[Clavicle fractures: practical approach in clinical routine]. / Klavikulafrakturen ­ praktisches Vorgehen im klinischen Alltag.

Fractures of the clavicle are among the most common fractures. They typically result from a fall onto the lateral shoulder or the extended arm and are often related to sports and bicycle accidents. Obtaining the exact trauma mechanism, proper clinical findings and adequate X­rays usually lead to the correct diagnosis. Non-displacement fractures can be treated conservatively with good results. Unstable and displaced fractures should be treated operatively. Open fractures or looming penetration are emergencies und should be treated immediately. In addition to fracture classification and morphology, other factors such as additional injuries and patient-related factors need to be considered in order to make an individualized therapy decision. In operative treatment, angular stable plating is the therapy of choice, and in most cases early functional aftercare is possible.

[Management of complications of acetabular fractures]. / Management der Komplikationen von Acetabulumfrakturen.

Surgical treatment of acetabular fractures represents a special challenge in the field of trauma surgery. Complications are mostly due to the trauma itself or are iatrogenic. The handling and strategy to overcome complications in acetabular surgery are oriented towards the type of complication and the time of occurrence. Generally, a differentiation is made between early perioperative complications and late complications. The present article describes the most frequent complications during the surgical treatment of acetabular fractures, discusses the various treatment options based on individual case examples and gives differentiated recommendations to overcome the complications. The treatment concept should initially comprise a comprehensive primary prophylaxis to prevent complications. In cases of early perioperative complications, e.g. postoperative wound infections, hemorrhage or incorrect implant positioning, rapid and systematic surgical revision should be performed. In contrast, the treatment of late complications (e.g. implant associated failures, secondary osteoarthrosis of the hip, periarticular heterotopic ossification, non-unions and late infections) depends on the clinical and functional condition of the patient. In symptomatic elderly patients secondary total hip replacement is usually a valid option, whereas younger patients with late complications can be candidates for joint-preserving procedures. The management of complications in acetabular surgery regularly requires intense patient guidance as well as thorough clarification and should be performed in specialized centers.

Minimal-invasive anterior approach to the hip provides a better surgery-related and early postoperative functional outcome than conventional lateral approach after hip hemiarthroplasty following femoral neck fractures.

INTRODUCTION: Femoral neck fractures (FNF) are one of the most frequent fractures among elderly patients and commonly require surgical treatment. Bipolar hip hemiarthroplasty (BHHA) is mostly performed in these cases. MATERIAL AND METHODS: In the present retrospective study geriatric patients with FNF (n = 100) treated either by anterior minimal-invasive surgery (AMIS; n = 50) or lateral conventional surgery (LCS; n = 50) were characterized (age at the time of surgery, sex, health status/ASA score, walking distance and need for walking aids before the injury) and intraoperative parameters (duration of surgery, blood loss, complications), as well as postoperative functional performance early (duration of in-patient stay, radiological leg length discrepancy, ability to full weight-bearing, mobilization with walking aids) and 12 months (radiological signs of sintering, clinical parameters, complication rate) after surgery were analyzed. RESULTS: Patients in the AMIS group demonstrated a reduced blood loss intraoperatively, while the duration of surgery and complication rates did not differ between the two groups. Further, more patients in the AMIS group achieved full weight-bearing of the injured leg and were able to walk with a rollator or less support during their in-patient stay. Of interest, patients in the AMIS group achieved this level of mobility earlier than those of the LCS group, although their walking distance before the acute injury was reduced. Moreover, patients of the AMIS group showed equal leg lengths postoperatively more often than patients of the LCS group. No significant differences in functional and surgery-related performance could be observed between AMIS and LCS group at 12 months postoperatively. CONCLUSIONS: In conclusion, geriatric patients treated by AMIS experience less surgery-related strain and recover faster in the early postoperative phase compared to LCS after displaced FNF. Hence, AMIS should be recommended for BHHA in these vulnerable patients.

