Complications after surgical management of proximal humeral fractures: a systematic review of event terms and definitions.

BACKGROUND: The most frequently used surgical procedures for treating a proximal humeral fracture (PHF) are plate osteosynthesis, nail osteosynthesis and arthroplasty. Evidence-based recommendations for an appropriate surgical procedure after PHF requires transparent and valid safety data. We performed a systematic review to examine reported terms and definitions of complications after surgically-treated PHFs. METHODS: A literature search was conducted on PubMed, Cochrane Library, EMBASE, Scopus and WorldCat to identify clinical articles and book chapters on complications of PHF published from 2010 to 2017. Complication terms and definitions were extracted from each selected article independently by two reviewers and grouped according to a predefined scheme. RESULTS: From 1376 initial references, we selected 470 articles, of which 103 were reviewed in reverse chronological order until no further information was gained. Twelve book chapters were reviewed. We found 667 local event terms associated with complications after surgical treatment of PHFs. The most frequently used event terms were infection (52 references), nonunion (n = 42), malunion (n = 35), avascular necrosis (n = 27) and pain (n = 25). Overall, 345, 177, 257 and 102 local event terms were related to plating, nailing, arthroplasty and other surgical techniques, respectively. Radiological assessment was the basis for the majority of event terms and complication definitions. Thirty-six event definitions were extracted, mostly defining the terms "secondary fracture displacement", "screw perforation/cutout", "malunion", "delayed healing" and "notching". CONCLUSION: Scientific literature on surgically-managed PHF uses different terms to describe complications and without approved definitions, which highlights a lack of agreement on adverse event terminology for PHFs. Defined event terms are mostly based on radiological observations. Consensus among shoulder surgeons on a core event set is indispensable to support the standardization of safety reporting for surgically-treated PHFs.

Healthcare costs and loss of productivity in patients with trapeziometacarpal osteoarthritis.

The objective of this study was to analyse healthcare and productivity costs in patients with trapeziometacarpal osteoarthritis. We included 161 patients who received surgery or steroid injection and calculated their healthcare costs in Euro (€) over 1 year. Patients filled out the Work Productivity and Activity Impairment Questionnaire to assess loss of productivity at baseline, and after 3, and 12 months. In the surgical group, loss of productivity among employed patients first increased and then decreased (50%, 64%, and 25% at 0, 3, and 12 months). Productivity was more stable over time in the injection group (52%, 38%, and 48%). In the surgical group, estimated total annual healthcare and productivity costs were €5770 and €5548, respectively. In the injection group, healthcare and productivity costs were €348 and €3503. These findings highlight the need for assessing productivity costs to get a comprehensive view of the costs associated with a treatment.Level of Evidence III.

Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus.

INTRODUCTION: Aim of this study was to evaluate outcomes of operative as compared to conserveative treatment for two-part humerus fractures at the surgical neck. METHODS: Data from a prospective multi-centre cohort study on four treatment options (conservative treatment and three implants, i.e. LPHP, PHILOS and PHN) for proximal humerus fractures were evaluated in this post hoc analysis. All patients with two-part fractures of the surgical neck (AO types A2, n = 54 and A3, n = 110) were identified and included for the analysis. All operatively treated patients were gathered and compared to those receiving conservative treatment. Primary outcome parameters were pain, range of motion and absolute and relative Constant scores at 3, 6 and 12 months following injury and coronal plane alignment at 12 months. RESULTS: Operative (n = 133) and non-operative (n = 31) groups were comparable with regard to all parameters assessed including mean age (62.9 vs. 65.6, P = 0.479), gender (27 vs. 29 % male, P = 0.826) and fracture distribution (65 vs. 77 % A3 type, P = 0.207). 26 of the 31 conservatively treated and 103 of the 133 operatively treated patients (84 and 77 %, respectively) were available for final follow-up. There was a continuous improvement for all outcome parameters in both treatment groups (P < 0.001). Operative treatment resulted in a more effective reduction of pain at 3 months (51 vs. 76 % reporting pain at fracture site, P = 0.03) and a reduction of coronal plane malalignment. Both range of motion and Constant scores were, however, comparable in both groups at all follow-up visits. Relative and absolute Constant scores were generally excellent at final follow-up (74 vs. 74, P = 0.528 and 89 vs. 91, P = 0.494, respectively). CONCLUSIONS: Both non-operative treatment and operative treatment using modern implants (LPHP, PHILOS and PHN) can be considered safe and effective treatment options for two-part fractures of the proximal humerus. Operative treatment may result in better range of motion and reduced pain in the early postoperative course of treatment.

