[Minimally invasive lumbopelvic stabilization of sacral fracture and sacroiliac injury]. / Minimal-invasive lumbopelvine Stabilisierung bei Sakrumfraktur und Sprengung des Iliosakralgelenks.

OBJECTIVE: Rapid mobilization with full weight bearing by minimally invasive fixation of Os ilium to L5 in fractures of the sacrum and disruption of the sacroiliac joint (SIJ). INDICATIONS: Unstable injuries of the posterior pelvic ring in fractures of the sacrum and disruption of the SIJ. CONTRAINDICATIONS: Fracture of ilium and not injury related implants in the screw trajectory, neurological deficits regarding the fracture, decubitus in the area of surgical approach. SURGICAL TECHNIQUE: Minimally invasive screw placement in the pedicles of L5, access of ilium screw via the posterior superior iliac spine. Radiological display for the iliacal screw bearing trajectory in Os Ilium as a drop-shaped/triangle canal. Insert a Jamshidi needle orthograde in the beam path, change to guide wire and placement of iliacal screw after resection of the bone in the screw head area. Submuscular insertion of the longitudinal rods, in case of double-sided instrumentation similar procedure on the opposite side, reduction of the fracture and fixation of the rods to screws. POSTOPERATIVE MANAGEMENT: Postoperative mobilization with full weight bearing under physiotherapeutic guidance. RESULTS: Patients treated with lumbopelvic stabilization in our facility between 2012 and 2017 were identified via the hospital database and retrospectively evaluated. In 24 patients with median age of 60.1 years and a follow-up-time of 11.8 months, we found no implant displacement, infection and no wound healing problems. Full weight bearing was permitted in 21 of 24 cases, in 3 cases partial load bearing due to other injuries. Three patients reported moderate mechanical irritation of iliacal screws; 1 patient reported severe irritability with removal of the implants after bony healing of fracture 1 year postoperatively.

[Treatment-process analysis of orthopaedic trauma surgery patients at an outpatient setting in a university hospital]. / Prozessanalyse der ambulanten Behandlung unfallchirurgischer Patienten an einer universitären Poliklinik.

BACKGROUND: The cost pressure in a competitive environment forces hospitals and physicians to optimize clinical processes. In order to secure competitive advantages, a continuous evaluation of relevant processes is necessary. OBJECTIVE: Administrative and medical processes in a university outpatient department for orthopedics and traumatology were evaluated using the lean method in order to reduce patient waiting times. MATERIAL AND METHODS: Over a period of 2 weeks all patients who were treated in the department for orthopedic and trauma surgery on an outpatient basis were included in the assessment of the process. Personnel in the policlinic were prepared and trained to record times for appointments made by telephone, arrival time at the hospital, first contact, administrative procedure, first contact with the doctor, length of stay in the radiology and anesthesiology departments and completion of treatment. In addition, potential inefficiencies were identified through patient flow analysis and personal interviews with personnel in the administration and outpatient departments as well as residents and senior physicians. RESULTS: A total of 126 patients were enrolled in the study. The average length of stay of patients in the outpatient clinic was 144 min (range 30-371 min). A necessary imaging examination increased the length of stay by an average of 53 min and a necessary premedication by an average of 78 min compared to patients with no further consultations. CONCLUSION: By analyzing the pathways and times of patients, various reasons for waiting times in the university outpatient clinic could be shown. This study shows that a structured application of lean management and a dedicated analysis create added value for patients by reducing waiting times.

[Neglected, lonely and sick - the social breakdown : A special patient group in the emergency department]. / Verwahrlost, einsam und krank ­ der soziale Breakdown : Eine spezielle Patientengruppe in der zentralen Notaufnahme.

