. CONCLUSION: In this cohort, functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.

Trauma mechanism and patient reported outcome in tibial plateau fractures with posterior involvement.

INTRODUCTION: Posterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome. METHODS: An international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: A total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1-43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the 'symptoms' (p = 0.004) and 'pain' subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except 'pain'. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome. CONCLUSIONS: Fracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed.

Does preoperative hemodynamic preconditioning improve morbidity and mortality after traumatic hip fracture in geriatric patients? A retrospective cohort study.

INTRODUCTION: Dehydration is a major problem in the older population with traumatic hip fractures (THF). A preoperative hemodynamic preconditioning (PHP) protocol may help in achieving hemodynamic stability to ensure adequate perfusion and oxygenation using only clinical parameters to assess cardiovascular performance. MATERIALS AND METHODS: A single-centre retrospective study in geriatric trauma patients was conducted in a Level 1 Trauma Centre in Switzerland. Patients over the age of 70 with THFs and with Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM) scores ≥ 5% who underwent surgical treatment between February 2015 and October 2017 were included. It was hypothesized that patients whose hemodynamic stability was optimised before surgery would have fewer complications and reduced mortality postoperatively. Primary outcomes were complications and mortality. Secondary outcomes were hospital length of stay (HLOS) and place of discharge. RESULTS: 100 patients were included in the PHP group and 79 patients were included in the non-PHP group. The median age was 86.5 (82-90) in the PHP group and 86 (82-90) in the non-PHP group. Patients who had been treated according to the PHP protocol showed a significant reduction in mortality at 30 days (p = 0.02). The PHP group showed an 8.1 and 3.5% reduced mortality at 90 days and at 1 year, respectively. The PHP group showed an 11.7% reduction of patients with complicated courses. No significant differences were seen in HLOS and discharge disposition. CONCLUSIONS: The PHP group showed a significant reduction in short-term mortality, a reduction in long-term mortality, and a reduction in the number of patients with complicated courses. The PHP protocol is a safe, strictly regulated, non-invasive fluid resuscitation protocol for the optimization of geriatric patients with a THF that requires minimal effort. LEVEL OF EVIDENCE: Level III, therapeutic.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients.

BACKGROUND: Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores). METHODS: A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design. RESULTS: A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. CONCLUSION: Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses: A Prospective, Randomized Controlled Trial.

BACKGROUND: Soft tissue abscesses are among the most frequently encountered medical problems treated by different surgeons. Standard therapy remains incision and drainage with sterile saline irrigation during postoperative wound healing period. Aim of this prospective randomized controlled trial was to compare sterile irrigation versus nonsterile irrigation. STUDY DESIGN: A single center randomized controlled trial was performed to investigate postoperative wound irrigation. The control group used sterile irrigation, and the intervention group used nonsterile irrigation. Primary endpoints were reinfection and reintervention rates, assessed during follow-up controls for up to 2 years. Secondary endpoints were the duration of wound healing, inability to work, pain and quality of life. RESULTS: Between 04/2016 and 05/2017, 118 patients were randomized into two groups, with 61 allocated to the control- and 57 to the intervention group. Reinfection occurred in a total of 4 cases (6.6%) in the sterile protocol and 4 (7%) in the nonsterile protocol. Quality of life and pain values were comparable during the wound healing period, and patients treated according to the nonsterile irrigation protocol used significantly fewer wound care service teams. Despite equal wound persistence rates, a substantially shorter amount of time off from work was reported in the nonsterile protocol group (p value 0.086). CONCLUSION: This prospective, randomized trial indicates that a nonsterile irrigation protocol for patients operated on for soft tissue abscesses is not inferior to the standard sterile protocol. Moreover, a nonsterile irrigation protocol leads to a shorter period of inability to work with comparable pain and quality of life scores during the wound healing period.

Results of plate fixation for humerus fractures in a large single-center cohort.

INTRODUCTION: This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified. MATERIALS AND METHODS: This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1 year. RESULTS: Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach. CONCLUSION: Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

Absolute or relative stability in plate fixation for simple humeral shaft fractures.

