[Distal femoral fractures in geriatric patients : Does time to surgery affect revision and mortality?] / Die distale Femurfraktur beim geriatrischen Patienten : Ist der Zeitpunkt der Operation relevant für Revision und Sterblichkeit?

BACKGROUND: For proximal femoral fractures the time to surgery has been reported to influence the mortality rate. To date, detailed analyses in geriatric patients with distal femoral fractures are not available. MATERIAL AND METHODS: A monocentric study with retrospective data retrieved from an electronic database was performed. The study included distal femoral fractures with surgical treatment between 2006 and 2017 in patients aged 65 years and older. A total of ten variables were evaluated and two outcome measures were investigated: revision and mortality in relation to time of surgery within 24 h or later. The minimum follow-up was 2 years. For patients who were still alive the Parker score was calculated. The null hypothesis was that time to surgery does not affect revision and mortality. RESULTS: A total of 57 consecutive patients with 60 fractures and an average age of 82.5 years (65-97 years) were included. Most of the fractures were supracondylar (n = 42). All but three fractures were treated with internal fixation. The revision rate was 17.5% (peri-implant fractures n = 4, infections n = 2, non-union n = 2, impaired wound healing n = 2 and secondary dislocation n = 1). The 1­year mortality rate was 20%. No significant effects on revision (p = 0.414) and survival rate (log rank 0.175) were observed for patients treated within 24 h or later. After a mean postoperative period of 5.5 years, the mean Parker score for 18 living patients was 5.9. CONCLUSION: Time to surgery demonstrated no significant effects with respect to revision and mortality. Multicenter studies are absolutely necessary to increase the sample size and statistical power.

A prospective study with ten years follow-up of two-hundred patients with proximal femoral fracture.

BACKGROUND: The proximal femoral fracture is one of the most common injuries in the elderly. Nevertheless, no results beyond the second year post surgery have been reported in the literature. Therefore, the purpose of this study was to evaluate any revision and mortality within 10 years follow-up as well as the walking ability of still alive patients. METHODS: A total of 200 consecutive patients were included. A prospective database was first used to collect the demographic data. Exactly ten years after the surgery, a final evaluation was conducted by telephone for every patient. Any revision, any contralateral as well as other fractures and the date of death were recorded. For all patients who were still alive, the mobility score according to Parker was also surveyed. RESULTS: The average age was 79.0 years (SD: 12.5); women were affected at higher numbers (73.5%). The total surgical revision rate was 17.5% (35/200), due in particular to hematoma (9×) or infection (7×). A surgical revision later than two years was only needed in three patients (1.5%). The risk of another fracture caused by a fall was 19% (38/200), most often a contralateral femoral fracture (22/200; 11%) that happened on average 51.9 months (1-97) after the initial surgery. The risk of a contralateral femoral fracture was 15.4% (22/143) in patients who survived the first year post surgery. The postoperative mortality was 1, 2, 5 and 10 years or 23.5%, 32.5%, 55% as well as 81.5%, respectively. An average Parker's mobility score of 6.3 points (0-9) was determined for the 37 patients (18.5%) who were still alive at the time of the follow-up. CONCLUSION: The long-term study showed that revision surgery was only required in 3/200 patients (1.5%) beyond the second year of that surgery. On the other hand, more than half of all patients had already passed away five years after the initial surgery. The exact incidence of a contralateral femoral fracture was 11.9%, climbing to 15.4% if the patient survived at least one year. Nearly every fifth patient experienced another fall resulting in a severe fracture requiring treatment during the long-term course.

Peri-implant femoral fractures: The risk is more than three times higher within PFN compared with DHS.

