Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects.

BACKGROUND: Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation. METHODS: Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed. RESULTS: Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected. CONCLUSION: A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

[Minimally invasive stabilization of sacral fractures]. / Minimal-invasive Stabilisierung bei Frakturen des Sakrums.

BACKGROUND: Sacral fractures can be of traumatic origin and can also occur as insufficiency fractures. While the therapeutic target of mechanically stable insufficiency fractures is mainly pain relief, mechanically unstable insufficiency fractures and traumatic sacral fractures following high-energy trauma require biomechanical stabilization. Various surgical strategies are available for this, whereby minimally invasive techniques are now preferred whenever possible. OBJECTIVE: This article presents the clinical challenges and options for minimally invasive treatment of sacral fractures. MATERIAL AND METHODS: Selected important study data are discussed and our own treatment approach is presented. RESULTS: The most important minimally invasive techniques for operative treatment of sacral fractures are presented: sacroiliac screw osteosynthesis, lumbopelvic stabilization and sacroplasty. The selection of the surgical technique should be made on an individual basis. While sacroiliac screw osteosynthesis is the international gold standard, diverse authors have also published minimally invasive techniques for lumbopelvic stabilization. The latter enables a higher mechanical stability. In contrast, sacroplasty should only be used as an alternative treatment in insufficiency fractures. Comparative studies of the described techniques are still missing. CONCLUSION: All surgical options have their indications. Nevertheless, the biomechanical stability which can be achieved differs widely. Therefore, an exact analysis should be carried out of what is necessary with respect to reduction and retention and what should be achieved when treating sacral fractures.

Development of an intraoperative 3D C-arm technique for torsion control of femur fractures: a cadaver study.

AIM: This study aims to test the accuracy and feasibility of a measurement of femoral torsion of a 3D C-arm system (Linea aspera method) in a cadaver setting. MATERIALS AND METHODS: A total of 11 intact femora were used. Schanz screws were inserted in the femoral bone in a parallel manner with the help of a fixed drill sleeve. Femur bones were then fractured in a controlled manner and three different internal and external torsion angles were fixed with the help of a Goniometer. After that, a 3D scan was performed. The 3D data set was analyzed using a radiologic software (Visage 7, Visage Imaging Inc, USA). Measurements were then compared in the two methods with a dependent t test. RESULTS: Specific measurements for different angles did not show any differences between those two utilities. CONCLUSION: Intraoperative estimation of femoral antetorsion using a 3D C-Arm system and the Linea aspera method seems to be an accurate and feasible method. Nevertheless, more studies with higher patient numbers, comparison to CT seems to be the next step and can be recommended.

The rotational fixator: A new device.

OBJECTIVES: Malrotation after surgical treatment of femoral shaft fractures is a common problem and often leads to follow-up procedures with uncertain outcome. The aim of this study is the validation of a new device (Rotational Fixator) to perform the correction safely and accurately. METHODS: In an in-vitro study, we tested the Rotational Fixator on 21 corpse bones against a commercially available standard goniometer for measurement inaccuracies. For this purpose, we varied the rotation width from 10 to 30° in inside and outside rotation. RESULTS: We found a small measurement inaccuracy of 1-2° with increasing rotation. The smallest differences are found at 10° IR with 0.9524° (SD ± 1.0713; p = 0.001) difference and 10° ER with at 0.5952° (SD ± 0.6823; p = 0.001) difference and increase up to 30° (IR 1.6667°, SD ± 1.7121, p < 0.000/ER 1.5000°, SD ± 1.0488, p < 0.000). CONCLUSIONS: The measurement results of the device show a constant deviation from the gold standard but are constant in the measurement error and slightly in relation to the desired correction range, so that a further review of the device and further testing in in vivo studies makes sense. LEVELS OF EVIDENCE: Level 3.

Kinetic therapy in multiple trauma patients with severe blunt chest trauma: an analysis at a level-1 trauma center.