BACKGROUND: The emergency department (ED) is increasingly becoming the primary care unit of patients who are no longer able to meet the necessary minimum requirements for a healthy life. In the emergency medical care of these patients, fixation errors and stereotyped thinking can distract from serious illnesses, which can be tended by emergency medicine. This group of patients, with their multifactorial problems, represents a special challenge for the staff of the ED. The aim of this study is to improve the quality of the care for a special patient group. MATERIALS AND METHODS: A monocentric retrospective observation study was conducted at the University Hospital Bonn (UKB). On the basis of case studies, the emergency medical care of this special patient group was examined in the ED. RESULTS: Over the period of 7 years (2009 to 2016), 17 patients in a state of total neglect could be examined. The endpoints identified, during the emergency care, are the therapy of life-threatening diseases, laboratory pathologies, introduction of infectious protective measures, initiation of diagnostic measures, measures to be initiated within different departments (operating room, intensive care unit) and outcome. CONCLUSION: Patients in a state of total neglect require interdisciplinary primary care at a hospital with extended care structures. The apparent primary impression of these patients must not lead to a fixation error. Due to the often not obtainable history of the patient's and the complex appearance of these patients, the evaluation should be carried out according to a defined algorithm in the emergency room.

Radiofrequency-activated PMMA-augmentation through cannulated pedicle screws: A cadaver study to determine the biomechanical benefits in the osteoporotic spine.

INTRODUCTION: PMMA-augmentation of pedicle screws strengthens the bone-screw-interface reducing cut-out risk. Injection of fluid cement bears a higher risk of extravasation, with difficulty of application because of inconsistent viscosity and limited injection time. OBJECTIVE: To test a new method of cement augmentation of pedicle screws using radiofrequency-activated PMMA, which is suspected to be easier to apply and have less extravasations. METHODS: Twenty-seven fresh-frozen human cadaver lumbar spines were divided into 18 osteoporotic (BMD ≤ 0.8 g/cm2) and 9 non-osteoporotic (BMD > 0.8 g/cm2) vertebral bodies. Bipedicular cannulated pedicle screws were implanted into the vertebral bodies; right screws were augmented with ultra-high viscosity PMMA, whereas un-cemented left pedicle screws served as negative controls. Cement distribution was controlled with fluoroscopy and CT scans. Axial pullout forces of the screws were measured with a material testing machine, and results were analyzed statistically. RESULTS: Fluoroscopy and CT scans showed that in all cases an adequately big cement depot with homogenous form and no signs of extravasation was injected. Pullout forces showed significant differences (p < 0.001) between the augmented and non-augmented pedicle screws for bone densities below 0.8 g/cm2 (661.9 N ± 439) and over 0.8 g/cm2 (744.9 N ± 415). CONCLUSIONS: Pullout-forces were significantly increased in osteoporotic as well as in non-osteoporotic vertebral bodies without a significant difference between these groups using this standardized, simple procedure with increased control and less complications like extravasation.

[Surgical treatment of sternoclavicular joint instability with tenodesis]. / Die operative Therapie der sternoklavikulären Instabilität mittels Tenodese.

BACKGROUND: Instability of the sternoclavicular joint is a very uncommon disorder of the shoulder girdle. Acute traumatic dislocations are commonly treated nonoperatively. But severe displacement or chronic instability with recurrent symptomatic subluxation may require surgical intervention. We present our results with open reduction and internal fixation through an autologous gracilis tendon transplant or fiber tape in 8 patients treated surgically. The operative stabilisation of the sternoclavicular joint reduces pain level and improves function of the shoulder. This technique provides an effective surgical procedure for treatment of symptomatic sternoclavicular joint instability. OBJECTIVE: Restoration of the function and aspect of the sternoclavicular joint. INDICATIONS: Chronic and painful instabilities. CONTRAINDICATIONS: Local infection, tumor. SURGICAL TECHNIQUE: The gracilis tendon graft is harvested as previously described by Petersen. Direct incision over the sternoclavicular joint. Sharp dissection of the periostal sleeve and partial release of sternocleidomastoideus and pextoralis muscle. Resection of osteophytes. Careful placement of a raspatorium under the proximal clavicle and sternum to protect the mediastinal structures. Application of 2.5 or 3.2 mm drill holes to the sternum and the proximal clavicle. The gracilis tendon or the fiber tape is pulled through the drill holes in a figure of eight and then sutured. Recontruction of the joint capsule, closure of the wound. POSTOPERATIVE MANAGEMENT: Gilchrist brace for 3-5 days, functional physiotherapy with a maximum abduction of 90° for 6 weeks. No carrying or lifting of weights greater than 5 kg for 3 months. RESULTS: During the period from January 2006 to December 2010, 8 patients with sternoclavicular instability were treated. Four patients were treated with fiber tape and four were treated with a gracilis tendon autograft. Postoperative all patients described a reduction of pain and improved shoulder function. The Constant score was 72 points, the DASH 58 points.