INTRODUCTION: Information is lacking regarding incidence rates, treatment regimens, and outcomes concerning peri-implant femoral fractures (PIF). Therefore, we performed a retrospective study to provide scientific data concerning incidence and outcome of PIF following osteosynthesis of proximal femoral fractures (PFF). MATERIAL AND METHODS: We retrospectively included all patients who received osteosynthesis for PFF between 2006 and 2015 and in whom PIF was confirmed postoperatively. All available patients with PIF were contacted minimum one year post-surgery. RESULTS: A total of 1314 osteosynthesis procedures were performed, of which 705 were proximal femoral nails (PFNs), 597 were dynamic hip screws (DHSs), and 12 were screws appliances only. During the same period, 18 PIFs (1.4%) were reported. However, PIF was 3.7 times higher within PFN when compared to DHS (15/705:2.1% versus 3/597:0.5%; odds ratio: 3.7). The following analysis also included 8 patients with PIF who were referred from other hospitals, resulting in a total of 26 patients. Mean patient age was 84.8 years (range, 57-95), with a predominance in female (23×) and in the left femur (19×). PIF occurred after an average of 23.6 months (range, 1-81) post-surgery. The fractures, most of which were spiral-shaped, were most commonly treated with locking plate osteosynthesis. The surgical revision rate was 7.7%, and the one-year mortality was 23.1%. At an average of 43.0 months (range, 12-100) post-surgery, it was possible to contact 18/26 patients (69.2%), and their mean Parker Mobility Score was 5.2 points (range 2-9). CONCLUSIONS: Peri-implant femoral fracture is a rare incident within the old age traumatology of PFF. However, based on our small number of cases, it occurred within PFN much more frequently compared with DHS. Locking plate osteosynthesis has been shown to be effective and reliable. Surgical revision and mortality rates do not appear to be increased when compared to those with the initial treatment of proximal femoral fractures.

Treatment and outcome of destructive tuberculosis of the talus.

We describe a case of isolated destructive talar tuberculosis that is, to the best of our knowledge, the first reported case in Germany. Caseous talar necrosis was finally detected after repeated surgical debridements of an infection eight months after subtalar screw arthrodesis. Following the diagnosis of TB, we performed a total of three additional surgical revisions within a three-month period; these revisions included a talectomy and an induction of a septic tibiocalcaneal arthrodesis with an external fixator that was removed after solid fusion six months later. Following this treatment regime, which included pharmaceutical anti-tuberculosis therapy, the 50-year-old male patient was fitted with orthopaedic shoes. He resumed work as a professional farmer with a number of restrictions 12 months after the diagnosis and treatment of destructive talar tuberculosis.

[Percutaneous cement-augmented screw fixation of bilateral osteoporotic sacral fracture]. / Perkutane zementaugmentierte Verschraubung einer bilateralen osteoporotischen Sakrumfraktur.

We describe the case of a 71-year-old woman who presented with persisting painful symptoms of the back and pelvis which had begun 4 weeks previously. A preceding trauma was plausibly excluded. Diagnostics showed a slightly dislocated bilateral sacral fracture with underlying osteoporosis also known as an insufficiency fracture. We performed a percutaneous and cement-augmented bilateral iliosacral joint revision using screws and 6 months after surgery, imaging showed a stable fracture with appropriate screw positions.

Periprosthetic fractures around the knee: update on therapeutic algorithms for internal fixation and revision arthroplasty.

Effective treatment of periprosthetic fractures following TKA continues to represent a surgical challenge. The incidence and frequency of these complicated type of fractures is expected to increase as the number of TKA as well as the activity level of these patients steadily rises. A careful and correct analysis of the fracture pattern, its classification, the quality of the existing bone stock and the fixation / loosening of the underlying prosthetic system has to precede decision making for successful conservative or surgical treatment. Therefore, improved diagnostic radiographic imaging of fracture patterns and reliable assessment of prosthesis loosening progressive development of new implant methods and refinement of soft tissue preserving surgical techniques will hold the key for regaining the functional level prior to the fracture.

[Causes of failed osteosynthesis of ankle fractures]. / Ursachen der fehlgeschlagenen Osteosynthese am Sprunggelenk.

Ankle fractures are the most common osseous injuries of the lower extremity. In most cases, open reduction and internal fixation is indicated due to fracture dislocation. Operations of the ankle are generally considered classic, standardized, training procedures. An exact reconstruction with correct length and rotation of the joint as well as stabilization of the tibiofibular ligamentous complex is essential. Beside age and gender of the patient, outcome depends on fracture morphology and comorbidities, e. g., osteoporosis, vascular status, neuropathic disorders, and diabetes mellitus. Additional chondral lesions, extensive closed or open soft tissue injuries, and compartment syndrome due to trauma impact can lead to further problems in the postoperative period. Furthermore, iatrogenic complications like fixed malpositions, instabilities, and implant-associated failure of osteosynthesis may also occur. This article illustrates the causes of preventable mistakes and points out options to increase clinical outcome.