INTRODUCTION: Minimal invasive plating (MIPO) techniques for humeral shaft fractures appear to have fewer complications and higher union rates compared to open reduction and internal fixation (ORIF). It is questionable if this also applies to simple humeral shaft fractures, as simple fractures are generally treated with absolute stability which cannot be obtained with MIPO. This raises the question whether biology or biomechanics is more important in fracture healing. This study was developed to investigate the biomechanical part of this equation. The aim of the study was to compare relative stability to absolute stability in simple humeral shaft fractures with regard to fracture healing METHODS: This was a retrospective study of all patients treated with plate fixation for AO/OTA type A1-B3 humeral shaft fractures. Patients were categorized into two groups: absolute stability and relative stability. Both groups were compared with regard to time to radiological union and full weight bearing RESULTS: Thirty patients were included in the relative-stability-group with either an AO/OTA type A (n = 18) or type B (n = 12) humeral shaft fracture and a mean age of 55 (SD 21) years. A total of 46 patients were included in the absolute-stability-group: 27 patients had a type A and 19 type B fracture. The mean age in this group was 45 (SD 19) years. Median follow-up was 12 months (IQR 8-13). Minimally invasive approach was used in 15 (50%) patients in the relative stability group. Time to radiological union was significantly shorter in the absolute-stability-group with a median of 14 (IQR 12-22) versus 25 (IQR17-36) weeks and HR 2.60 (CI 1.54-4.41)(p < 0.001). This difference remained significant after correction for type of approach (adjusted HR 3.53 CI 1.72-7.21) (p 0.001). There was no significant difference in time to full weight bearing. The addition of lag screws in the absolute stability group did not influence time to radiological healing or full weight bearing. CONCLUSION: Absolute stability for simple humeral shaft fractures leads to a significantly shorter time to radiological union compared to relative stability. The addition of lag screws to gain interfragmentary compression does not reduce fracture healing time.

The implementation of a Geriatric Fracture Centre for hip fractures to reduce mortality and morbidity: an observational study.

INTRODUCTION: The aim of this study was to evaluate the effect of an orthogeriatric treatment model on elderly patients with traumatic hip fractures (THF). The Geriatric Fracture Centre (GFC) is a multidisciplinary care pathway with attention for possible age-related diseases, discharge management and out-of-hospital treatment. MATERIALS AND METHODS: A prospective cohort study with a historical cohort group was conducted at a level I trauma centre in Switzerland. Patients over the age of 70 years with THFs who underwent surgical treatment at GFC in 2013 and 2016 were included. Primary outcomes were mortality and complications. Secondary outcomes were hospital length of stay (HLOS), time to surgery and place of discharge. RESULTS: A total of 322 patients were included in this study. In 2016, mortality showed a reduction of 2.9% at 30 days (p = 0.42) and 3.4% at 90 days (p = 0.42) and 0.1% at 1 year (p = 0.98). The number of patients with a complicated course showed a decrease of 2.2% in 2016 (p = 0.69). A significant increase in the diagnosis of delirium by 11.2% was seen in 2016 (p < 0.001). The median HLOS was significantly reduced by 2 days (p < 0.001). An increase of 21.1% was seen in patients who were sent to rehabilitation in 2016 (p < 0.001). Day-time surgery increased by 10.2% (p = 0.04). CONCLUSION: The implementation of the GFC leads to improved processes and outcomes for geriatric patients with THFs. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts might lead to more significant effects and an increase in the reduction of morbidity and mortality in the future.

Secondary prevention of minor trauma fractures: the effects of a tailored intervention-an observational study.