[Low-intensity pulsed ultrasound for treatment of fractures and nonunions - current evidence and insights from basic research and clinical application]. / Niedrigintensiver gepulster Ultraschall zur Behandlung von Frakturen und Pseudarthrosen - Evidenz und Erkenntnisse aus Forschung und Klinik.

In Germany, 800,000 fractures are treated per year, and up to 10 % of these patients may suffer subsequently from a delayed union or a nonunion at the fracture site. Surgical treatment of these complications is tedious and associated with high costs. Therefore non-operative treatment is recently receiving more scientific and clinical attention. The adjuvant treatment with ultrasound has been propagated for the past years to enhance fracture healing and bony union, and has been discussed controversially. This review article demonstrates the significance of the low intensity pulsed ultrasound application in fracture treatment, on the basis of basic science results, animal experiments and the results of clinical trials.

PMMA-augmentation of incompletely cannulated pedicle screws: a cadaver study to determine the benefits in the osteoporotic spine.

BACKGROUND: Pedicle screw pullout due to poor bone quality, mainly caused by osteoporosis, is a common problem in spine surgery. Special implants and techniques, especially PMMA augmentation, were developed to improve the fixation of pedicle screws. PMMA injection into a pilot hole or through a screw involves the same risks as vertebroplasty or kyphoplasty, regardless of the technique used. Especially when using fully cannulated screws anterior leakage is possible. OBJECTIVE: To prove PMMA injection is safe and possible without leakage through an incompletely cannulated screw and also increases pullout forces in the osteoporotic vertebra. METHODS: Incompletely cannulated pedicle screws were tested by axial pullout in human cadavers, divided into osteoporotic and non-osteoporotic groups. Non-augmented and PMMA-augmented pedicle screws were compared. Twenty-five human vertebrae were measured by DEXA and divided into osteoporotic and non-osteoporotic groups. In each vertebra both pedicles were instrumented with the new screw (WSI-Expertise 6×45 mm, Peter Brehm Inc. Germany); the right screw was augmented with a 3 mL PMMA injection through the screw. On each screw axial pullout was performed after X-ray and CT scan. RESULTS: Radiographs and CT scans excluded PMMA leakage. Cement was distributed in the middle and posterior third of the vertebrae. Pullout forces were significantly higher after pedicle screw augmentation, especially in the osteoporotic bone. All augmented pedicle screws showed higher pullout forces compared with the unaugmented screws. CONCLUSIONS: We minimized the risk of leakage by using a screw with a closed tip. On the whole, PMMA augmentation through an incompletely cannulated pedicle screw is safe and increases pullout forces in osteoporotic bone to the level of healthy bone. Therefore the new incompletely cannulated screw can be used for pedicle screw augmentation.

[PMMA augmentation of pedicle screws: results of a survey in Germany]. / PMMA-Augmentation von Pedikelschrauben: Ergebnisse einer Umfrage in Deutschland.

BACKGROUND: The anchorage of pedicle screws can be challenging in the osteoporotic spine. A promising technique are cement augumented pedicle screws. The goal of this study was to gain more information regarding application of pedicle screw augmentation in Germany. MATERIALS AND METHODS: Participants of the National German Spine Congress 2009 were invited to participate in an internet-based anonymous survey regarding application of pedicle screw augmentation. The questionnaire was related to different aspects of materials and procedures for pedicle screw augmentation. The frequency of answers was divided according to the specialty state of the surgeons: orthopaedic and trauma surgeons vs. neurosurgeons. The Mantel-Haenszel test was applied to evaluate the differences between the groups. RESULTS AND CONCLUSION: 69 (64 %) orthopaedic and trauma surgeons and 39 (36 %) neurosurgeons participated (n = 108). Nearly 80 % of the participants use cement-augmented pedicle screws in their daily practice. Almost 2/3 of the specialists apply cannulated screws or other special screws. The Expedium (Company) screws are particularly preferred. The insertion of screws is combined with kyphoplasty or vertebroplasty in 20 % of the cases. The balloon kyphoplasty was applied most commonly. There was no statistical difference between the surgeon groups regarding the different techniques. The main indications for pedicle screw augmentation were osteoporosis, intraoperative findings as well as loosening of screws, and revision. The most frequently observed complication is cement extravasation into the spinal canal (28 %). The cost issue is considered as being important but unknown to most of the participants. It can be assumed that the use of pedicle screws in Germany is well established in spine surgery, without as yet a standard technique being established.