[Complications after pertrochanteric fractures]. / Komplikationen bei pertrochantären Frakturen.

Fractures at the coxal end of the femur have an incidence of almost 100.000 p.a. in Germany. Pertrochanteric femur fractures make up almost half of this collective. The highest incidence of 1.32% is seen in patients over the age of 85. Osteosynthesis is the treatment of choice. The options include extramedullary nail/screw systems or intramedullary nail systems. Study findings to date do not show a clear advantage of one procedure over another. The published complication rates remain high. The main complication is secondary reduction loss with cutout of the hip screw. Other complications include femoral neck shortening and lateralization of the hip screw with local irritation at the iliotibial tract. Functional outcomes after osteosynthesis are still less than satisfactory. Surgery only frees one third of patients from pain. In addition, a majority of patients also suffer loss of independence and social contacts. An alternative approach to treatment is total joint replacement. This is indicated in extreme cases of osteoporosis in combination with osteoarthritis. However, initial high stability must be weighed against an increased risk of dislocation and a higher rate of 1-year mortality.

[Emergency open surgical treatment of extravasations of cytostatic agents in the upper extremity]. / Sofortige offene chirurgische Behandlung von Zytostatika-Paravasaten der oberen Extremität.

Extravasations of cytostatic agents can create necrosis of soft tissues in the hand and forearm. The early emergency subcutaneous "wash-out" with liposuction is the treatment of choice to avoid the development of soft-tissue defects. The objective of this study was to evaluate the open surgical debridement as a possible alternative method since the liposuction device is not commonly available in every hospital. In our study 10 patients were treated for extravasations of cytostatic drugs with a high potential for necrosis by emergency open debridement. All patients were evaluated prospectively by photography and clinical examination. 9 patients out of ten had a primary wound healing, one displayed a wound dehiscence with pre-existing MRSA infection. Another patient developed a seroma postoperatively which was treated by puncture. The mean functional outcome was good. The Eemergency open surgical treatment is a simple, in every hospital suitable therapy to prevent soft-tissue necrosis after extravasation of cytostatic drugs.

[The pelvic subcutaneous cross-over internal fixator]. / Der subkutane ventrale Fixateur interne (SVFI) am Becken.

The pelvic subcutaneous cross-over internal fixator is a minimally invasive technique for the fixation of instable anterior pelvic ring fractures. A USS-II-VAS screw is anchored bilaterally in the supra-acetabular region of the os ileum by a mini-incision approach. An angled fixation rod is inserted subcutaneously and after successful closed reduction attached to the screws forming a locking internal fixation. In a retrospective study of the clinical and radiological outcomes of 19 patients after an average follow-up of 2.54 years, results were excellent and good in 31.6%, moderate in 63.2% and poor in 5.3%. Complications were one wound infection, one loosening of the VAS screw and seven temporary lesions of the lateral femoral cutaneous nerve. The main benefits are a simple surgical technique preventing damage to soft tissue, a low risk of neurovascular lesions and the avoidance of pin infections. Moreover patients with multiple trauma profit from a shorter time of surgery and greater comfort allowing a prone position. The new procedure combines the advantages of internal osteosynthesis and a minimally invasive technique, providing early mobilization under full-weight bearing for instable pelvic fractures.

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.

Proximal humerus fractures: a comparative biomechanical analysis of intra and extramedullary implants.