INTRODUCTION: Minor trauma fractures (MTF) in the elderly are associated with an increase in mortality, morbidity, and the risk of subsequent fractures. Often, these patients who sustain MTF have an underlying bone disease, such as osteopenia or osteoporosis. Osteoporosis is known to be underdiagnosed and undertreated, and adequate treatment is essential to reduce the occurrence of MTFs. At our hospital, this has led to the implementation of Osteofit, a patient-education-based intervention targeted at improving screening and prevention of osteoporosis, with the goal to reduce the rate of subsequent MTF. OBJECTIVE: The aim of this study was to assess the efficacy of Osteofit in improving osteoporosis screening and treatment in patients after an initial MTF episode. METHODS: The study is a prospective, single-center, cohort study of MTF patients aged 50 years or older. A standardized questionnaire and telephone interview were used to collect 1-year follow-up data. The primary outcome was the rate of patients undergoing Dual X-ray Absorptiometry (DXA) scanning. Secondary outcomes were the rate of patients with a diagnosis of osteoporosis or osteopenia, the rate of patients treated with anti-osteoporotic medication, and the rate of patients with a subsequent fracture. DXA scanning rate, the prevalence of a diagnosis (osteoporosis/osteopenia), and data on medical treatment for osteoporosis were compared to the results of a previous study in the same hospital, published in 2004. RESULTS: Between 2012 and 2015, 411 of 823 eligible patients consented to participate and were included in this study. The mean age was 72 ± 9.3 years. Sixty-three percent (63.3%, n = 252) of the patients received a DXA scan, compared to 12.6% reported in our previous study. Of all patients who received a DXA scan, 199 (82.9%) were diagnosed with osteoporosis or osteopenia. A total of 95 patients (23.1%) received specific medical treatment for osteoporosis and 59.8% reported the intake of any unspecific medication (vitamin D, calcium, or both). Fifteen patients (3.9%) had a subsequent fracture as a result of a minor trauma fall. CONCLUSION: The implementation of a MTF secondary prevention program with dedicated health professionals improved the rate of patients who underwent DXA screening by fivefold. Despite this improvement, DXA screening was missed in over a third of patients, with only 23% of eligible patients receiving specific medical treatment for osteoporosis at 1-year follow-up. Consequently, this tailored intervention is a promising first step in improving geriatric fracture care. However, further work to improve the rate of osteoporosis screening and medical treatment initiation for the long-term prevention of subsequent MTF is recommended. We believe osteoporosis screening and adequate osteoporosis medication should be integrated as standard procedure in the aftercare of MTF. LEVEL OF EVIDENCE: II.

[Reduction techniques for minimally invasive stabilization of proximal humeral fractures]. / Repositionstechniken bei minimal-invasiver Stabilisierung proximaler Humerusfrakturen.

OBJECTIVE: The aim of surgical stabilization of proximal humerus fractures is to restore the anatomical relations between the greater and lesser tubercle, to reconstruct the joint and preserve the vascular supply of the fragments. INDICATIONS: Approximately 80% of proximal humeral fractures can be treated conservatively. Surgical treatment is indicated based on the fracture pattern, patient-related factors and the risk of avascular head necrosis. Two-part fractures with a metaphyseal comminution zone and 3/4-part fractures can benefit from near to anatomic reconstruction depending on the patient's demands and bone quality. Minimally invasive stabilization procedures allow for an anatomical reconstruction in the majority of fresh proximal humeral fractures with or without a proximal shaft fracture, provided that intraoperative traction allows the fracture to be aligned axially in the image intensifier by ligamentotaxis. Indirect, combined with direct reduction maneuvers, allow for an almost anatomical reconstruction, despite minimal invasive approaches. SURGICAL TECHNIQUE: Beach chair position. The arm is held in a pneumatic articulating traction device. Evaluation of the indirect reduction potential by ligamentotaxis with visualization of the alignment of the head fragments in relation to the shaft by traction, abduction/adduction, flexion/extension and rotation. The traction device and a foam roll in the axilla to neutralize the tension of the pectoralis major and teres major muscles while simultaneously adducting the elbow hold the reduction. Insufficient reduction of the fragments requires additional direct reduction maneuvers. Opening of the bursa and fixation of the rotator cuff with sutures to adjust reposition. A 2.5 mm-threaded K­wire is inserted into the head fragment as a joystick. Under protection of the axillary nerve, the plate is inserted under protection of the axillary nerve. Temporary fixation of the plate with Kirschner wires for positioning the plate 5-8 mm below the greater tubercle and 2-3 mm laterally of the sulcus of the long biceps tendon and subsequent radiographic control. Reduction of the shaft against the plate with a cortex screw. The threaded K­wire in the head can be used to adjust the varus and valgus alignment and to achieve adequate support of the calcar. Finally, complete the osteosynthesis with angular stable screws. POSTOPERATIVE MANAGEMENT: Immediate active assisted exercise in the shoulder under physiotherapeutic supervision. Temporary immobilization for patient comfort. Standard active and resistive mobilization after the first clinical and radiological checkup 6 weeks after surgery. Further radiological checks after 3 and 6 months and 1 year. No routine plate removal.