Focussed classification of scapula fractures: failure of the lateral scapula suspension system.

INTRODUCTION: Following an increase in the incidence of scapular fractures and interest in the outcome of their treatment, a basic classification system was developed for ease of use in the emergency setting. It has been expanded to a comprehensive system to allow for more in-depth classification of scapular fractures for clinical research and surgical decision making. It focusses on three specific regions of the scapula: the scapular body, the glenoid fossa and the lateral scapular suspension system (LSSS). This article presents a classification of the LSSS involvement to better characterise the injuries of this region and to emphasise its relevance to evaluation of the position of the scapula, hence the glenoid fossa, and so the centre of rotation of the shoulder joint. METHODS: An iterative consensus and evaluation process comprising an international group of seven experienced shoulder specialist and orthopaedic trauma surgeons was used to specify and evaluate the failure of the LSSS associated with scapula fractures. This was supported by a series of agreement studies. The system considered lack of involvement (S0), incomplete (S1) and complete (S2) failure of the LSSS. The last evaluation was conducted on a consecutive collection of 120 scapula fractures documented by three-dimensional computed tomography (3D CT) reconstruction videos. RESULTS: Surgeons agreed on the involvement/failure of the LSSS in 47% of the 120 cases with an overall Kappa of 0.54. The sample most likely included 70 S0, 29 S1 and 21 S2 cases, where surgeons showed median classification accuracies of 93%, 71% and 80% for these categories, respectively. While two surgeons showed some uncertainty about their classification, the remaining surgeons only failed to identify LSSS failure in <20% of the cases. Kappa coefficients of reliability for classification of incomplete and complete LSSS involvement according to subcategories were 0.85 and 0.82, respectively. CONCLUSION: While LSSS involvement can be reliably identified, its characterisation regarding complexity is problematic even with 3D CT images. The proposed LSSS system is considered clinically relevant and sufficient to further assess its role in treatment-decision processes and outcome prognosis.

Characteristics of two different locking compression plates in the volar fixation of complex articular distal radius fractures.

OBJECTIVES: To investigate the differences of open reduction and internal fixation (ORIF) of complex AO Type C distal radius fractures between two different models of a single implant type. METHODS: A total of 136 patients who received either a 2.4 mm (n = 61) or 3.5 mm (n = 75) distal radius locking compression plate (LCP DR) using a volar approach were followed over two years. The main outcome measurements included motion, grip strength, pain, and the scores of Gartland and Werley, the Short-Form 36 (SF-36) and the Disabilities of the Arm, Shoulder, and Hand (DASH). Differences between the treatment groups were evaluated using regression analysis and the likelihood ratio test with significance based on the Bonferroni corrected p-value of < 0.003. RESULTS: The groups were similar with respect to baseline and injury characteristics as well as general surgical details. The risk of experiencing a complication after ORIF with a LCP DR 2.4 mm was 18% (n = 11) compared with 11% (n = 8) after receiving a LCP DR 3.5 mm (p = 0.45). Wrist function was also similar between the cohorts based on the mean ranges of movement (all p > 0.052) and grip strength measurements relative to the contralateral healthy side (p = 0.583). In addition, DASH and SF-36 component scores as well as pain were not significantly different between the treatment groups throughout the two-year period (all p ≥ 0.005). No patient from either treatment group had a step-off > 2 mm. CONCLUSIONS: Differences in plate design do not influence the overall final outcome of fracture fixation using LCP.

Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically. METHODS: In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays. RESULTS: Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°-20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases. CONCLUSIONS: End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.

Comparison of angle stable plate fixation approaches for distal radius fractures.