INTRODUCTION: The biomechanical stability of a newly developed humerus nail (Sirustrade mark) for the treatment of fractures of the proximal humerus was analyzed in comparison to established systems. In total, three randomized groups were formed (n = 4 pairs) from 12 matched pairs of human cadaver humeri. MATERIALS AND METHODS: All intact bones were mechanically characterized by five subsequent load cycles under bending and torsional loading. The bending moment at the osteotomy was 7.5 N m the torsional moment was 8.3 N m over the hole specimen length. Loading was consistently initiated at the distal epiphysis and the deformation at the distal epiphysis was continuously recorded. Prior to implant reinforcement, a defect of 5 mm was created to simulate an unstable subcapital humerus fracture. For paired comparison, one humerus of each pair was stabilized with the Sirus proximal humerus nail while the counterpart was stabilized by a reference implant. In detail, the following groups were created: Sirus versus Proximal humerus nail (PHN) with spiral blade (group I); Sirus versus PHILOS plate (group II); Sirus versus 4.5 mm AO T-plate (group III). RESULTS: The Sirus nail demonstrated significantly higher stiffness values compared to the reference implants for both bending and torsional loading. The following distal epiphyseal displacements were recorded for a bending moment of 7.5 N m at the osteotomy: Sirus I: 8.8 mm, II: 8.4 mm, III: 7.7 mm (range 6.9-10.9), PHN 21.1 mm (range 15.7-25.2) (P = 0.005), PHILOS plate 27.5 mm (range 21.6-35.8) (P < 0.001), 4.5 AO T-plate 26.3 mm (range 24.3-33.9) (P = 0.01). The rotations corresponding to 8.3 N m torsional moment were: Sirus I: 9.1 degrees , II: 9.3 degrees , III: 10.6 degrees (range 7.5-12.2), PHN 13.5 degrees (range 10.3-15.6) (P = 0.158), PHILOS plate 15.6 degrees (range 13.7-20.8) (P = 0.007), 4.5 AO T-Platte 14.1 degrees (range 11.5-19.7) (P = 0.158). CONCLUSION: The intramedullary load carriers were biomechanically superior when compared to the plating systems in the fracture model presented here. Supplementary, the Sirus Nail showed higher stiffness values than the PHN. However, the latter are gaining in importance due to the possibility of minimal invasive implantation. Whether this will be associated with functional advantages requires further clinical investigation.

A comparative biomechanical analysis of implants for the stabilization of proximal humerus fractures.

A new humerus nail (Sirus) has become available for the treatment of fractures of the proximal humerus. The aim of the study was the biomechanical comparison of this implant with established systems. 12 matched pairs of human humeri were employed for testing. Three randomized groups were formed (n = 4 pairs). A bending moment of 7.5 Nm and a torsional moment of 8.3 Nm were applied in a test of five loading cycles to all intact bones. Loading was consistently initiated at the distal epiphysis. The consequent deformation at the distal epiphysis was continuously recorded. Then an osteotomy with a defect of 5 mm was created to simulate an unstable subcapital humerus fracture. For paired comparison, one of each pair was stabilized with the Sirus proximal humerus nail. The other side was fixed with a reference implant. The following groups were created.: Group I: Sirus versus Proximal humerus nail (PHN) with spiral blade. Group II: Sirus versus PHILOS plate. Group III: Sirus versus 4.5 mm AO T-plate. The proximal humerus nail (Sirus) demonstrated significantly higher stiffness values than the reference implants for both bending and torsional load. The following values were recorded at a bending moment of 7.5 Nm: Sirus 14.2 mm, PHN 20.7 mm, PHILOS plate 28.1 mm, 4.5 AO T-plate 29.3 mm p < 0.0012). The values at 8.3 Nm torsional moment were: Sirus 8.5 degrees , PHN 12.3 degrees , PHILOS plate 16.4 degrees , 4.5 AO T-Platte 15.6 degrees (p < 0.002). The intramedullary load carriers were biomechanically superior when compared to the plating systems in the fracture model presented here. Supplementary, the Sirus Nail showed higher stiffness values than the PHN. However, the latter are gaining in importance due to the possibility of minimal invasive implantation. Whether this will be associated with functional advantages requires further clinical investigation.

First clinical and biomechanical results of the Trochanteric Fixation Nail (TFN).

Conventional osteosynthesis of proximal femur fractures is still affected by serious complication rates between 4-18%, even though advanced implant modifications and surgical techniques are common practice. In terms of increasing age and co-morbidity of patients this complication ratio is expected to increase even further in the immediate future. One major reason for implant failure is the decreasing stability potential of the implant due to a loss in mechanical properties of cancellous bone. Therefore, efforts in new intramedulary techniques specifically focus on the load bearing characteristics of the implant by developing new geometries to improve the implant-tissue interface. This investigation discusses first clinical results of the trochanteric fixation nail TFN (145 patients) and a biomechanical analysis of the blade/femur head interaction under different static loading conditions. The TFN shows promising performance in first clinical results. In the clinical study the overall complication rate was significantly lower compared to other similar osteosynthesis. For the investigation of the biomechanical stability of the helical TFN blade the following experiments were performed: Analysis of the axial load required for insertion of the blade by free rotation; measurement of the corresponding rotation angle for total insertion (32 mm) (n = 8); pull-out forces with suppressed rotation (n = 4); loads for rotational overwinding of the implant in the fully inserted condition (n = 4). All investigations were performed on human femoral heads. The bone mineral densities of the specimens were detected by QCT-scans. Prior to cadaveric testing the experimental set-up was validated (n = 8) by the use of synthetic foam blocks (Sawbone).