Locking Nail versus Plate Fixation in Calcaneal Fractures: Brief report on a Retrospective Analysis of Treatment Characteristics and Radiographic Correction Potential.

PURPOSE OF THE STUDY Minimal and limited access techniques are gaining increasing interest for the treatment of displaced intra-articular calcaneal fractures. The ideal treatment method is however still debated and largely based on individual case factors and surgeon experience. Aim of this study was thus to compare the treatment characteristics and radiographic correction potential of a locking nail system with a sinus tarsi approach to plate fixation via an extended lateral approach. MATERIAL AND METHODS We retrospectively reviewed 39 cases of patients with calcaneal fractures that received primary fracture treatment for displaced intra-articular calcaneal fractures between July 2017 and March 2020. Patient characteristics, time to surgery, time to discharge, OR time and the correction achieved were analyzed and comparative statistics performed. RESULTS In total 19 patients treated with the locking nail and 20 patients treated with plate fixation were analyzed. Patient age and fracture severity according to the Sanders classification were comparable between the groups. Overall surgical time, as well as the achieved reduction was equal between both groups. Time to surgery, as well as time from surgery to discharge was significantly shorter in the locking nail group. 2 additional soft tissue procedures were necessary in the extended lateral approach group. DISCUSSION AND CONCLUSIONS The results with the locking calcaneus nail and sinus tarsi approach suggest, that similar treatment results can be achieved as with plate osteosynthesis and an extended lateral approach. Soft tissue management, as well as pre- and postoperative timing and discharge management can be improved with the nail. Further controlled trials comparing the longterm outcome between the treatment options are needed. Key words: calcaneus fracture, sinus tarsi approach, calcaneal nail, C-Nail.

Weight-Bearing Restrictions after Acetabular Fracture, Necessity or False Hope? A Brief Observational Study.

PURPOSE OF THE STUDY Most common postoperative treatment recommendations after acetabulum fractures suggest at least 6 weeks of postoperative partial or non weight-bearing. To protect the osteosynthetic construct this surgically set weight-bearing limit is trained by physical therapy. Aim of our analysis was to determine the free field patient compliance to these weight-bearing restrictions and observe their influence on the early postoperative radiographic imaging. MATERIAL AND METHODS Patients after surgical treatment of an acetabulum fracture were included in our analysis. Every patient was instructed to maintain a 20 kg weight-bearing limit for 6 weeks. Postoperative weight-bearing was continuously monitored during this time with a pressure measuring insole. Maximum weight-bearing per day was recorded and maintenance of reduction assessed after this time. RESULTS In total 10 patients were included into the study. Only 1 patient stayed within the weight-bearing limit during the analysis. Maximum weight-bearing as high as 110 kg was recorded. All patients maintained postoperative reduction at the 6 week timepoint. DISCUSSION AND CONCLUSIONS Despite regular physical therapy training compliance to the generally accepted weight-bearing limits was low. Regardless of the non-compliance the radiographic outcome remained unchanged. Further analysis on the use of permissive weightbearing aftercare regimes are warranted. Key words: weight-bearing, acetabulum fracture, compliance.

The effect of an infra-acetabular screw for anatomically shaped three-dimensional plate or standard plate designs in acetabulum fractures: a biomechanical analysis.