BACKGROUND AND OBJECTIVES: Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. METHODS: A retrospective analysis (2000-2009) of polytrauma patients (age > 16 years, ISS ⩾ 16) with severe chest trauma (AIS(Chest) ⩾ 3) was performed. Patients with AIS(Head) ⩾ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS(Chest), Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. RESULTS: Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS(Chest), age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. CONCLUSIONS: Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS(Chest), but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.

Mechanisms of motor vehicle crashes related to burns--an analysis of the German In depth Accident Study (GIDAS) database.

BACKGROUND: Patients of motor vehicle crashes (MVCs) suffering burns are challenging for the rescue team and the admitting hospital. These patients often face worse outcomes than crash patients with trauma only. Our analysis of the German In-depth Accident Study (GIDAS) database researches the detailed crash mechanisms to identify potential prevention measures. METHODS: We analyzed the 2011 GIDAS database comprising 14,072 MVC patients and compared individuals with (Burns) and without (NoBurns) burns. Only complete data sets were included. Patients with burns obviously resulting of air bag deployment only were not included in the Burns group. Data acquisition by an on call team of medical and technical researchers starts at the crash scene immediately after the crash and comprises technical data as well as medical information until discharge from the hospital. Statistical analysis was done by Mann-Whitney-U-test. Level of significance was p < 0.05. RESULTS: 14,072 MVC patients with complete data sets were included in the analysis. 99 individuals suffered burns (0.7%; group "Burns"). Demographic data and injury severity showed no statistical significant difference between the two groups of Burns and NoBurns. Injury severity was measured using the Injury Severity Score (ISS). Direct frontal impact (Burns: 48.5% vs. NoBurns: 33%; p < 0.05) and high-energy impacts as represented by delta-v (m/s) (Burns: 33.5 ± 21.4 vs. NoBurns: 25.2 ± 15.9; p < 0.05) were significantly different between groups as was mortality (Burns: 12.5% vs. NoBurns: 2.1%; p < 0.05). Type of patients' motor vehicles and type of crash opponent showed no differences. CONCLUSIONS: Our results show, that frontal and high-energy impacts are associated with a frequency of burns. This may serve automobile construction companies to improve the burn safety to prevent flames spreading from the motor compartment to the passenger compartment. Communities may impose speed limits in local crash hot spots.

Toxicity-reduced, myeloablative allograft followed by lenalidomide maintenance as salvage therapy for refractory/relapsed myeloma patients.

Relapse after dose-reduced allograft in advanced myeloma patients remains high. To reduce the risk of relapse, we investigated a myeloablative toxicity-reduced allograft (aSCT) consisting of i.v. BU and CY followed by lenalidomide maintenance therapy in 33 patients with multiple myeloma (MM) who relapsed following an autograft after a median of 12 months. The cumulative incidence of non-relapse mortality at 1 year was 6% (95% confidence interval (CI): 0-14). After a median interval of 168 days following aSCT, 24 patients started with a median dose of 5 mg (r, 5-15) lenalidomide without dexamethasone. During follow-up, 13 patients discontinued lenalidomide owing to progressive disease (n=6), GvHD (n=3), thrombocytopenia (n=2), or fatigue (n=2). Major toxicities of lenalidomide were GvHD II-III (28%), viral reactivation (16%), thrombocytopenia (III-IV°,16%), neutropenia (III/IV°, 8%), peripheral neuropathy (I/II°, 16%), or other infectious complication (8%). Cumulative incidence of relapse at 3 years was 42% (95% CI: 18-66). The 3-year estimated probability of PFS and OS was 52% (95% CI: 28-76) and 79% (95% CI: 63-95), respectively. Toxicity-reduced myeloablative allograft followed by lenalidomide maintenance is feasible and effective in relapsed patients with MM, but the induction of GvHD should be considered.

[Handling modern imaging procedures in a high-tech operating room]. / Handling moderner Bildgebung in einem Hightech-Operationssaal.