[Reduction of the amputation rate in bone and soft tissue sarcoma by interdisciplinary cooperation]. / Senkung der Amputationsrate bei Knochen- und Weichgewebssarkomen durch interdisziplinäres Vorgehen.

On the basis of three patients with bone and soft tissue sarcoma,we would like to illustrate the necessity of a well working inter-disciplinary cooperation of radiologists, internal oncologists, radiation therapists, orthopaedic surgeons and plastic surgeons. Functional extremity preservation in sarcoma patients can be achieved by a good interdisciplinary management without im-pairing the total prognosis of the patients. Patients with sarcoma should be treated in centres in which all specialised divisions are experienced and well trained in the treatment of tumour patients. Only then can a promising approach be achieved.

First results with the trochanter fixation nail (TFN): a report on 120 cases.

A complication rate between 4-18% for the conventional osteosynthesis of the proximal femur fracture continues to be unacceptable even if increasing age and co-morbidity of patients are taken into account. Therefore, new intramedullary techniques are under development, and we here report our results with the novel trochanteric fixation nail (TFN). During the study period (March 2003-February 2004) all patients with a trochanteric fracture Type A1-A3 (AO/ASIF classification) were eligible for the study, and 120 patients (mean age 81 years, range 47-100; male/female 1:4) subsequently enrolled. Most frequent was the (according to the AO classification) A.2.1. type of fracture (n=39) and the A.2.2. fracture (n= 39). Operation time from cut to stitch was 45 mins (minimal 21/maximal 194). Thirty-seven (31%) postoperative X-rays were classified as very good, 60 (50%) as good, 18 (15%) as satisfying and five (4%) as bad post-reposition results according to the Garden Alignment Index. The clinical results were documented by the time of hospital stay, postoperative mobilization and time of rehabilitation compared to the old social status. Time to hospital discharge was 17 days (9 /25). Overall complication rate was 7.5% (9 patients) with 5.8% [7] local wound infection; 1.6% [2] cutting out of the helical blade through the cortex of the femoral head. We had three (2.5%) hospital deaths in our patient group. We conclude that TFN is a safe and reliable technique. Compared with techniques like PFN and Gamma-nail, clinical results are excellent with less complications.

[The minimally invasive stabilization of the dorsal pelvic ring with the transiliacal internal fixator (TIFI)--surgical technique and first clinical findings]. / Die minimal-invasive Stabilisierung des dorsalen Beckenrings mit dem transiliakalen Fixateur interne (TIFI) Operative Technik und erste klinische Ergebnisse.

The Trans Iliacal Internal Fixator (TIFI) is a minimally invasive technique for the stabilization of sacro-iliac joint ruptures and fractures lateral to the sacral ala or through the sacral foramen. In this study, 7.0 mm pedicle screws of the Universal-Spine-System (USS, Synthes) were inserted 1-2 cm on the cranial side of the posterior superior iliac spine and parallel to the superior gluteal line. The connecting bar was inserted subfascially and fixed with the locking head pedicle screws to form an fixed-angle construction. In a prospective study 31 patients with vertical shear injuries of the pelvis were treated with the TIFI. There were two wound infections and one loosening of a pedicle screw. None of the screws were incorrectly positioned and no neuro-vascular lesions were caused by the implant. 2 years postoperatively we found 50% good and excellent results for type C pelvic ring injuries. Early findings show that the TIFI is well suited to stabilization of sacro-iliac joint ruptures and fractures of the lateral sacrum. Closed reduction and minimally invasive insertion technique are possible. The implant leads to sufficient biomechanical stability but there is a very low intraoperative risk of neuro-vascular lesion.

[Treatment of dislocated 3- and 4-part fractures of the proximal humerus with an angle-stabilizing fixation plate]. / Die Versorgung dislozierter 3- und 4-Fragmentfrakturen des proximalen Humerus mit einem winkelstabilen Plattenfixateur.