[Definitions and explanations on the topic of fracture reduction]. / Definitionen und Erklärungen zum Thema Frakturreposition.

The process of reduction is a key step for successful fracture treatment. The goal of fracture reduction is the realignment of the displaced fractured fragments caused by muscle tension or impaction back into the original anatomic relationship. The reduction process includes not only the application of force at or remote from the fracture site to reverse the deforming forces but also the preoperative planning where to apply these forces and by what means. Furthermore, consideration should be preoperatively given on how to position the patient and the C­arm and how to temporarily maintain reduction for intraoperative x­ray control of the axis, rotation and lengths before definitive fixation.

Defining the pubic symphysis angle with respect to the coronal plane - Clinical and biomechanical considerations.

BACKGROUND: Fixation strength of constructs placed across the pubic symphysis after injury is dependent on screw length, maximisation of which requires knowledge of the bony anatomy. The aim of this study was to describe the ideal angle of drilling to achieve maximal safe screw placement within the pubic body. Furthermore, the influences of age and gender on the skeletal topography were investigated. METHODS: Three hundred CT scans of patients without pelvic injury were analysed to record the angle of the pubic body (APB) with respect to the coronal plane, and the depth of the pubic body (DPB) in the sagittal plane. RESULTS: Mean APB and DPB were 54.69° and 55.35mm, respectively. Females had a significantly higher mean APB than males (57.29° vs. 52.41°; p<0.001), whereas males had a significant larger mean DPB (59.13mm vs. 51.03mm; p<0.001). Age had no effect on the mean APB. Mean width of the pubic body at the base was 9.38mm. CONCLUSION: The anatomy of this region is reliable in terms of angles and sizes; a drill angle of 55° with respect to the operating table will allow maximal screw length, which should be in the region of 55mm. The mean width of the pubic body should allow for placement of a 3.5 or 4.5mm diameter screw.

[Miniplates as augmentation implants in osteosynthesis of complex distal radial fractures]. / Miniplatten als Ergänzungsimplantat bei der Osteosynthese komplexer distaler Radiusfrakturen.

THE PROBLEM: Dislocated intra-articular fractures of the distal radius are operatively treated to achieve anatomical reconstruction of the joint. In complex distal radial fractures with multiple joint fragments, fixation with angular stable plates alone may be technically challenging. Smaller fragments, such as the lip of ulnopalmar joint, are often difficult to control. THE SOLUTION: The supplementary application of mini plates, as employed in maxillofacial surgery, is a helpful tool for reduction and fixation. RESULT: In this article the operative technique, clinical and radiographic results of 4 complex distal intra-articular radial fractures are presented.

[Treatment of an osteo-fascio-cutaneous defect of the femur with a serial connected flow-through free-flap]. / Therapie eines osteo-fascio-cutanen Femurdefektes mit in Reihe geschalteter Durchflusslappenplastik.

Covering large osteo-fascio-cutaneous defects after debridement often calls for elaborate soft tissue reconstruction. Large tissue loss or structural damage that requires distinct repair is rarely coverable by a single conventional flap. Here, we report the case of serial flap coverage using sequentially connected fibular and latissimus dorsi free flaps.

[Long-term outcome after surgical treatment of breast asymmetry: analysis of the patient's perspective in 51 cases]. / Langzeitresultate nach chirurgischer Behandlung von Brustasymmetrien aus Sicht der Patientinnen: Eine Analyse von 51 Fällen.