INTRODUCTION: The aim of the study was to compare radiological and functional outcomes between volar and dorsal surgical fixation of distal radius fractures using low-profile, fixed-angle implants. PATIENTS AND METHODS: A total of 305 distal radius fracture patients were treated with Synthes locking compression plate (LCP) 2.4- or 3.5-mm fixation using either a volar (n=266) or dorsal (n=39) approach. The patients were examined at 6 months, 1 and 2 years for radiological assessment of fracture healing, alignment, reduction and arthritis, as well as the determination of various functional outcome scores. RESULTS: Both groups were comparable with respect to baseline and injury characteristics. The complication rate was higher for the volar approach (15%). No significant differences were observed for Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form (36) Health Survey (SF-36) scores, pain, arthritis grade, grip strength and radiological measurements. However, a significantly better functional outcome represented by a low mean Gartland and Werley score was observed for the volar approach after 6 and 12 months. Significantly higher percentages of dorsal extension, palmar flexion, ulnar deviation and supination angle (relative to the mean contralateral healthy wrist) were also reported for volar approach patients at the 6-month follow-up. CONCLUSIONS: Volar internal fixation of distal radius fractures with LCP DR implants can result in earlier and better functional outcome compared with the dorsal approach, yet is associated with a higher incidence of complications. After 2 years, these differences are no longer observed between the two surgical methods.

Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery.

The second, internet-based multicenter study (MCSII) of the Spine Study Group of the German Association of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie) is a representative patient collection of acute traumatic thoracolumbar (T1-L5) injuries. The MCSII results are an update of those obtained with the first multicenter study (MCSI) more than a decade ago. The aim of the study was to assess and bring into focus: the (1) epidemiologic data, (2) surgical and radiological outcome, and (3) 2-year follow-up (FU) results of these injuries. According to the Magerl/AO classification, there were 424 (57.8%) compression fractures (A type), 178 (24.3%) distractions injuries (B type), and 131 (17.9%) rotational injuries (C type). B and C type injuries carried a higher risk for neurological deficits, concomitant injuries, and multiple vertebral fractures. The level of injury was located at the thoracolumbar junction (T11-L2) in 67.0% of the case. 380 (51.8%) patients were operated on by posterior stabilization and instrumentation alone (POSTERIOR), 34 (4.6%) had an anterior procedure (ANTERIOR), and 319 (43.5%) patients were treated with combined posteroanterior surgery (COMBINED). 65% of patients with thoracic (T1-T10) and 57% with lumbar spinal (L3-L5) injuries were treated with a single posterior approach (POSTERIOR). 47% of the patients with thoracolumbar junction (T11-L2) injuries were either operated from posterior or with a combined posterior-anterior surgery (COMBINED) each. Short angular stable implant systems have replaced conventional non-angular stable instrumentation systems to a large extent. The posttraumatic deformity was restored best with COMBINED surgery. T-spine injuries were accompanied by a higher number and more severe neurologic deficits than TL junction or L-spine injuries. At the same time T-spine injuries showed less potential for neurologic recovery especially in paraplegic (Frankel/AISA A) patients. 5% of all patients required revision surgery for perioperative complications. Follow-up data of 558 (76.1%) patients were available and collected during a 30-month period from 1 January 2004 until 31 May 2006. On average, a posterior implant removal was carried out in a total of 382 COMBINED and POSTERIOR patients 12 months after the initial surgery. On average, the rehabilitation process required 3-4 weeks of inpatient treatment, followed by another 4 months of outpatient therapy and was significantly shorter when compared with MCSI in the mid-1990s. From the time of injury until FU, 80 (60.6%) of 132 patients with initial neurological deficits improved at least one grade on the Frankel/ASIA Scale; 8 (1.3%) patients deteriorated. A higher recovery rate was observed for incomplete neurological injuries (73%) than complete neurological injuries (44%). Different surgical approaches did not have a significant influence on the neurologic recovery until FU. Nevertheless, neurological deficits are the most important factors for the functional outcome and prognosis of TL spinal injuries. POSTERIOR patients had a better functional and subjective outcome at FU than COMBINED patients. However, the posttraumatic radiological deformity was best corrected in COMBINED patients and showed significantly less residual kyphotic deformity (biseg GDW -3.8° COMBINED vs. -6.1° POSTERIOR) at FU (p = 0.005). The sagittal spinal alignment was better maintained when using vertebral body replacement implants (cages) in comparison to iliac strut grafts. Additional anterior plate systems did not have a significant influence on the radiological FU results. In conclusion, comprehensive data of a large patient population with acute thoracolumbar spinal injuries has been obtained and analyzed with this prospective internet-based multicenter study. Thus, updated results and the clinical outcome of the current operative treatment strategies in participating German and Austrian trauma centers have been presented. Nevertheless, it was not possible to answer all remaining questions to contradictory findings of the subjective, clinical outcome and corresponding radiological findings between different surgical subgroups. Randomized-controlled long-term investigations seem mandatory and the next step in future clinical research of Spine Study Group of the German Trauma Society.