Operating rooms are the central unit in the hospital network in trauma centers. In this area, high costs but also high revenues are generated. Modern operating theater concepts as an integrated model have been offered by different companies since the early 2000s. Our hypothesis is that integrative concepts for operating rooms, in addition to improved operating room ergonomics, have the potential for measurable time and cost savings. In our clinic, an integrated operating room concept (I-Suite, Stryker, Duisburg) was implemented after analysis of the problems. In addition to the ceiling-mounted arrangement, the system includes an endoscopy unit, a navigation system, and a voice control system. In the first 6 months (9/2005 to 2/2006), 112 procedures were performed in the integrated operating room: 34 total knee arthroplasties, 12 endoscopic spine surgeries, and 66 inpatient arthroscopic procedures (28 shoulder and 38 knee reconstructions). The analysis showed a daily saving of 22-45 min, corresponding to 15-30% of the daily changeover times, calculated to account for potential savings in the internal cost allocation of 225-450 EUR. A commercial operating room concept was evaluated in a pilot phase in terms of hard data, including time and cost factors. Besides the described effects further savings might be achieved through the effective use of voice control and the benefit of the sterile handle on the navigation camera, since waiting times for an additional nurse are minimized. The time of the procedure of intraoperative imaging is also reduced due to the ceiling-mounted concept, as the C-arm can be moved freely in the operating theater without hindering cables. By these measures and ensuing improved efficiency, the initial high costs for the implementation of the system may be cushioned over time.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]. / Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit Femurschaftfrakturen: Nutzen und Kosten.

INTRODUCTION: Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS: In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS: In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION: From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

[Conservative functional treatment of Achilles tendon ruptures]. / Konservativ-funktionelle Behandlung der Achillessehnenruptur.

The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.

[Surgical treatment of Achilles tendon rupture]. / Operative Behandlung der Achillessehnenruptur.

The open tendon suture is the most commonly used method of treatment for Achilles tendon rupture in Germany. Over the last decade the therapeutic spectrum of operative methods has been further enlarged by the development of new minimally invasive surgical techniques. Important criteria for planning treatment are the location and age of the rupture and comorbidities. For recent Achilles tendon ruptures minimally invasive suturing is indicated but for older ruptures a reconstruction often has to be carried out. The decisive disadvantage of an open tendon suture is the relatively high risk of infection. Using minimally invasive surgical techniques the frequency of postoperative infection could be significantly reduced. The suture methods without opening the ruptured region can be collectively grouped under the term percutaneous suture techniques and the minimally invasive methods with opening of the rupture region as combined open percutaneous techniques. Documented problems with the Ma-Griffith technique, such as injury of the sural nerve, low stability of the suture and insufficient adaption of the tendon stumps have been minimized by new minimally invasive operation techniques. Achilles tendon ruptures which nearly always arise without any external influence or accidents can have substantial psychological consequences regarding the integrity of one's own body especially for people actively engaged in sport. This aspect should be considered and accepted in particular during postoperative treatment.

[Quad driving--life-endangering fun? A medical and technical analysis]. / Quad-Fahren--ein lebensgefährlicher Spaß? Eine medizinische und technische Unfallanalyse.