[Comparative findings of balloon kyphoplasty in patients with vertebral fractures due to osteoporosis, metastases and myeloma]. / Vergleichende Befunderhebungen der Ballonkyphoplastie bei Patienten mit Wirbelkörperfrakturen infolge von Osteoporose, Metastasen und Myelomen.

OBJECTIVE: By evaluations of treatment protocols, the documentation of balloon kyphoplasty regarding efficacy, duration of action and safety should be expanded. In addition, the evaluations should help to clarify the differences in balloon kyphoplasty for patients with vertebral fractures concerning efficacy and safety in relation to the underlying diseases: osteoporosis, bone metastases or myeloma. MATERIAL AND METHODS: In order to reposition the endplates of the vertebrae a balloon was inserted after placement of the working channels. After removal of the balloon, the resulting caverns were filled with PMMA. The radiological and clinical follow-up examinations were carried out over a period of up to 3 years. The clinical and radiological findings before and after treatment at specified visits were transferred to a statistical programme and evaluated. RESULTS: The comparisons of the postoperative results according to the initial diagnosis (metastases: n = 222, osteoporosis: n = 122, myeloma: n = 122) demonstrated significant differences with respect to the cement leakage (14 %, 5 %, 7.5 %), but in all cases without any clinical relevance. The small differences related to the reduction in pain intensity (VAS > 50 mm in each group) after surgery were up to 12 months with no clinical significance. Also in the Oswestry score no differences between the 3 groups were registered. In the case of osteoporosis patients, due to the lower starting position a more significant increase of vertebral body height could be achieved by the kyphoplasty than in the comparison groups of patients with metastases or myeloma (∅ 3.1 mm vs. 0.4-0.5 mm; P < 0.001). Consequently, the kyphosis angle decreased in the osteoporotic group also more strongly than in the comparison groups. CONCLUSIONS: It is evident that the pain relief in the vast majority of cases started immediately after surgery. Additionally, a significant improvement in functioning (Oswestry score) was registered. Both clinical parameters - as far as they could be checked - showed a steady degree of improvement over a period of at least 3 years. This comparative analysis led to the conclusion that balloon kyphoplasty can be successfully applied indiscriminately in patients with vertebral fractures as a result of osteoporosis and also to fractures associated with bone metastases or with myeloma.

[Diagnosis and treatment of radiocarpal fracture dislocations]. / Diagnostik und Therapie von radiokarpalen Luxationsfrakturen.

In contrast to the common intra- or extra-articular fractures of the distal radius, radiocarpal fracture dislocations are rare injuries. Concerning this issue, only a small number of publications can be found. Nevertheless, it is important to be informed about this injury since prompt operative treatment is often required and immobilization alone will not be sufficient. Sometimes, radiocarpal fracture dislocations are combined with carpal injuries. In such cases, both the radiocarpal dislocation and carpal injury have to be treated. Diagnostic difficulties can lead to misinterpretation or underdiagnosis. Insufficient reduction and fixation may result in joint incongruity and subsequent osteoarthritis. Reconstruction of the radiocarpal ligaments is a substantial part of operative treatment.

[Mid-term results after post-traumatic knee joint replacement in elderly patients]. / Mittelfristige Behandlungsergebnisse der posttraumatischen Alloarthroplastik des Kniegelenks beim geriatrischen Patienten.

