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.

[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.

[Surgical treatment of an acetabular fracture during pregnancy]. / Operative Versorgung einer Acetabulumfraktur in der Schwangerschaft. Fallbericht und Literaturübersicht.

We report about a case of a pregnant women in the 23rd gestation week who sustained an isolated acetabular fracture in a car accident. The fracture was treated surgically by open reduction and internal fixation 6 days after trauma. The outcome for the mother and the baby was excellent; both could be followed up for 1.5 years. The baby did not suffer from any disease related to the diagnostic or surgical procedures. We conclude from this case and from reviewing the literature that the operative fixation of an acetabular fracture during pregnancy is the appropriate treatment with minimal risk for the unborn child and best outcome for the mother.

[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.

[Ventilation in prone position in a 5-year-old child after multiple trauma. Effective treatment of persistent atelectasis]. / Beatmung in Bauchlage bei einem 5-jährigen Kind nach Polytrauma. Effektive Therapie persistierender Atelektasen.

We report on the ventilation in prone position in a 5-year-old traumatized child with severe thoracic and abdominal injuries (lung contusion, rib fractures, rupture of liver and spleen). Under continuous analgesic sedation, the young patient was ventilated in prone position for 6 h, since acute lung injury and atelectasis persisted despite various therapeutic measures (artificial ventilation in the pressure controlled mode, fiberoptic bronchoscopy, reexpansion maneuver). After initiation of the prone position, we observed a rapid increase in arterial oxygenation, which persisted in the following period. The hemodynamic situation remained stable. The complete disappearance of atelectasis was demonstrated radiologically after supine repositioning. After cessation of analgesic sedation, the extubation was performed 2 days later. Furthermore, we found no side effects of the prone position on the injured abdomen, and the liver function improved rapidly. Although there is a lack of experience with ventilation in prone position in pediatric intensive care, our report might be a recommendation for the indication of this technique in children.

NOAH--A mobile emergency care system.

Experiencing communication problems in our emergency services, we developed an innovative communication network and system the NOAH-system (NOAH, which stands for Notfall -, Organisations - und Arbeitshilfe or Emergency-Organisation Active Aide System). In contrast with the currently established emergency services communication in Germany by radio wave, data is transferred from the scene in the form of an electronic record on a mobile computer by means of the wireless data communication network Modacom (Mobile Data Communication), which is provided by German Telekom. It is received at the dispatch-centre in mentioned format and transferred to the admitting hospital without any loss of data. - In a prospective study, the technical and conceptual suitability of this system was investigated. It was shown that an admitting hospital was informed more than 20 minutes in advance about the admittance of a patient. To assure the quality of transferred data, information was ranked by different criteria. This further demonstrated that much more precise information about a patient's condition was already available upon admittance in the hospital.

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life.

STUDY DESIGN: Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively. OBJECTIVES: To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases. SUMMARY OF BACKGROUND DATA: The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential. METHODS: The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted. RESULTS: First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients. CONCLUSIONS: Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.

Medical communication from emergency scenes using a notepad computer.

We have developed a communication system in which data are transferred from the scene of an emergency in the form of an electronic record on a notepad computer by means of a satellite link (MODACOM). The data are received at the dispatch centre and transferred to the admitting hospital automatically. In a prospective study of 53 emergencies the technical suitability of the system was investigated. First-sight information could be fed into the computer in 15 s and transmitted within 3 min of arrival on the scene. For 16 patients with life-threatening conditions, the admitting hospital was notified on average after 13.6 min (SD 6.0), whereas by conventional VHF radio it took 35.5 min (SD 8.9). In addition, more precise information about the patient's condition was received at the hospital.

Fracture healing of the sheep tibia treated using a unilateral external fixator. Comparison of static and dynamic fixation.

It is generally accepted that when a fracture is treated with external fixation, dynamization of the fixation accelerates formation of the bony callus by transferring part of the functional loads. The aim of the research presented here was to validate this principle using in vivo measurements of callus stiffness. We created a transverse fracture in the mid third of the tibial shaft in 12 sheep and maintained a 3 mm gap between the fragments for 3 weeks. Two types of unilateral external fixators were applied. Axial loading was permitted (dynamization) from the fourth week onwards in 6 animals. In the other 6 animals, fixation remained static for both types of fixation. Weekly measurements of callus stiffness were obtained using a goniometer and load cell to assess bending stiffness. Two slightly different fixators were used. Callus formed in all 12 animals. Callus stiffness increased exponentially to reach the degree of stiffness measured on the contralateral side. There was no clear difference in healing between the two types of fixations nor between dynamic and static fixation. If a unilateral fixator was applied which did not maintain absolutely rigid fixation, the fracture generally healed well even without contact between the fragment ends. If the process of callus formation had begun normally, dynamic fixation offered no further benefit. Measuring the stiffness of the callus with an adequate measurement apparatus in vivo indicated that the fixator could be removed earlier than would have been authorized on the basis of radiological evidence alone.

[Telecommunication in trauma surgery. Communication networks of hospitals in East Bavaria]. / Telekommunikation in der Unfallchirurgie. Vernetzung medizinischer Versorgungseinrichtungen in Ostbayern.