AIM: Quads or all-terrain vehicles do not seem to play a major role either in traffic accidents or in hospital admissions in Germany. However, reports about spectacular quad crashes in the press are not that infrequent. In contrast, no scientific survey or study regarding the issue of quad crashes in Germany has been published so far. Thus, this study aims to evaluate the present incidence of quad crashes, accident circumstances and resulting injury patterns, and to discuss possible consequences. METHOD: At a level I trauma centre, data from accident and hospital records of quad drivers were analysed focusing on the following parameters: injury type, localisation and mechanism, treatment details, abbreviated injury scale (AIS) score, maximum AIS (MAIS) score, delta-v, collision speed, and other technical parameters. Comparisons to motorcycle accidents were performed. RESULT During a five-year period from 2005 to 2009, there were ten admissions of quad drivers out of around 11 000 emergency trauma patients (0.1 %). Five accidents had happened off-road, four were traffic accidents. Eight patients were male; the mean age was 30 years. The mean total hospital stay was 15 days; there was a mean of 1.5 stays per patients with 2.0 surgical procedures needed. One patient died, only two recovered fully. The accident research data bank revealed 14 cases of quad accidents out of 18 990 (0.1 %). The mean impact velocity was 35 km/h (motorcyclists 40.0 km/h). The most frequent injury mechanism was a collision with a car. The upper extremity was the predominant injured region (AIS 0.7), while it was the lower extremity for motorcyclists (AIS0.91). The maximum AIS were 1.4 in quad drivers and 1.49 in motorcyclists. CONCLUSIONS: Although the absolute incidence of quad accidents in Germany is low, they pose a relatively high risk for severe injuries. Possible reasons are the comparatively low active and passive safety of quads as well as limited experience with quad driving and the "fun" aspect which might provoke risky driving behaviour. Larger series from the US report a high incidence of drug abuse among quad casualties as well as very limited use of helmets. In Germany, helmet usage has been mandatory since 2006. Possible additional measures to prevent a rise in quad accidents could be the total prohibition of alcohol consumption for quad drivers as well as special courses or driving licenses or an increase of the legal age for driving quads.

Calcineurin inhibitor-free GVHD prophylaxis with sirolimus, mycophenolate mofetil and ATG in Allo-SCT for leukemia patients with high relapse risk: an observational cohort study.

Certain leukemias have a high relapse risk even after allo-SCT, and GVHD prophylaxis with calcineurin inhibitors (CNIs) may interfere with a possible GVL effect. Therefore, we replaced CYA by sirolimus in patients with high relapse risk. In contrast to CNIs, sirolimus promotes the generation of regulatory T-cells and has potent antineoplastic activity. Sirolimus has been used in combination with CNI for GVHD prophylaxis in hematopoietic SCT. However, no CNI-free prophylactic regimen with sirolimus has been evaluated so far. Within the FLAMSA-RIC protocol, 15 patients received GVHD prophylaxis with sirolimus and mycophenolate mofetil (MMF). The underlying diagnoses were relapsed or refractory T-ALL (n=3), AML with FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) or mixed-lineage leukemia-partial tandem duplication (MLL-PTD; n=10; 5 with refractory disease) and CML in refractory myeloid blast crisis (n=2). All evaluable patients (n=14) were engrafted. Grades II-IV acute GVHD occurred in 21% and chronic GVHD in 30% of patients. Non-relapse mortality rate was 14%. No thrombotic microangiopathy or sinusoidal obstruction syndrome was observed. Three patients with FLT3-ITD+ AML relapsed after a median of 112 days. At a median follow-up of 10 months after transplantation, 10 patients are alive and in complete remission. In conclusion, sirolimus-based GVHD prophylactic regimens deserve further investigation.

[Injury situation of novice drivers in road traffic--a medical and technical analysis]. / Verletzungssituation von Fahranfängern im Strassenverkehr - eine medizinische und technische Unfallanalyse.

AIM: Novice drivers are at high risk for crash involvement. We performed an analysis of causations, injury patterns and distributions of novice drivers in cars and on motorcycles in road traffic as a basis for proper measurements. METHOD: Data of accident and hospital records of novice drivers (licence < 2 years) were analysed focusing on the following parameters: injury type, localisation and mechanism, abbreviated injury scale (AIS), maximum AIS (MAIS), delta-v, collision speed and other technical parameters and compared with those of experienced drivers. RESULTS: In 18 352 accidents in the area of Hannover (years 1985-2004), 2602 novice drivers and 18 214 experienced drivers were recorded as having an accident. Novice car drivers were more often and more severely injured whereas on motorcycles the experienced drivers were at higher risk. Novice drivers of both groups sustained more often extremity injuries. 4.5 % of the novice car drivers were not restrained by seatbelts as compared to 3.7 % of the experienced drivers and 6.1 % of the novice motorcycle drivers did not wear a proper helmet (versus 6.5 %). Severe injuries were sustained in 20 % at collision speeds below 30 km/h and in 80 % at collision speeds above 50 km/h. Novice car drivers drove significantly older cars. The risk profile of novice drivers is similar to that of drivers older than 65. CONCLUSION: Structural protection and special lectures like skidding courses could be proper measurements next to harder punishment of violations.