The efficacy of closed reduction in displaced distal radius fractures.

INTRODUCTION: Closed reduction (CR) to restore fracture alignment and subsequent cast fixation is a common practice in the treatment of distal radius fractures. No clear consensus exists about the appropriate indication for CR. This study aims to compare radiological and functional results in patients with moderately to severely displaced distal radius fractures that were immobilised by cast fixation with or without prior CR. PATIENTS AND METHODS: A total of 206 patients with distal radius fractures from one UK hospital were prospectively documented between 2001 and 2002. Patients with moderately to severely displaced fractures that were treated conservatively with or without CR were eligible for this analysis. Fracture displacement was assessed by measurements on injury radiographs and latent class analysis. The radiological and functional results as assessed by range of motion; and the Disabilities of the Arm, Shoulder and Hand (DASH); Gartland and Werley; and SF-36 scores were compared after 6 weeks, 6 months and 1 year. RESULTS: As many as 83 patients (seven males) with a mean age of 62.2 years were included; 62 patients were treated with CR, the remaining 21 did not receive CR. During the follow-up period, no differences were found in the measurements of range of motion, DASH and SF-36 scores between the treatment groups. Fractures that were treated with CR lost anatomical restoration. However, after 1 year, palmar tilt and radial angles had significantly improved compared with the baseline measurements. Although no significant difference of radiological parameters between the treatment groups was found, the Gartland and Werley score resulted in a significantly better outcome for those patients without CR after 1 year. CONCLUSIONS: Although all patients - independent of their treatment - reached a successful level of activities in their daily life, there was no benefit of CR for patients with moderately to severely displaced fractures. The decision to treat with CR should be made carefully, especially in patients with high wrist-function demands.

Complication reporting in orthopaedic trials. A systematic review of randomized controlled trials.

BACKGROUND: The nature and frequency of complications during or after orthopaedic interventions represent critical clinical information for safety evaluations, which are required for the development or improvement of orthopaedic care. The goal of this systematic review was to check whether essential data regarding the assessment of the prevalence, severity, and characteristics of complications related to orthopaedic interventions are consistently provided by the authors of papers on randomized controlled trials. METHODS: Five major peer-reviewed orthopaedic journals were screened for randomized controlled trials published between January 2006 and July 2007. All relevant papers were obtained, anonymized, and evaluated by two external reviewers. A checklist consisting of three main parts (definition, evaluation, and reporting) was developed and applied for the assessment of complication reporting. The results were stratified into surgical and nonsurgical categories. RESULTS: One hundred and twelve randomized controlled trials were identified. Although complications were included as trial outcomes in two-thirds of the studies, clear definitions of anticipated complications were provided in only eight trials. In 83% of the trials, the person or group assessing the complications was not identified. No trial involved a data safety review board for assessment and classification of complications. CONCLUSIONS: The lack of homogeneity among the published studies that we reviewed indicates that improvement in the reporting of complications in orthopaedic clinical trials is necessary. A standardized protocol for assessing and reporting complications should be developed and endorsed by professional organizations and, most importantly, by clinical investigators.

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column: Part III: Follow up data]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil III: Nachuntersuchung.

