[Atypical femoral fracture : Pitfalls in surgical treatment]. / Atypische Femurfraktur : Fallstricke bei der chirurgischen Versorgung.

Atypical femoral fractures are a very rare complication after treatment with bisphosphonates. This case report describes the diagnostic criteria and some particularities of the surgical treatment. Atypical femoral fractures are typically stabilized with intramedullary nails but some pitfalls in surgical treatment, e.g. the choice of implant, have to be considered. Basically, these fractures can be treated using conventional intramedullary nails, which, however, must be used by being adapted depending on the morphology of the femur. The fact that atypical femoral fractures can occur under bisphosphonate treatment should in no way influence the indications for starting anti-osteoporotic treatment.

Progress of instability in fragility fractures of the pelvis: An observational study.

Fragility fractures of the pelvis (FFP) are an increasing entity among elderly persons. Characteristics are different from high-energy pelvic trauma. Little is known about the natural course of FFP in conservative and after operative treatment. MATERIALS AND METHODS: Medical charts and radiologic data of 148 patients with an FFP, who were admitted in a 3-year period, were analysed retrospectively. Incidence and characteristics of fracture progression (FP) were noted. RESULTS: Patients presenting early after a traumatic event had more often non-displaced fractures, fractures with lower FFP Type classification and were more frequently treated conservatively. FP was observed in 21 cases (14.2%), twenty times after conservative and once after operative treatment. FP under conservative treatment occurred in female patients only. Patients with FP were younger than patients without. FP occurred in all fracture types, most frequently in FFP Type I. A second CT scan was positive for FP in 39.2% of patients with prolonged pain or restricted mobility. CONCLUSION: FP is a real phenomenon, occurring in a minority of FFP patients. Female patients are at highest risk. Repeated CT scan is positive in nearly 40% of patients with continuing pain or restricted mobility. Operative treatment is a good preventive measure of FP as FP does only exceptionally occur after operative fixation of FFP.

Reconstruction of complex radial head fractures using fine-threaded K-wires : clinical outcome and remaining instability.

Radial head replacement or ORIF are established treatment options for Mason type-III and type-IV fractures. The aim of this study was to provide results for reconstruction of these complex fractures using fine-threaded K-wires. We present results after reconstruction of 15 Mason type-III and 8 Mason type-IV fractures. Parameters used to describe the functional outcome were pain level, range of motion, and clinical scores. To estimate the elbow stability we performed ultrasound examinations under valgus/varus stress. All radial heads could be reconstructed. The average resting pain level was 0.9 of 10. The average ROM for extension/flexion was 134°, average forearm rotation was 159°. For the whole patient collective the mean MEPS was 86.5 points and the mean QuickDASH was 16.8 points with no significant difference for both groups. We can recommend ORIF with fine-threaded K-wires for Mason type-III and type-IV fractures of the radial head. Ligamentous injuries can be addressed successfully with external fixation.

[Reduction techniques in intramedullary nailing osteosynthesis]. / Repositionstechniken in der Marknagelosteosynthese.

Intramedullary nailing was originally conceived for the stabilization of shaft fractures of long bones. Due to new nail designs and multiple interlocking possibilities, the spectrum of nailing has significantly increased. Nailing of fractures beyond the isthmus is technically challenging because fractures need to be reduced before the nailing procedure starts. Indirect techniques of reduction include the use of an extension table, a large distractor or an external fixator. Direct reduction with pointed reduction forceps, lag screws, a cerclage wire or a short plate can optimize indirect reduction. The choice of the correct entry portal is of utmost importance for an optimal operative result. The location of the entry portal is dependent on the local anatomy and the bend of the nail. The optimal entry portal at the proximal tibia is directly behind the patellar tendon and accessible with the knee in more than 90° of flexion, alternatively through a suprapatellar approach with a slightly flexed knee joint. Insertion of the nail through the suprapatellar approach is possible without stress on the reduced fracture fragments. Blocking screws create an artificial isthmus in the metaphyseal area and force the guide wire in the desired direction. Blocking screws help to avoid axial malalignment during nail insertion. Interlocking of the nail with screws coming from different directions prevents secondary dislocation.

Intramedullary Nailing of Metaphyseal Fractures of the Lower Extremity.