[Drilling with 3D fluoroscopic navigation in osteonecrosis of the femoral condyle]. / 3D-fusionierte navigierte Anbohrung einer Osteonekrose des Femurkondylus.

The primary goal of drilling procedures for the treatment of osteonecrotic lesions is revascularisation of the defect area. In the literature good results are reported for this technique in 70% of cases. Precise drilling of the necrosed area as part of a minimally invasive technique does, however, require unequivocal intraoperative identification of the region visually, either by arthroscopy or by fluoroscopy. In the case of inadequate imaging, as in our case, there is no longer any guarantee of precise drilling.Computer-assisted navigation system have already improved the precision of drilling procedures performed for various indications. Basically, however, a navigation is only as accurate as the underlying imaging. The use of preoperative data sets assumes an invasive and/or elaborate intraoperative recording procedure. For a procedure not requiring recording to be possible, image diffusion of the MRI and ISO-C(3D) data sets during the surgery would be necessary. In the present case a preoperative MRI data set was first combined with the ISO-C(3D) data set acquired intraoperatively. To this end, following application of the reference base a 3D scan was performed, and the data ascertained were transferred to the navigation system and in addition to the planning software. After fusion of the images the drilling canals were planned and implemented on the basis of the additional information emerging from the combination of the data. To be sure of success postoperatively, this was also merged with the preoperative MRI. The example shows that combining data sets makes it possible to improve the precision and safety of drilling in target areas that cannot be adequately imaged. In future, we hope it will prove possible to transfer the image data back into the navigation system after they have been merged. At present this is only possible with CT and MRI images. A comparative clinical trial is needed to find to what extent the success rate is improved over that achieved with conventional techniques.

[Cost-benefit analysis of intraoperative 3D imaging]. / Kosten- und Nutzenanalyse der intraoperativen 3D-Bildgebung.

BACKGROUND: With intraoperative 3D imaging, inevitable corrections may be done already during the operation, and a second procedure can be avoided. The purpose of this study was to perform a cost-benefit analysis during the first year of intraoperative 3D application in order to provide a cost transparency for the surgeon within the current DRG system. METHODS: On the basis of internal data and the literature, the annual operating costs of the ISO-C(3D) were calculated at 27,940 euros (purchase price, depreciation, maintenance, repair), the costs of an average revision as a secondary operation at 2,385 euros (costs avoided with the ISO-C(3D), Siremobil, Siemens, Erlangen, Germany), and the dynamic costs of an intraoperative 3D scan were averaged to 131.08 euros (draping, additional time, personnel). RESULTS: In the year 2003 intraoperative 3D scanning was done in 126 patients, and intraoperative revision was performed in 24 (19%) due to the additional intraoperative 3D information provided by the Siremobil. In 11 (8.7%) patients the implant position was corrected and in 13 (10.3%) patients the reduction was improved. Taking only fixed costs into consideration, 29,311.52 euros could be saved, and when fixed and dynamic costs are taken into account 12,795.44 euros could be saved. Since the parameters for each hospital are different, the following formula for an individual computation is suitable. For the calculation of the cost the following mathematical relationship results: (annual fixed costs) + (costs per scan x number of cases) - (revision costs x revision rate [p]) x number of cases [N]) = 0. DISCUSSION: Although the costs of an ISO-C(3D) are considerably high, an economic benefit can also accrue with frequent application and high rates of avoided revision. However, if the rate of avoided revision adds up to only 5%, a substantial deficit may result.