In this third and final part, the Spine Study Group (AG WS) of the German Trauma Association (DGU) presents the follow-up (NU) data of its second, prospective, internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries including 865 patients from 8 trauma centers. Part I described in detail the epidemiologic data of the patient collective and the subgroups, whereas part II analyzed the different methods of treatment and radiologic findings. The study period covered the years 2002 to 2006 including a 30-month follow-up period from 01.01.2004 until 31.05.2006. Follow-up data of 638 (74%) patients were collected with a new internet-based database system and analyzed. Results in part III will be presented on the basis of the same characteristic treatment subgroups (OP, KONS, PLASTIE) and surgical treatment subgroups (Dorsal, Ventral, Kombi) in consideration of the level of injury (thoracic spine, thoracolumbar junction, lumbar spine). After the initial treatment and discharge from hospital, the average duration of subsequent inpatient rehabilitation was 4 weeks, which lasted significantly longer in patients with persistent neurologic deficits (mean 10.9 weeks) or polytraumatized patients (mean 8.6 weeks). Following rehabilitation on an inpatient basis, subsequent outpatient rehabilitation lasted on average 4 months. Physical therapy was administered significantly longer to patients with neurologic deficits (mean 8.7 months) or type C injuries (mean 8.6 months). The level of injury had no influence of the duration of the inpatient or outpatient rehabilitation. A total of 382 (72.2%) patients who were either operated from posterior approach only or in a combined postero-anterior approach had an implant removal after an average 12 months. During the follow-up period 56 (8.8%) patients with complications were registered and of these 18 (2.8%) had to have surgical revision. The most common complications reported were infection, loss of correction, or implant-associated complications. Clinical data showed a 2.9 higher relative risk for smokers compared to non-smokers to suffer from wound healing problems. The neurologic status of 81 (60.4%) out of 134 patients with neurologic deficits at the time of injury improved until follow-up. Neurologic deterioration was documented in 8 (1.3%) cases. Complete neurologic deficits after injury to the thoracic spine improved in 9% of the cases, whereas 59% of the cases with complete neurologic deficit improved after injury to the thoracolumbar junction. The surgical approach (posterior or combined postero-anterior) had no significant influence on neurological results at follow-up. Patient age, sex and neurologic deficits showed a statistically significant influence (p<0.05) on the fingertip-floor distance (FBA) at follow-up. Patient back function improved during the follow-up period. More than 2 years after the time of injury 32.2% of the patients had no complaints with respect to back function. The relative frequency of patients with unrestrained back function was greater after posterior surgery (24.2%), than anterior surgery (13.8%), or combined surgery (17.3%) (p=0.005; chi(2)-test). At follow-up there were no statistically significant differences of unrestrained back function between different levels of injury (thoracic spine 17.4%, TL junction 22.5% and lumbar spine 13.6%). The relative frequency of patients with injury to the thoracolumbar junction who reported "no complaints from the anterior approach" at follow-up, was calculated to be 55.6% after open versus 63.8% after endoscopic approaches with no significant differences. Of the patients 56.3% reported no donor site morbidity following iliac crest bone harvesting. The VAS spine score at follow-up was calculated within different treatment subgroups: OP 58.4 points, KONS 59.8 points, and PLASTIE 59.7 points. Statistically significant differences of the VAS spine score between posterior (64.9 points) versus combined surgery (47.8 points) were only verified at the level of injury of the thoracic spine (p=0.004). The relative frequency of patients regaining at least 80% of the initial score level was OP (posterior 60.4%, anterior 61.1%, combined 51.4%), 52.9% KONS and 67.6% PLASTIE. After surgery the mean period of incapacity from work was 4 months. Patients with a sedentary occupation before the time of injury were fully reintegrated into work in 71.1% of the cases. Patients with a physical occupation were fully reintegrated in 38.9% of the cases at follow-up. At follow-up 87 (31.2%) patients after posterior and 50 (20.1%) after combined surgery had no restrictions to their recreational activities (p=0.001). Treatment subgroups PLASTIE and KONS show a similar radiological result at follow-up with a bisegmental kyphotic deformity (GDW) of -9 degrees and -8.5 degrees, respectively. With all operative methods it was possible to correct or partly correct the posttraumatic kyphotic deformity. Until follow-up there was a loss of correction depending on the surgical approach and level of injury. Combined postero-anterior stabilization gave statistically significant better radiological results with less kyphotic deformity (-3.8 degrees) than posterior stabilization alone (-6.1 degrees) (p=0.005; ANOVA). Thus combined surgery was superior in its capability to restore spinal alignment within the observational period. At follow-up the use of titanium vertebral body replacement implants (cages) to reconstruct and support the anterior column showed significantly better radiological results with less kyphotic deformity and loss of correction (GDW 0.3 degrees) than the use of iliac bone strut grafts (-3.7 degrees ) (p<0.001). Neither additional anterior plates nor the combination of anterior plates with a cage or bone graft had a statistically significant influence on the kyphotic deformity measured at follow-up. A matched-pair analysis of anterior surgery alone versus combined surgery for the treatment of compression fractures (type A) at the thoracolumbar junction showed a significantly greater intraoperative blood loss but better radiological results in terms of monosegmental and bisegmental kyphotic deformity after combined surgery (p<0.05). A matched-pair analysis of treatment results between non-operative and operative treatment for burst fractures (type A3.1-2) showed a period of inability to work (6 months) which was twice as long for the non-operative treatment group. At the same time significantly better radiological results at follow-up were achieved after operative treatment of these fractures (p<0.05).