BACKGROUND: Due to the increasing prevalence of elderly people in Germany, the number of geriatric fractures will continue to increase. Typical geriatric skeletal and physical changes are osteoporosis, arthrosis, and reduced ability of coordination. Altogether, these factors may lead to a failure of a performed osteosynthesis, or may make the classical fracture treatment of reduction and internal fixation appear to be impossible. The aim of this study was to examine the results of peri-knee fractures treated directly or within 3 months by implantation of a knee prosthesis. MATERIAL AND METHODS: 15 geriatric patients could be identified who were treated in the described way in the last 4 years. The follow-up time was 39 months. The knee injury occurred in all cases after a banal trauma. RESULTS: 14 patients could be examined by applying the HSS scoring system. We furthermore checked the operative management and postoperative course. The patients reached a good score level and showed few complications. CONCLUSION: For elderly patients, the primary knee arthroplasty after periarticular fractures of the knee is a valid treatment option. Nevertheless, the surgeon has to identify those fractures which are impossible to treat by a classical osteosynthesis. Furthermore, the application of the appropriate knee prosthesis, regarding the degree of hinge constrainment or augmentation of the tibial or femoral bone stock, is important.

[Bilateral femoral neck fracture after seizure]. / Beidseitige Schenkelhalsfraktur nach Krampfanfall.

Femoral neck fractures after seizure are rare. This injury can easily be underdiagnosed due to generalised, musculoskeletal pain after seizure. In case of persisting groin pain and limited range of motion X-rays are indicated. Within the first 6 hours after the trauma a joint-preserving therapy is possible. After a delayed diagnosis total hip arthroplasty is necessary. As the result of prolonged intra-articular haematoma the incidence of a femoral head necrosis increases. When choosing the implant, an elevated risk of joint dislocation should be considered.

[The articular fracture of the lower limb]. / Die synchrone OSG- und Unterschenkelfraktur.

AIMS: The combination of a distal tibia fracture with an additional upper ankle joint injury is a challenge. Apart from various implants the intraoperative problem is the handling of these two injuries with appropriate reduction and retention. The existing and further developing soft tissue damage has to be taken into consideration. The aim of this study is to evaluate the surgical management of this type of fracture. PATIENTS AND METHODS: Between 2000 and 2007 we treated 22 patients with tibia fractures and coexisting upper ankle fractures. All patients could be traced for follow-up examinations. We deduced the impact energy of the trauma and the soft tissue damage. The tibial and ankle fracture sites were categorised. The time elapsed until full weight bearing was measured. The ankle joint function was inspected. RESULTS: A high energy trauma existed in 10 and a low energy trauma in 12 patients. In the high energy group we found in 5 cases A3, in 2 cases B1 and 1 B2 and 1 B3 and 1 C2 fracture of the tibia. In 5 cases a bimalleolar ankle injury existed, once a medial ankle fracture und in 3 cases an isolated distal fibula fracture. One patient had an open ankle joint luxation. In some cases an additional fibula shaft fracture was seen. "Fracture communication" between the tibia fracture and the ankle injury was not seen at all. An intramedullary nail stabilisation was used in 9 cases, while in 1 patient due to the soft tissue damage an external fixator was applied. In the low-energy group there were 4 B1, 4 B2 and 4 C1 fractures of the tibia. We found 6 injuries of the posterior plafond and 6 cases with a central fracture line of the pilon. A fracture communication between ankle and tibial shaft was detected in all cases. In 7 patients we used a minimally invasive locking plate and in 5 cases a nailing technique for stabilisation of the tibia fracture. Overall, we saw 1 distraction fault, 1 valgus misfitting of the fracture, 1 pin infection and 2 soft tissue necrosis as postoperative complications. The time interval until osseous union was 3.5 months. Monoarticular fractures of the upper ankle joint had better results according to the Weber score. CONCLUSION: One can divide the distal articular tibial shaft fracture into two groups. In the high energy entity the ankle joint injury happens first, and afterwards the tibial shaft fracture occurs. Therefore, both fracture sites are usually not communicating, which means they are in fact two types of fracture. On the other hand, in the low energy group, both fractures are communicating. Here, the tibial shaft fracture is equal to the inner ankle fracture in a classic bimalleolar fracture. Therefore we have only one fracture site.

[Primary endoprosthetic replacement of fractured elbow in elderly patients]. / Primäre Alloarthroplastik des frakturierten Ellenbogens beim hochbetagten Patienten.