The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95% of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.

[Percutaneous minimal invasive autologous spongiosa transplantation]. / Die perkutane minimal invasive autologe Spongiosatransplantation.

In eight patients with delayed union or nonunion after 3 degrees open fracture of the tibia, a minimally invasive technique of autologous bone grafting was performed. Bone harvesting from the iliac crest and debridement of the fracture side were done percutaneous by using a 5.5 mm acromionizer without complications. In seven of eight patients complete fracture healing could be achieved (88%). Percutaneous autologous bone grafting can be recommended on limited bone defects in patients with nonunion or delayed union of the tibia and severe soft tissue damage in the lower leg.

[Improvement of the amplification rate of human chondrocytes with IGF-I and RGD]. / Verbesserung der Amplifikationsrate humaner Chondrozyten unter dem Einfluss von IGF-I und RGD.

Human chondrocytes were incubated under following conditions: Group 1 (control group): Incubation in 25 cm2 cell culture flasks (Costar) with RPMI-medium (6%-AB-serum, L-Glutamin, Hepes-buffer and antibiotics); Group 2: Different concentrations of IGF-I (1 ng/ml, 10 ng/ml) were added to the RPMI-medium; Group 3: Incubation (like control group) with additional coating of the cell culture flasks with different concentrations of RGD (5 mg/ml; 7.5 mg/ml; 10 mg/ml; 20 mg/ml); Group 4: Combination of coating with RGD (5 mg/ml; 10 mg/ml) and addition of IGF-I (1 ng/ml; 10 ng/ml) to the medium. The cells of the control group could be doubled within 2 weeks. The amplification rate of the groups 2 and 3 was improved in comparison to group 1 with the following maxima: Group 2 (5 mg/ml RGD) 3.1 times and group 3 (1 ng/ml IGF-I) 2.6 times of the number of the cells in the beginning. Group 4 (RGD and IGF-I) showed additive effects, for 4.1 times of the number of the cells in the beginning could be counted after 14 days. RGD and IGF-I (groups 2 to 4) made possible an earlier dedifferentiation and adhesion of the cells to the bottom of the cell culture flasks. By using both growth factors (RGD and IGF-I), the number of the cells could be enhanced more than 2 times in comparison to the control group within the same time. So less than half of the autologous patient's cartilage is necessary for cultivation of hyaline cartilagee.

Algorithms for early management of pelvic fractures.

The successful management of pelvic fractures depends upon proper diagnosis and timely treatment. Severe pelvic fractures are life-threatening injuries in which a clear-cut treatment strategy is required to make decisions within the shortest possible time. An algorithm is presented in the form of a flow chart that has proven useful in facing difficult situations in the initial management of pelvic fractures. Decision-making is based on progressive clinical examination and a series of key questions. The sequence starts with the arrival of the patient, followed by the resuscitation phase, proceding through the initial examination and assessment of the patient to the final diagnosis and appropriate treatment. A safe approach to pelvic fractures is gained by following the proposed algorithm. The algorithm is an excellent teaching tool, but no guarantee can be given since every case is different and requires a specific approach.

[Rockwood capsulorrhaphy in shoulder instability. A clinical follow-up study]. / Die Kapselplastik nach Rockwood bei Schulterinstabilität. Eine klinische Nachuntersuchung.

Rockwood described a capsulorrhaphy technique for operative treatment of multidirectional shoulder instability with anterior dislocation. We have used this technique mainly in patients with severe multidirectional instability and now have 8 years' experience with it, which is reported below. The surgical technique involves refixation of the Bankart lesion with transosseous suture and double breasting of the anterior capsule. No transposition of the subcapularis muscle was performed. A functional rehabilitation program without immobilization was used in all patients. The daily activity level, the degree of discomfort upon shoulder-related activities and the subjective assessment of outcome were recorded for each patient. General outcome was determined with reference to Rowe's score. A clinical examination was performed as well as radiography. Strength was evaluated by standardized bilateral dynamometry. Follow-up examination was possible in 73 out of 82 patients. The mean age at follow up was 32.7 +/- 4.1 years, and the mean follow-up time, 4.3 years. The reason for surgery was recurrent dislocation in 81% of patients, pain in 4% and both pain and dislocation in 15% of patients. In 8 patients (10.9%) multiple (up to 4) previous surgical attempts by various methods had been unsuccessful. Postoperatively 59% (n = 44) were able to take part in sports without restrictions, 27.4% could take part only in sports not involving the shoulder, and 13.5% (n = 10) did not engage in any sports postoperatively. The redislocation rate was 12.3% (n = 9), and there was 1 traumatic redislocation. A deficit in abduction/elevation by 10-60 degrees was found in 4 patients (5.4%) and by > 60 degrees in 2 patients (2.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapy of extensive lymphangioma of the vulva]. / Therapie eines ausgedehnten Lymphangioms der Vulva.

The lymphangioma of the vulva offers difficulties in differential diagnosis because of its wart-like appearance [7]. Is the diagnosis histologically confirmed, there often arise uncertainties about an adequate therapy [7, 2, 15]. By this case report these problems will be explained. Vaporisation with the CO2-Laser showed to be the predominant therapeutical procedure.