In the presented prospective study 35 consecutive patients with displaced 3- and 4-part fractures of the proximal humerus, including fracture dislocations, were treated with a fixator plate comprising angular stability between May 2001 and December 2002. After 18.5 (8-29) months 31 (89%) fractures were available for follow-up. Good and very good results were obtained in 64%. A poor result was documented in 23%. 64% of the patients had no or mild pain, 71% were able to abduct the arm over 90 degrees . Fracture classification according to Neer and AO had no influence on the outcome, with a mean Constant Score of 76 points. Partial avascular necrosis (AVN) of the humeral head was seen in 16% of all cases representing 4% of the fractures without dislocation and 80% of the fracture dislocations. Fracture dislocation (p=0.02) and AVN (p=0.005) had a negative effect on the Constant Score, with AVN being a predictor for a high level of pain (p=0.04). Secondary dislocation of the greater tuberosity was seen in two patients, loosening of screws in one patient and a fracture below the plate in another one. Secondary dislocation or loss of reduction of the head was not recorded. Angle stable plate fixation with tension band wiring of the tuberosities is an effective and safe option to treat this difficult fractures, also in elderly patients with osteoporotic bone. Because 40% of the 4-part fractures with fracture dislocation yielded a satisfactory or better result, the plate fixator with angular stability may be an alternative to prosthetic replacement in selected cases.

The influence of cyclic compression and distraction on the healing of experimental tibial fractures.

Interfragmentary displacement has a main effect on callus formation in fracture healing. To test whether compressive or distractive displacements have a more pronounced effect on new bone formation, a sheep osteotomy model was created whereby the gap tissue was subjected to constant bending displacement. A diaphyseal osteotomy with a gap of 2 mm was created in 18 sheep tibiae and stabilized with a special unilateral actuator-driven external fixator. Two experimental groups with six sheep each received either 10 or 1000 cycles evenly distributed over 24 h. The third group of six sheep served as a control group without actively induced displacement. The amount and direction of cyclic displacement was kept constant throughout the observation period, resulting in 50% compressive and 50% distractive displacement within the osteotomy gap. At sacrifice, six weeks after surgery, bending stiffness was measured and new bone formation was assessed radiologically and microradiographically. In all cycled groups, the amount of periosteal callus formation was up to 25 times greater on the compression compared to the distraction side (p < 0.001). The application of the higher number of daily cycles resulted in an up to 10-fold greater amount of periosteal new bone formation on the compression side (p < 0.012), while the difference on the distraction side was not significant. Ten cycles applied a day were sufficient to create an abundant periosteal callus on the compression side. In the 1000 cycle group, bending stiffness revealed slightly lower values but the difference was not significant. Solid periosteal bridging of the gap was observed in two sheep in the control group, whereas bridging in the cycled groups was observed exclusively at the medullary side. In conclusion, cyclic compressive displacements were found to be superior over distractive displacements. A higher number of enforced and maintained compressive displacements enhanced periosteal callus formation but did not allow bony bridging of the gap.

[Repositioning femoral neck fracture in younger patients. Valgus or anatomic reposition?]. / Reposition der Schenkelhalsfraktur des jüngeren Menschen. Valgus- oder anatomische Reposition?

In a retrospective study, 51 patients with femoral neck fractures received open reduction and internal fixation. They were divided into two groups. Group A included all patients treated with anatomical reduction. In Group V, the bone fragments were positioned in > or = 5 degrees valgus. The median age of the patients was 37.4 years (range 13-58). 51 patients were available for follow-up assessment at 10.1 (+/- 4.3) years. There were 33 patients in Group A and 18 in Group V. All patients were examined with regard to early and long-term complications. In the first five years, avascular necrosis was seen in 18% in Group A and not at all in Group V. Nonunion occurred in 9% of Group A and 5.5% of Group V. On average at 10 years after the operation, coxarthritis (Kellgren 2) was evident in 21.2% of Group A and 55.6% of Group V (p = 0.04). According to the Hip-Score of Merle d'Aubigné, the patients treated with anatomical reduction had a better functional outcome after 10 years. With respect to the results we recommend in younger patients (< 60 years) anatomical reduction in Pauwels I and Garden-II-fractures. Valgusreduction should be performed as well in Pauwels II and III as Garden-III-and-IV-fractures.