Intramedullary nailing is a worldwide accepted technique for stabilization of fractures of long bones. Technique, instruments and implants primarily have been developed for the fixation of short (transverse and oblique) diaphyseal fractures. First generation nails were hollow and slotted, which gave them some elasticity. When the tip of the nail passed the fracture gap, picked up the opposite fracture fragment and was driven further down, the longitudinal axis of the bone was restored and the extremity realigned. Bone length was restored by closure of the fracture gap. The tight connection between the deformable hollow nail and the inner cortex at the isthmus realized a press-fit, which achieved a very stable bone-implant construct. The nail had the function of a weight-shearing implant. Interlocked nails represent the second-generation nails. They changed the spectrum of indications for nailing considerably. Not only short middle-third shaft fractures, but shaft fractures of all types (from transverse to comminuted) and all localizations can be stabilized with an interlocked nail. Due to interlocking, length and rotation are controlled. The nail bridges the area of instability, being a weight-bearing implant. Small diameter, solid nails formed the next generation of nail implants. They were conceived for the provisional treatment of fractures with an enhanced risk of postoperative infection such as open fractures or closed fractures with severe soft tissue damage. They were increasingly used for minimal invasive treatment of closed fractures without soft tissue damage as well, as reaming was not necessary and endosteal blood supply less damaged. Nevertheless, it became clear that they were connected with a higher incidence of implant failure and revision surgery. Another development was the creation of nails with multiple and angular stable interlocking options. Major advantage is that high stability is obtained in the fracture fragment, in which multiple interlocking is used. This property gives the possibility of nailing fractures close to a joint with a short fracture segment (24). Nevertheless, intramedullary nailing of metaphyseal fractures remains controversial. Major complications to be avoided are malalignment, delayed union, nonunion and implant failure due to suboptimal fracture reduction (23).

The effect of different collagen modifications for titanium and titanium nitrite surfaces on functions of gingival fibroblasts.

OBJECTIVES: Targeted modifications of the bulk implant surfaces using bioactive agents provide a promising tool for improvement of the long-term bony and soft tissue integration of dental implants. In this study, we assessed the cellular responses of primary human gingival fibroblasts (HGF) to different surface modifications of titanium (Ti) and titanium nitride (TiN) alloys with type I collagen or cyclic-RGDfK-peptide in order to define a modification improving long-term implants in dental medicine. MATERIALS AND METHODS: Employing Ti and TiN implants, we compared the performance of simple dip coating and anodic immobilization of type I collagen that provided collagen layers of two different thicknesses. HGF were seeded on the different coated implants, and adhesion, proliferation, and gene expression were analyzed. RESULTS: Although there were no strong differences in initial cell adhesion between the groups at 2 and 4 hours, we found that all surface modifications induced higher proliferation rates as compared to the unmodified controls. Consistently, gene expression levels of cell adhesion markers (focal adhesion kinase (FAK), integrin beta1, and vinculin), cell differentiation markers (FGFR1, TGFb-R1), extracellular protein markers (type I collagen, vimentin), and cytoskeletal protein marker aktinin-1 were consistently higher in all surface modification groups at two different time points of investigation as compared to the unmodified controls. CONCLUSION: Our results indicate that simple dip coating of Ti and TiN with collagen is sufficient to induce in vitro cellular responses that are comparable to those of more reliable coating methods like anodic adsorption, chemical cross-linking, or RGD coating. TiN alloys do not possess any positive or adverse effects on HGF. CLINICAL RELEVANCE: Our results demonstrate a simple, yet effective, method for collagen coating on titanium implants to improve the long term integration and stability of dental implants.

Mosaicplasty for the treatment of a large traumatic osteochondral femoral head lesion: a case report with 2 year follow-up and review of the literature.

Different joint-preserving techniques have been described for the treatment of traumatic osteochondral lesions of the femoral head especially in young active patients. Mosaicplasty with autologous transplantation of osteochondral cylinders is an established surgical technique in the knee. Little evidence, however, exists for the treatment of osteochondral lesions in the hip using this technique. Here, we report on the result of treatment of a traumatic 5 cm(2) osteochondral lesion of the femoral head in a young patient treated with mosaicplasty. Grafts were taken from the ipsilateral knee. After 2 years, the outcome was satisfactory with partial return to previous activity level.

Fragility fractures of the pelvis: should they be fixed?

Due to the aging population, there is an increasing number of fragility fractures of the pelvis (FFP). They are the result of low energy trauma. The bone breaks but the ligaments remain intact. Immobilizing pain at the pubic region or at the sacrum is the main symptom. Conventional radiographs reveal pubic rami fractures, but lesions of the dorsal pelvis are hardly visible and easily overlooked. CT of the pelvis with multiplanar reconstructions show the real extension of the lesion. Most patients have a history of osteoporosis or other fragility fractures. The new classification distinguishes between four categories of different and increasing instability. FFP Type I are anterior lesions only, FFP Type II are non-displaced posterior lesions, FFP Type III are displaced unilateral posterior lesions and FFP Type IV are displaced bilateral posterior lesions. Subgroups discriminate between the localization of the dorsal instability. FFP Type I lesions are treated non-operatively. FFP Type II lesions are fixed in a percutaneous procedure when a trial of conservative treatment was not successful. FFP Type III lesions are treated with open reduction and internal fixation (ORIF). FFP Type IV lesions are treated with bilateral ORIF or with a bridging osteosynthesis. Iliosacral screw osteosynthesis is widely used, but has an elevated risk of screw loosening due to diminished bine mineral density. Transsacral bar osteosynthesis enable interfragmentary compression and does not have this danger of loosening. Bridging plate osteosynthesis is used as an additional fixation to iliosacral screw osteosynthesis. Lumbopelvic fixation is restricted to highly unstable lumbopelvic dissociations. More studies are needed to find the optimal treatment for each type of instability. Key words: pelvis, fragility fracture, diagnosis, classification, treatment.