[Operative treatment of traumatic fractures of the thorax and lumbar spine. Part II: surgical treatment and radiological findings]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule. Teil II: Operation und röntgenologische Befunde.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) presents its second prospective Internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries. This second part of the study report focuses on the surgical treatment, course of treatment, and radiological findings in a study population of 865 patients. A total of 158 (18,3%) thoracic, 595 (68,8%) thoracolumbar, and 112 (12,9%) lumbar spine injuries were treated. Of these, 733 patients received operative treatment (OP group). Fifty-two patients were treated non-operatively and 69 patients were treated with kyphoplasty/vertebroplasty without additional instrumentation (Plasty group). In the OP group, 380 (51.8%) patients were instrumented from a posterior (dorsal) position, 34 (4.6%) from an anterior (ventral) position, and 319 (43.5%) cases with a combined posteroanterior procedure. Angular stable internal spine fixator systems were used in 86-97% of the cases for posterior and/or combined posteroanterior procedures. For anterior procedures, angular stable plate systems were used in a majority of cases (51.1%) for the instrumentation of mainly one or two segment lesions (72.7%). In 188 cases (53,3%), vertebral body replacement implants (cages) were used and were mainly implanted via endoscopic approaches (67,4%) to the thoracic spine and/or the thoracolumbar junction. The average operating time was 152 min in posterior-, 208 min in anterior-, and 298 min in combined postero-anterior procedures (p<0,001). The average blood loss was highest in combined operations, measuring 959 ml vs. 650 ml in posterior vs. 534 ml in anterior operations (p<0,001).Computer-assisted intraoperative navigation systems were used in 95 cases. At the time of hospital admission, 58,7% of the patients had spinal canal narrowing of an average of 36% (5-95%) at the level of their injury. The average spinal canal narrowing in patients with a complete spinal cord injury (Frankel/ASIA A) was calculated to be 70%, vs. 50% in patients with incomplete neurologic deficits (Frankel/ASIA B-D), and 20% in patients without neurologic deficits (Frankel/ASIS E; p<0,001). The average procedure in the plasty treatment subgroup was 50 min (18-145 min) to address one (n=59) or two (n=10) injured vertebral bodies. In patients with nonoperative treatment mainly three-point-corsets (n=36) were administered for a duration of 6-12 weeks. During their hospital stay 93 of 195 (44,7%) patients with initial neurologic deficits improved at least one Frankel/ASIA grade until the day of discharge. Two patients (0,2%) showed a neurologic deterioration. The highest rate of complete spinal cord injury (n=36, 23%) was associated with thoracic spine injuries. Nine (1%) patients died during the initial course of treatment. A total of 105 (14,3%) cases with intraoperative (n=56) and/or postoperative complications (n=69) were registered. The most common intraoperative complication was bleeding (n=35, 4,8%). A higher relative frequency of intraoperative complications was noticed in combined (n=34, 10,7%) vs. isolated posterior (n=22, 5,9%; p=0,021) procedures. The most common postoperative complication was associated with wound healing problems in 14 (1,9%) patients. Except in the non-operative treatment subgroup, a correction of the posttraumatic measured radiological deformity was achieved to a different extent within every treatment subgroup. There were no statistically significant differences between the postoperative radiological results of the treatment subgroups (dorsal vs. combination), taking into consideration the influence of relevant parameters such as different fracture types, patient age, and the amount of posttraumatic deformity (p=0,34, ANOVA).