BACKGROUND: Various plate shapes and implant configurations are used for stabilization of acetabulum fractures via anterior approaches. Little is known about the biomechanical stability of a two-dimensionally shaped "conventional" plate ("J-Plate"-JP) in comparison to three-dimensionally shaped plate configurations (3DP). In addition, the augmentary effect of an infra-acetabular lag-screw (IACS) fixation for anterior column and posterior hemi-transverse acetabulum fractures has not been clarified in comparison of JP and 3DP constructs. This study analyzed the difference between the biomechanical stability of JP compared to 3DP and the role of an IACS in a standardized acetabular fracture model in a single-leg stance loading configuration. METHODS: In an artificial bone substitute pelvis model (Synbone© Malans, Switzerland), a typical and standardized fracture pattern (anterior column and posterior hemi-transverse) was created with osteotomy jigs. After anatomic reduction the stabilization was performed using JP or 3DP. Eight pelvises per group were axially loaded in a single-leg stance model up to 400 N. After the load cycle, an additional infra-acetabular screw was placed and the measurement repeated. Fragment displacement was recorded by an optical tracking system (Optitrack Prime 13®, Corvallis, USA). RESULTS: In the pure placement, 3DP provided significantly superior stability when compared to JP. Augmentation of JP by IACS increased the stability significantly, up to the level of 3DP alone, whereas augmentation of the 3DP did not result in further increase of overall stability. CONCLUSION: The anatomically shaped plate alone provides a superior biomechanical stability in fixation of an anterior column and posterior hemi-transverse fracture model. In a JP fixation the augmentation by IACS provides similar strength as the anatomically shaped 3DP. By use of the anatomically shaped 3DP the need of a clinically risky application of IACS might be avoidable. LEVEL OF EVIDENCE: IV, Experimental study.

Amlodipine accelerates bone healing in a stable closed femoral fracture model in mice.

Calcium channel blockers (CCBs), which are widely used in the treatment of hypertension, have been shown to influence bone metabolism. However, there is little information on whether CCBs also influence the process of fracture healing. Therefore, the effect of the CCB amlodipine on bone healing was studied in a stable closed fracture model in mice using intramedullary screw fixation. Bone healing was investigated by radiology, biomechanics, histomorphometry and Western blot analysis 2 and 5 weeks after fracture healing. Animals were treated daily (post operatively) per os using a gavage with amlodipine low dose (1 mg/ kg body weight, n = 20), amlodipine high dose (3 mg/kg body weight, n = 20) or vehicle (NaCl) (control, n = 20) serving as a negative control. At 2 and 5 weeks, histomorphometric analysis revealed a significantly larger amount of bone tissue within the callus of amlodipine low-dose- and high-dose-treated animals when compared to controls. This was associated with a smaller amount of cartilaginous and fibrous tissue, indicating an acceleration of fracture healing. Biomechanics showed a slightly, but not significantly, higher bending stiffness in amlodipine low-dose- and high-dose-treated animals. Western blot analysis revealed a significantly increased expression of bone morphogenetic protein (BMP)-2 and vascular endothelial growth factor (VEGF). Moreover, the analysis showed a 5-fold higher expression of osteoprotegerin (OPG) and a 10-fold elevated expression of the receptor activator of NF-κB ligand (RANKL), indicating an increased bone turnover. These findings demonstrated that amlodipine accelerated fracture healing by stimulating bone formation, callus remodelling and osteoclast activity.

Local Application of Mineral-Coated Microparticles Loaded With VEGF and BMP-2 Induces the Healing of Murine Atrophic Non-Unions.

Deficient angiogenesis and disturbed osteogenesis are key factors for the development of nonunions. Mineral-coated microparticles (MCM) represent a sophisticated carrier system for the delivery of vascular endothelial growth factor (VEGF) and bone morphogenetic protein (BMP)-2. In this study, we investigated whether a combination of VEGF- and BMP-2-loaded MCM (MCM + VB) with a ratio of 1:2 improves bone repair in non-unions. For this purpose, we applied MCM + VB or unloaded MCM in a murine non-union model and studied the process of bone healing by means of radiological, biomechanical, histomorphometric, immunohistochemical and Western blot techniques after 14 and 70 days. MCM-free non-unions served as controls. Bone defects treated with MCM + VB exhibited osseous bridging, an improved biomechanical stiffness, an increased bone volume within the callus including ongoing mineralization, increased vascularization, and a histologically larger total periosteal callus area consisting predominantly of osseous tissue when compared to defects of the other groups. Western blot analyses on day 14 revealed a higher expression of osteoprotegerin (OPG) and vice versa reduced expression of receptor activator of NF-κB ligand (RANKL) in bone defects treated with MCM + VB. On day 70, these defects exhibited an increased expression of erythropoietin (EPO), EPO-receptor and BMP-4. These findings indicate that the use of MCM for spatiotemporal controlled delivery of VEGF and BMP-2 shows great potential to improve bone healing in atrophic non-unions by promoting angiogenesis and osteogenesis as well as reducing early osteoclast activity.