Retrograde tibial nail: anatomical implantation and surgical feasibility study.

PURPOSE OF THE STUDY The treatment of distal tibial fractures requires a stable fixation while minimizing the secondary trauma to the soft tissues by the surgical approach and implant. The experimental Retrograde Tibial Nail is currently investigated as a minimally invasive alternative to plating and antegrade nailing. The purpose of this study was to evaluate the surgical feasibility in a cadaver model for all distal tibial fracture types generally considered treatable by nailing. MATERIAL AND METHODS Five different fracture types (AO/OTA 43-A1/A2/A3 and 43-C1/C2) were created on separate cadaveric limbs. In simple fractures (AO/OTA 43-A1/A2/A3) primary nailing was performed. In intraarticular fractures (AO/OTA 43-C1/2) reduction of the articular block and lag screw fixation was performed before nailing. Intraoperative complications, quality of reduction, fluoroscopy duration and operative time were evaluated. RESULTS Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps. Retrograde nailing is possible in fractures with simple intraarticular involvement after primary lag screw fixation. The duration of surgery averaged 51.8 minutes (range 40-62 min). No major complications occurred during nailing. CONCLUSIONS The minimally invasive retrograde nail combines a minimally invasive local osteosynthesis with the ability to adequately fix extraarticular and simple intraarticular distal tibial fractures. The results suggests that retrograde tibia nailing is a promising new concept for the treatment of distal tibia fractures. Key words: minimally invasive surgery, tibia, metaphyseal fractures, intramedullary nailing, retrograde nailing.

Haemorrhage in fragility fractures of the pelvis.

INTRODUCTION: Fragility fractures of the pelvis (FFP) are one of the most visible and debilitating consequences of osteoporosis. In contrast to pelvic ring fractures of the young, fragility fractures are caused by falls from a standing height or even by repetitive physiological loads. Even though haemorrhage is rarely found in fragility fractures of the pelvis, one must be aware of the potential risk. MATERIALS AND METHODS: In a computer literature search, we identified eight papers about patients with haemorrhage and/or haemodynamic instability as a complication of a low-velocity pelvic ring fracture, all of which were case reports. CONCLUSION: In our review, an overview of the case reports is provided, risk factors identified and a recommendation for the treatment and clinical observation given.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient's comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient's mobility.

Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits.

PURPOSE AND METHODS: External fixation is a safe option for stabilisation of extremity lesions in the polytraumatised patient as well as in fractures with severe soft tissue damage. Nevertheless, long-term-complications are to be expected when external fixation is chosen as a definitive treatment. The purpose of this review article is twofold: primarily, to define the rationale of a procedural change from an external fixator to an intramedullary nail; secondarily, to assess the possible advantages and pitfalls of a single- or two-staged procedure. RESULTS AND CONCLUSIONS: External fixation of the femur is recommended in multiply injured patients who are critically ill to avoid an additional inflammatory response caused by the surgical trauma of primary nailing. The conversion towards nailing must be done as soon as the clinical condition of the patient has been stabilised. Stable polytraumatised patients do not benefit from initial stabilisation with an external fixator and should immediately be treated with a definitive osteosynthesis. In tibial fractures, external fixation followed by intramedullary nailing is recommendable in fractures with severe soft tissue injuries. Conversion should be done as soon as the soft tissues allow before pin-tract infections occur and performed in a one-staged procedure.

The role of intramedullary nailing in treatment of open fractures.

The management of open fractures remains one of the greatest challenges to orthopedic trauma surgeons. Damage to the soft tissue envelope together with periosteal stripping are the most important factors making open fractures prone to complications such as nonunion and infection. Urgent and thorough soft tissue debridement, proper surgical fracture stabilization as well as the administration of intravenous and local antibiotics as adjunctive therapy are mandatory to reduce the risk of infection. Intramedullary nail osteosynthesis has become an accepted treatment method of open long bone fractures. Especially at sites of sparse soft tissue coverage like the proximal and distal tibia, early intramedullary stabilization proved advantageous for its superior biomechanical stability, the chance of early soft tissue reconstruction, shorter healing times, and quicker rehabilitation. However, due to a potential risk of deep infection, especially when a reamed technique is applied, nailing of open fractures remains contentious. In this review, we focus on the current evidence of nail osteosynthesis in open fractures and delineate its value with respect to other possible treatment options.