INTRODUCTION: Literature provides 3 studies only investigating the long-term outcome after surgical correction of breast asymmetry. The goal of this study was to analyse from a patient's perspective, which factors influence postoperative satisfaction most. PATIENTS AND METHODS: All patients undergoing surgical treatment for breast asymmetry between 2000 and 2009 were included. With help of the visual analogue scale the patients conducted a subjective assessment of their own long-term result using the following parameters: overall satisfaction, symmetry, size, shape, scarring and sensitivity. Anthropometric measurements of the breasts followed. RESULTS: 51 patients (80% follow-up) were seen 2-11 (mean 5±2.5) years postoperatively. The following mean values were recorded for overall satisfaction 8.31 (±1.91), symmetry 7.86 (±2.25), size 8.42 (±1.93), shape 8.12 (±2.03), scarring 7.82 (±1.94) and sensitivity 7.92 (±2.19). Overall satisfaction increased significantly with good scores for the parameters symmetry [p=0.01] and shape [p=0.048]. Neither size [p=0.46] nor scarring [p=0.69] nor sensitivity [p=0.34] had a statistically significant influence on overall satisfaction. Furthermore, overall satisfaction did not depend on the surgical technique, preoperative size, preoperative asymmetry, age of the patient at time of surgery, period of time between the operation and the assessment, resected weight (absolute and difference between left and right) or on postoperative symmetry of the nipple areola complex. CONCLUSION: In our patients, long-term overall satisfaction after surgical correction of breast asymmetry was primarily dependent on symmetry and shape. Size, scarring and sensitivity did not have a statistically significant influence on postoperative overall satisfaction. This also applied to preoperative size, preoperative extent of asymmetry, age of the patient at time of surgery, surgical technique and the time span between the operation and the assessment.

[Minimally invasive plate osteosynthesis of the distal femur]. / Minimal-invasive plattenosteosynthese des distalen femurs.

OBJECTIVE: Minimally invasive stabilization of articular and extra-articular fractures of the distal femur with anatomically preshaped, locking compression plates. INDICATIONS: Distal extra-articular femoral fractures. Distal periprosthetic or periosteosynthetic femoral fractures. Multifragmentary articular fractures of the distal femur. CONTRAINDICATIONS: Local soft tissue infection or osteitis. SURGICAL TECHNIQUE: Patient in a supine position on a radiolucent table with both legs draped free. Fractured leg supported with a towel to release traction of the gastrocnemius muscles onto the distal fragment. Reduction and fixation of articular fractures with 3.5 mm lag screws. Indirect reduction of the metaphyseal fracture component and temporary fixation with different instruments (e.g. cerclage) or reduction to the plate with special tools (e.g. collinear reduction clamp). Submuscular epiperiosteal introduction of the plate. Plate fixation through the aiming device. Intraoperative image intensification control to check plate position and reduction with special emphasis on rotation and longitudinal axes. POSTOPERATIVE MANAGEMENT: Continuous passive motion without range limitations from day 1. Mobilization on crutches with toe-to-tip weight bearing during the first 6 weeks. No full weight loading until osseous consolidation. RESULTS: Between January 2009 and November 2011, minimally invasive plate osteosynthesis using the minimally invasive cerclage passer or the collinear reduction clamp was performed in 21 patients with 23 distal femoral fractures. None of the patients suffered from postoperative malalignment or malrotation. Mean time to adequate fracture consolidation was 128 days (range 53-470 days).

Current concepts in fractures of the distal femur.

This paper describes current treatment strategies of distal femoral fractures as well as their evidence based rationale. The treatment of distal femoral fractures has improved with the evolution of plating and nailing technologies. The commonly selected surgical approaches are outlined and surgical treatment techniques including both internal and external fixation are discussed.

[The influence of ulnar variance on the healing of scaphoid fractures]. / Einfluss der Ulnavarianz auf die Kahnbein-Frakturheilung.

The recent literature shows that a negative ulnar variance could pose a risk factor for scaphoid fractures.The aim of the current study was to determine whether the ulnar variance also affects the healing of a scaphoid fracture.2 cohorts of 50 patients each, with either a scaphoid fracture or a non-union, were retrospectively compared. The ulnar variance was measured on the X-rays using the Gelberman method.The average value of the ulnar variance in patients with a scaphoid fracture was -1.0 mm. The negative ulnar variance was measured in 64% of the patients. In the second group with scaphoid non-union, the average value of ulnar variance was -0.8 mm. The negative ulnar variance was similarly high, in 68% of the patients. Our results demonstrated almost identical values in both groups with regard to ulnar variance or its distribution, neutral, negative or positive, without statistical significance.Thus, we can exclude the negative ulnar variance as a risk factor for the development of non-union in cases of scaphoid fractures.