Erythropoietin does not improve fracture healing in aged mice.

Fracture healing in the elderly is associated with a declined healing potential caused by multiple factors including a delay of vascularization. Erythropoietin (EPO) has been demonstrated to improve vascularization and fracture healing in adult mice. We, therefore, hypothesized that EPO in aged mice also improves fracture healing. For this purpose, EPO was given daily in a femoral fracture model in aged mice and compared to vehicle-treated controls using radiological, biomechanical, histomorphometric and Western blot techniques. Blood analyses revealed significantly higher concentrations of hemoglobin and a higher hematocrit in EPO-treated animals at 14 and 35 days after fracture. Micro-computed tomography (µCT) indicated that the fraction of bone volume/tissue volume within the callus did not differ between the two groups. However, µCT showed a 3-fold increased tissue mineral density (TMD) in the callus of EPO-treated animals compared to controls. The callus TMD of the EPO-treated animals was also 2-fold higher when compared to the TMD of the unfractured contralateral femur. Interestingly, biomechanical analyses revealed a reduced bending stiffness in femurs of EPO-treated animals at day 35. The histomorphometrically analyzed callus size and callus composition did not show significant differences between the study groups. However, Western blot analyses exhibited an increased expression of osteoprotegerin (OPG), but in particular of receptor activator of NF-κB ligand (RANKL) in the callus of the EPO-treated animals. Further histological analyses of the callus tissue showed that this was associated with an increased number of newly formed blood vessels and a higher number of tartrate-resistant acid phosphatase (TRAP)+ cells. Conclusion: In fracture healing of aged mice EPO treatment increases callus TMD as well as OPG and RANKL expression, indicating an accelerated bone turnover when compared to controls. However, EPO does not improve fracture healing in aged mice. The process of fracture healing may be altered by EPO due to a deterioration of the microcirculation caused by the worsened rheological properties of the blood and due to an increased bone fragility caused by the accelerated bone turnover. Thus, EPO may not be used to improve fracture healing in the elderly.

Effects of locally applied adipose tissue-derived microvascular fragments by thermoresponsive hydrogel on bone healing.

Insufficient vascularization is a major cause for the development of non-unions. To overcome this problem, adipose tissue-derived microvascular fragments (MVF) may serve as vascularization units. However, their application into bone defects needs a carrier system. Herein, we analyzed whether this is achieved by a thermoresponsive hydrogel (TRH). MVF were isolated from CD-1 mice and cultivated after incorporation into TRH, while non-incorporated MVF served as controls. Viability of MVF was assessed immunohistochemically over a 7-day period. Moreover, osteotomies were induced in femurs of CD-1 mice. The osteotomy gaps were filled with MVF-loaded TRH (TRH + MVF), unloaded TRH (TRH) or no material (control). Bone healing was evaluated 14 and 35 days postoperatively. MVF incorporated into TRH exhibited less apoptotic cells and showed a stable vessel morphology compared to controls. Micro-computed tomography revealed a reduced bone volume in TRH + MVF femurs. Histomorphometry showed less bone and more fibrous tissue after 35 days in TRH + MVF femurs compared to controls. Accordingly, TRH + MVF femurs exhibited a lower osseous bridging score and a reduced bending stiffness. Histology and Western blot analysis revealed an increased vascularization and CD31 expression, whereas vascular endothelial growth factor (VEGF) expression was reduced in TRH + MVF femurs. Furthermore, the callus of TRH + MVF femurs showed increased receptor activator of NF-κB ligand expression and higher numbers of osteoclasts. These findings indicate that TRH is an appropriate carrier system for MVF. Application of TRH + MVF increases the vascularization of bone defects. However, this impairs bone healing, most likely due to lower VEGF expression during the early course of bone healing. STATEMENT OF SIGNIFICANCE: In the present study we analyzed for the first time the in vivo performance of a thermoresponsive hydrogel (TRH) as a delivery system for bioactive microvascular fragments (MVF). We found that TRH represents an appropriate carrier for MVF as vascularization units and maintains their viability. Application of MVF-loaded TRH impaired bone formation in an established murine model of bone healing, although vascularization was improved. This unexpected outcome was most likely due to a reduced VEGF expression in the early phase bone healing.