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column. Part I: epidemiology]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil I: Epidemiologie.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) has now been in existence for more than a decade. Its main objective is the evaluation and optimization of the operative treatment for traumatic spinal injuries. The authors present the results of the second prospective internet-based multicenter study (MCS II) of the AG WS in three consecutive parts: epidemiology, surgical treatment and radiologic findings and follow-up results. The aim of the study was to update and review the state-of-the art for treatment of spinal fractures for thoracic and lumbar spine (T1-L5) injuries in German-speaking countries: which lesions will be treated with which procedure and what differences can be found in the course of treatment and the clinical and radiological outcome? This present first part of the study outlines the new study design and concept of an internet-based data collection system. The epidemiologic findings and characteristics of the three major treatment subgroups of the study collective will be presented: operative treatment (OP), non-operative treatment (KONS), and patients receiving a kyphoplasty and/or vertebroplasty without additional instrumentation (PLASTIE). A total of 865 patients (OP n=733, KONS n=52, PLASTIE n=69, other n=7) from 8 German and Austrian trauma centers were included. The main causes of accidents in the OP subgroup were motor vehicle accidents 27.1% and trivial falls 15.8% (KONS 55.8%, PLASTIE 66.7%). The Magerl/AO classification scheme was used and 548 (63.3%) compression fractures (type A), 181 (20.9%) distraction injuries (type B), and 136 (15.7%) rotational injuries (type C) were diagnosed. Of the fractures 68.8% were located at the thoracolumbar junction (T11-L2). Type B and type C injuries carried a higher risk for concomitant injuries, neurological deficits and additional vertebral fractures. The average initial VAS spine score, representing the status before the trauma, varied between treatment subgroups (OP 80, KONS 75, PLASTIE 72) and declined with increasing patient age (p<0.01).

A comprehensive classification of mandibular fractures: a preliminary agreement validation study.

This study evaluates a comprehensive classification system for mandibular fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest) was used. The mandible is divided into two vertical units (I and V), two lateral horizontal units (II and IV) and one central unit (III) comprising the symphyseal and parasymphyseal region. Type A fractures are non-displaced, type B are displaced and type C are multifragmentary/defect injuries. Groups and subgroups are further defined in the classification system. Two classification sessions using semi-automatic software with 7 and 9 surgeons were performed to evaluate 100 fracture cases in the first session and 50 in the second. Inter-observer reliability and individual rater's accuracy were evaluated by kappa coefficient and latent class analysis, respectively. The analysis of inter-observer agreement for the detailed coding showed kappa coefficients around 0.50 with higher agreement among raters in the vertical units. This system allows standardization of documentation of mandibular fractures, although improvement in the definition of categories and their application is required.

Comparison of two novel fluoroscopy-based stereotactic methods for cervical pedicle screw placement and review of the literature.

This experimental study was designed to compare two different fluoroscopy-based stereotactic surgical techniques for transcutaneous cervical pedicle screw (CPS) placement in the subaxial human cervical spine: (1) a custom-made aiming frame (AF) in combination with conventional fluoroscopy versus (2) a targeting device in combination with a computer-assisted image guidance system [i.e. virtual fluoroscopy (VF)]. Surgery was carried out on six preserved human total body specimens in a laboratory setting. Sixty pedicles (levels C3-C7) were measured in a multislice computed tomography (CT) image data set prior to surgery. Two groups consisting of three specimens and 30 pedicles each were defined according to the surgical technique. The AF consisted of radiolucent components with a fully adjustable arm for carrying the instruments necessary for placing the screws. The arm was angled according to the cervical pedicle axis, as determined by the preoperative CT scans and intraoperative lateral fluoroscopy. For VF, a targeting device was combined with a computer-assisted image-guided surgery unit. For both stereotactic techniques, 3.5 mm screws made of carbon fibre polyetheretherketone (ECF-PEEK) were inserted transcutaneously through stab incisions. Screw placement was assessed using a four-point grading system ranging from ideal (I) to unacceptable (III) where I = screw centred in pedicle, IIa = perforation of pedicle wall is less than one-fourth of the screw diameter, IIb = perforation of the pedicle wall is more than one-fourth of the screw diameter without contact to neurovascular structures, and III = CPS in contact with neurovascular structures. Fifty-eight pedicle screws could be evaluated without interfering metal artefacts according to the same CT protocol that was used preoperatively. The AF technique achieved a significantly smaller number of screws in contact with neurovascular structures compared with the VF technique (P = 0.021; Fisher's exact test) (Grade I n = 15; 64.3% AF vs. n = 13; 43.3% VF and Grade III n = 2; 7.1% AF vs. n = 10; 33.3% VF). Although neither of the two techniques was capable of completely preventing CPS perforations, transcutaneous CPS placement with a conventional fluoroscopy-based stereotactic AF can be considered a less expensive alternative to VF. This AF technique is able to reduce the number and severity of lateral pedicle wall violations compared to screw placement via the wide standard posterior open midline approach to the subaxial cervical spine. The results of this study are discussed in context with those obtained from different published modifications, since the first technical description of this surgical technique in 1994 by Abumi and co-workers.

Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices.

The choice between dynamic screw-intramedullary nail (DSIN) devices and dynamic screw-plate (DSP) devices for the fixation of unstable trochanteric fractures remains controversial. This study presents a meta-analysis of fixation failures in unstable trochanteric femoral fractures using DSP devices or DSIN devices. Two independent assessors selected randomised controlled trials using a range of electronic databases, as well as reference lists of selected articles. A study quality checklist was used. The occurrence of fixation failure, in particular cut-out, was the primary subject of analysis using descriptive statistics and random-effect meta-analyses. Seventeen trials were identified. Meta-analyses showed no significant difference in the frequency of implant-related complications between the two types of devices. Iatrogenic femoral fractures associated with the use of DSIN devices represent a rare, but persistent, risk. There was a tendency for less frequent cut-out with intramedullary devices compared with DSP devices.

[The importance of bovine neosporosis for abortion in Switzerland]. / Von der Bedeutung der bovinen Neosporose beim Abortgeschehen in der Schweiz.

The protozoan parasite Neospora caninum is one of the most important infectious abortion causes in cattle worldwide. In a Swiss case-control-study we investigated 113 abortion problem farms and 113 control farms. It was possible to detect N. caninum in 21% of 242 investigated aborted fetuses by PCR upon brain samples. Eighty-four % of mothers aborting N. caninum positive fetuses were serologically positive for this parasite. The seroprevalence for N. caninum of all aborting mothers was 44%. Within a period of 3 to 12 months 4,505 cattle from the participating farms were investigated serologically at two different time points. Strong fluctuations of the specific antibody concentration could be observed, resulting in a conversion to seronegativity in the second blood sample in 39% of formerly seropositive animals. Eighteen months after the end of the study, 42 case- and 42 controlfarms were questioned about their present abortion-status. Analysis of the questionnaire revealed that 80% of the former abortion problem farms observed an improvement of the situation. However, in 43% of those farms no preventive measures had been taken and no significant differences in hygiene, forage and animal turnover could be observed between case- and control-farms. Additionally, no significant differences were detected concerning risk factors such as the presence of farm dogs and the disposal procedure for placental and fetal material.

Risk factors associated with behavioural disorders of crib-biting, weaving and box-walking in Swiss horses.

REASONS FOR PERFORMING STUDY: Studies on the prevalence of behavioural disorders in horses and on associated risk factors have revealed inconsistent results. There are many studies on the neuropharmacological, surgical or mechanical therapy of stereotypies, but little is known about their causation. OBJECTIVES: To explore risk factors associated with the occurrence of behavioural disorders in horses. METHODS: A sample of horse owners, selected randomly and representative for Switzerland, was contacted in a postal survey. Answers were provided for 622 stables (response rate 35.2%). Individual data of 2,341 horses were examined with path analysis (multivariable linear and logistic regression), and adjustment made for possible confounding effects due to age and breed. RESULTS: Out of 60 possible risk factors, 11 were associated with the outcome at the univariable level (null-hypothesis path model) and 3 factors remained after the backward logistic regression procedure. Mature Warmbloods and Thoroughbreds, assessed by the owners to be reactive, fed 4 times a day and without daily pasture, had increased odds of displaying crib-biting, weaving and box-walking. Furthermore, indirect associations of 5 factors with the outcome were identified. CONCLUSIONS: The final logistic regression model of risk factors leads to the hypotheses that causal prevention of stereotypic behaviours should be based upon housing and management conditions which allow tactile contact with other horses (e.g. mutual grooming), daily free movement (paddock or pasture), as well as the provision of high amounts of roughage but of little or no concentrates. POTENTIAL CLINICAL RELEVANCE: It is one of the aims of population medicine to prevent the development of behavioural disorders. Further research is needed to test the concluding hypotheses in experimental studies or to verify them in the context of similar observational studies.