[Locking plate osteosynthesis of the radial head fractures : clinical and radiological results]. / Winkelstabile Plattenosteosynthese des Radiuskopfes : Klinische und radiologische Ergebnisse.

BACKGROUND: Therapy of radial head fractures is still controversially discussed. Especially comminuted fractures are at risk of complications such as radial head necrosis, nonunion and secondary loss of reduction after open reduction and internal fixation. The aim of this study was to evaluate clinical and radiographic results of ORIF (open reduction internal fixation) of radial head fractures using a new radial head-specific locking plate system. PATIENTS AND METHODS: A total of 21 patients (13 men and 8 women) were treated with locking plate osteosynthesis of radial head fractures. Mean age was 50 years (range 29-67 years). According to the Mason classification, 15 were type III and 6 type IV. Mean time between trauma and surgery was 5.6 days (range 0-23 days). These patients were reexamined using the Mayo Elbow Performance Score and x-rays in two planes. RESULTS: In all, 21 patients were reexamined with a mean follow-up of 12.1 months (range 5-23 months). The mean Mayo Elbow Performance Score was 87.1. Excellent results were obtained in 12 patients, good results in 6 patients, and fair results in 3 patients. Mean extension deficit was 12.1°, mean flexion 135.2°, mean pronation 70.9°, and mean supination 63.6°. All fractures healed uneventfully. There was no complete radial head necrosis but one partial. Four cases of heterotopic ossification were detected: Hastings classification I (n = 2), IIb (n = 1), IIIb (n = 1). CONCLUSION: ORIF of radial head fractures using locking plates can lead to good and excellent results. Modern implants may allow for reconstruction of comminuted fractures avoiding arthroplasty in these young patients.

Liquid dextran does not increase the elution rate of different antibiotics from bone cement.

PURPOSE: To investigate the possibility of increasing elution of fosfomycin, gentamicin, clindamycin, and vancomycin by the addition of dextran fluid during the cement-mixing phase. METHODS: In 12 test series, we produced standardized, antibiotic-loaded test specimens of cement, with and without addition of dextran, and determined their effectiveness against three reference pathogens in agar diffusion and elution tests. RESULTS: In the test series using combined agents, Refobacin(®)-Palacos(®)R plus fosfomycin continuously produced the largest zone of inhibition, both against methicillin-sensitive Staphylococcus aureus (p = 0.009) and against methicillin-resistant Staphylococcus aureus (p = 0.009). The addition of dextran to the various test series had no useful effect on the size of the zone of inhibition for any of the antibiotics tested. CONCLUSIONS: Dextran supplementation in Refobacin(®)-Palacos(®)R bone cement did not have the hope for positive effect on the elution rate of bound antibiotics.

Which future for traumatology in Europe?

The last decades have been characterized by rapid changes in society, medicine and surgery. There is a distinct evolution towards specialization and super-specialization. Trauma surgery also evolves towards a specialty, focused on the care of the injured. To optimize the quality of care and meet the needs of patients and care providers, a well-structured trauma surgery training program as well as the regionalization of trauma care with the implementation of Level I trauma centers are needed. The core competence of the European trauma surgeon is the coordination of the early management of the severely injured and the treatment of muskuloskeletal trauma, which represent the most common pathologies in our countries.

[Treatment of phalangeal fractures using the mini-hook plate. An alternative for surgical fixation of small phalangeal bone fragments?]. / Versorgung von Fingerfrakturen mit der Minihakenplatte. Alternative in der operativen Versorgung von knöchernen Ausrissen an den Phalangen?

BACKGROUND: Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate. PATIENTS AND METHODS: Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire. RESULTS: A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3 ° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed. CONCLUSION: Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.

[Nailing of metaphyseal fractures]. / Nagelung metaphysärer Frakturen.

Nailing of metaphyseal fractures demands thorough preoperative planning. The trauma surgeon has to take the specific morphology of the fracture, the individual anatomy of the broken bone, and the design and characteristics of the selected implant into consideration. The fracture has to be precisely reduced and the reduction controlled during nail insertion. The reduction technique and reduction aids must be chosen preoperatively. The nail has to be introduced with care and brought to its correct and ideal position. Only after successful proximal and distal interlocking can the nail become the central weight bearing implant, which holds the fracture stable and reduced. In the following contribution, the specific problems of reduction and nail fixation of metaphyseal fractures of the proximal humerus, proximal and distal femur, and proximal and distal tibia together with the needed reduction and fixation aids are presented.