Evaluation of strategies for the treatment of type B and C pelvic fractures: results from the German Pelvic Injury Register.

Aims: The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods: The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results: Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion: Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973-83.

[A new continuous gait analysis system for ankle fracture aftercare]. / Ein neues, kontinuierliches Ganganalysesystem zur Nachbehandlung von Sprunggelenkfrakturen.

BACKGROUND: Correct aftercare following lower extremity fractures remains a controversial issue. Reliable, clinically applicable weight-bearing recommendations have not yet been defined. The aim of the current study was to establish a new gait analysis insole during physical therapy aftercare of ankle fractures to test patients' continuous, long-term compliance to partial weight-bearing restrictions and investigate whether patients can estimate their weight-bearing compliance. MATERIALS AND METHODS: The postoperative gait of 14 patients after operative treatment of Weber B-type ankle fractures was monitored continuously for six weeks (OpenGO, Moticon GmbH, Munich). All patients were instructed and trained by physical therapists on how to maintain partial weight-bearing for this time. Discontinuous (three, six and twelve weeks) clinical (patient questionnaire, visual analogue pain score [VAS]) and radiographic controls were performed. RESULTS: Despite the set weight-bearing limits, individual ranges for overall weight-bearing (range 5-107% of the contralateral side) and patient activity (range 0-366 min/day) could be shown. A good correlation between weight-bearing and pain was seen (rs = -0.68; p = <0.0001). Patients significantly underestimated their weight-bearing time over the set limit (2.3 ± 1.4 min/day vs. real: 12.6 ± 5.9 min/day; p < 0.01). CONCLUSIONS: Standardized aftercare protocols and repeated training alone cannot ensure compliance to postoperative partial weight-bearing. Patients unconsciously increased weight-bearing based on their pain level. This study shows that new, individual and possibly technology-assisted weight-bearing regimes are needed. The introduced measuring device is feasible to monitor and steer patient weight-bearing during future studies.

Clinical outcome after alternative treatment of scaphoid fractures and nonunions.

PURPOSE: Achieving stable fixation of scaphoid fractures and nonunions continues to be a challenge. Compression screw fixation has been the current standard surgical procedure. However, in some cases, bone healing cannot be achieved and requires further revision. Recent series reintroduced volar plating as valid option for stable fixation. The aim of the study was to review clinical outcome of alternative scaphoid treatment. METHODS: From 2011 to 2014, nine patients with scaphoid fracture were treated by Headless Compression Screw (HCS) and seven patients with scaphoid nonunion by HCS or volar mini condylar plate with bone graft. The average age was 34.4 years and the average time to follow-up was 19.3 months. From 1996 to 1998, 38 patients with scaphoid nonunion were treated using compression screw (S-group) or volar mini condylar plate (P-group) with bone graft. The average age was 39.6 years and the average time to follow-up was 26.2 months. RESULTS: The union rate was 100%. For scaphoid fractures, the mean Modified Mayo Wrist Score (MMWS) was 94.1 and the DASH score 7.4. From 2011 to 2014, the MMWS was 87.9 and the DASH score 7 in scaphoid nonunions. In the period between 1996 and 1998, the MMWS was 67.2 in the P-group and 58.6 in the S-group, and the DASH score 16.8 and 28.2. CONCLUSIONS: Our study demonstrated that appropriate application of the HCS was able to produce very satisfactory results in scaphoid fractures and nonunions. In our opinion, however, the method of scaphoid plate osteosynthesis can achieve a higher degree of stability, particularly rotational stability, in case of multifragmentary avascular scaphoid nonunions.

[Periprosthetic acetabular fractures in geriatric patients]. / Die periprothetische Azetabulumfraktur des geriatrischen Patienten.

Periprosthetic acetabular fractures in geriatric patients are rare injuries; however, the incidence is increasing because of the current demographic developments. For diagnosis of periprosthetic acetabular fractures, conventional X­ray images are regularly complemented by computed tomography (CT). For exclusion of loosening of the prosthesis more advanced techniques, such as single photon emission CT (SPECT/CT) are applied. In addition to classification of periprosthetic acetabular fractures by the traditional system of Letournel there are several other classification systems, which take into account the etiology of the fracture and the stability of the prosthesis. While, under certain circumstances conservative treatment of periprosthetic acetabular fractures is possible, operative treatment often requires extensive surgical procedures to restore the stability of the acetabulum as a support for the cup of the prosthesis. Besides the traditional techniques of acetabular osteosynthesis, special revision systems, augmentations and allografts are used for the reconstruction of periprosthetic acetabular fractures. To determine a therapeutic regimen patient-specific preconditions as well as fracture pattern and type of prosthesis need to be taken into account. In the literature there are several algorithms, which are aimed at supporting the attending physician in making the correct decision for the treatment of periprosthetic acetabular fractures. In cases of periprosthetic acetabular fractures even experienced surgeons are faced with great challenges. Thus, treatment should be carried out in specialized centers.

BMP-2-coated mineral coated microparticles improve bone repair in atrophic non-unions.

Atrophic non-unions are a major clinical problem. Mineral coated microparticles (MCM) are electrolyte-coated hydroxyapatite particles that have been shown in vitro to bind growth factors electrostatically and enable a tuneable sustained release. Herein, we studied whether MCM can be used in vivo to apply Bone Morphogenetic Protein-2 (BMP-2) to improve bone repair of atrophic non-unions. For this purpose, atrophic non-unions were induced in femurs of CD-1 mice (n = 48). Animals either received BMP-2-coated MCM (MCM + BMP; n = 16), uncoated MCM (MCM; n = 16) or no MCM (NONE; n = 16). Bone healing was evaluated 2 and 10 weeks postoperatively by micro-computed tomographic (µCT), biomechanical, histomorphometric and immunohistochemical analyses. µCT revealed more bone volume with more highly mineralised bone in MCM + BMP femurs. Femurs of MCM + BMP animals showed a significantly higher bending stiffness compared to other groups. Histomorphometry further demonstrated that the callus of MCM + BMP femurs was larger and contained more bone and less fibrous tissue. After 10 weeks, 7 of 8 MCM + BMP femurs presented with complete osseous bridging, whereas NONE femurs exhibited a non-union rate of 100 %. Of interest, immunohistochemistry could not detect macrophages within the callus, indicating a good biocompatibility of MCM. In conclusion, the local application of BMP-2-coated MCM improved bone healing in a challenging murine non-union model and, thus, should be of clinical interest in the treatment of non-unions.

[Saw Injuries to the Hand - Epidemiological Aspects]. / Sägeverletzungen der Hand ­ epidemiologische Aspekte.

Background: No current studies regarding saw injuries have been published in German literature for quite some time. Despite awareness measures and safety instructions, saw accidents along with crush injuries are the most common causes of severe hand injuries. Approximately 12,000 circular saw injuries occur in Germany each year. Since professional providers have increased prices due to the rising energy costs and a wide range of different home appliance saws are available, increasing use has been made of portable circular saws in the do-it-yourself market sector. Patients and methods: At our hospital, we evaluated the data of 51 male patients with saw injuries. The present study investigated factors that may contribute to accidents involving saws. Results: 80 % of the accidents occurred at home, usually on weekends or after work. 51 % of the accidents happened while patients cut firewood. In 84 % of the cases, an electric table saw was used. The majority of severe hand injuries were sustained with lower priced saws. Injuries occurred most frequently between 11 a. m. and 2 p. m., primarily with injuries to bones, tendons, blood vessels and nerves. Replantable amputations or partial amputations occured rarely. In 37 % of the patients, anatomical reconstruction using osteosynthesis and/or microsurgical techniques was performed successfully. Conclusions: Saw injuries to the hand are sustained almost exclusively by men. Serious injuries from low-priced table saws and due to the lack of protective covering are predominant. Preventive measures and mandatory training could reduce the number of saw injuries in the years to come. The results obtained by us largely confirm the data from previous publications.

[Talus Fractures - an Update]. / Talusfrakturen ­ ein Update.

Background: Talus fractures are rare and often result from axial trauma. As most of the talus surface is covered by cartilage, the blood supply is limited. Thus talus fractures are seen as one of the most severe fractures and often lead to significant long-term complications. Several studies suggest that the initial fracture classification can lead to correct treatment and that this can influence the long-term outcome. The aim of the current study was to investigate the importance of the initial fracture classification in respect to the radiological outcome in a large patient cohort. Patients and Methods: Over a span of 12 years, 61 patients with talus fractures were treated at our institution. Overall 45 patients were available for a retrospective analysis. Correlation analysis was performed between the initial fracture severity and the radiological outcome. Results: The average follow-up was 17.3 months (range 6-68). Significant correlations were found between the Marti-Weber Classification and Bargon Score (rs = 0.78; p < 0.0001), as well as between the Hawkins Classification and the Bargon Score (rs = 0.80; p < 0.0001). Conclusions: Precise prediction of the expected radiological outcome of talar neck and body fractures is possible through the initial fracture classification alone. Computed tomography is the accepted standard to determine the exact diagnosis and extent of injury.

[Traumatic hip dislocation in a 6-year-old male child: Seldom but demanding]. / Die Traumatische Hüftgelenkluxation eines 6­jährigen Jungen: Selten, aber anspruchsvoll.

Traumatic hip dislocations in children are not frequent but constitute true emergencies. They require urgent reduction because of the risk of consecutive avascular necrosis of the femoral head. We report a 6-year-old boy with traumatic posterior hip dislocation on a vacation abroad. After closed reduction the day of the accident, a hip spica cast was applied and the patient was transferred home. Once home, X­ray and CT diagnostics were completed by MRI. In future, long-term clinical and radiological investigations for avascular necrosis and growth disorders, as well as thoroughly informing the parents, should be mandatory.

Does the implant make the difference ? - Prospective comparison of two different proximal femur nails.

The aim of this study was to compare two proximal femur nails with regard to the complication rate and midterm clinical outcome : the InterTAN nail (ITN) versus the third generation gamma nail (GN). 78 patients older than 60 years with an unstable intertrochanteric femoral fracture (AO/OTA 31 A2/A3) were randomised over a 20 month period into either ITN (n = 39) or GN (n = 39). The outcomes of interest were the perioperative implant-related complications and the functional status (Harris Hip Score) at 6 months postoperatively. In 14 of the ITN and in two of the GN procedures the surgeons rated the implant as cumbersome (p = 0.002). Functional outcome and complication rate did not differ between both groups. The mechanical failure correlated with the positioning of the lag screw independent on the used implant. The surgeon's technique (closed reduction, positioning of lag screw) and not implant configuration, is of crucial importance in achieving successful outcome.