AIM OF STUDY: Inadequate treatment of distal intra-articular fractures of the humerus results in painful restriction of movement or malarticulation. Especially in geriatric patients with osteoporosis, stable osteosynthesis can be difficult. Primary total endoprosthetic replacement of the cubital joint could offer an alternative. MATERIAL AND METHODS: In 12 patients with a distal intra-articular fracture of the humerus a cemented semi-constrained Coonrad-Morrey prosthesis was implanted. Patient were followed-up after an average of 13 months and assessed according to the Mayo score. RESULTS: In 6 patients additional computerized tomography was carried out. Minimally invasive Kirschner wire osteosynthesis resulted in immediate postoperative loss of correction due to osteoporosis. As with the external distraction-compression apparatus the ulnar pinholes can form a predetermined breaking point and fixation in a long-arm cast is recommended. The mean Mayo score was 90.5 points and mean range of motion in extension/flexion was 84.5 degrees. CONCLUSION: In elderly patients primary endoprosthetic treatment of a distal intra-articular fracture of the humerus with a semi-constrained cemented prosthesis may offer an alternative to osteosynthesis thus enabling creation of a mobile, painless and stable cubital joint.

[The "well-leg" syndrome: calf compartment after lithotomy position]. / Das "Gesunde-Bein'-Syndrom: Unterschenkelkompartment nach Steinschnittlagerung.

AIM: The lower leg compartment syndrome is in most cases a post-traumatic soft tissue complication. Nevertheless, it can also occur in a primarily not injured calf, due to external muscle compression during lithotomy positioning. This complication is seen rarely after gynaecological, urological or abdominal operations performed in the Lloyd-Davis position. METHOD: We present a case of calf compartment after prolonged lithotomy position of the uninjured leg during the nailing of a femur shaft fracture. RESULTS: Postoperatively a diffuse turgor of the healthy calf was seen. The compartment pressures were elevated and the enzyme creatine kinase was elevated up to 3000 U/l. After dermatofasciotomy the enzyme level normalised, but in the further course we had to resect the necrotic peroneal muscle compartment. CONCLUSION: During operative procedures at the coxal femur, it is necessary to deposit the other leg in the lithotomy postion. By this means, the compartment pressures can increase in the calf muscles to critical values. Together with operation times longer than 4 hours and a high ponderosity a bedding compartment can develop. As it is in the assumed "healthy" leg, this syndrome can be overseen, especially in sedated patients. It has to be considered with high creatine kinase levels and the typical risk factors. If a compartment syndrome is suspected, we recommend early dermatofasciotomy, as this is a low-risk and low-complication operation, in comparison to a later performed compartment decompression. By extending both legs, especially in risky patients, the surgeon can avoid this dangerous complication.

[Faster diagnostics by digital X-ray imaging in the emergency room: a prospective study in multiple trauma patients]. / Schnellere Diagnostik mit digitaler Röntgentechnik im Schockraum: eine prospektive Studie bei Schwerverletzten.

AIM: The object of this study was to provide evidence for a time-reduced diagnostic space in multiple trauma patients by use of a digital X-ray system in the emergency suite. METHOD: The same algorithm was used in the first attention of 66 severely injured patients. For 21 patients from October 2000 to March 2001 (group 1) conventional X-rays (thorax, pelvis, spine and extremities) were performed in the analogue way, for 45 patients from April to December 2001 (group 2) the new digital system (Philips Optimum and Philips PCR AC 500) was used. RESULTS: The two groups were similar concerning age, sex and injury severity. The time-space from the patient's delivery in the emergency suite to the handing over in the operation theatre or intensive care unit was significantly lower in group 2 (87 +/- 33 min, p < 0.001) than in group 1 (121 +/- 49 min). CONCLUSION: Digital imaging with conventional X-rays in the first attention of multiple trauma patients reduces the diagnostic time by more than half an hour, when applying the same diagnostic algorithm.

The sheep as a knee osteoarthritis model: early cartilage changes after meniscus injury and repair.

The purpose of this study was to analyse cartilage changes after traumatic meniscal lesions and to provide a detailed description of the model used with a view to reducing the number of animals used in future studies. The sheep's knee was chosen, as ovine biomechanics are similar to that of humans. In two groups of 10 animals each, a radial tear in the medial meniscus was either sutured with polydioxanone (PDS) or left untreated (sham-operated). Half of the animals in each group were sacrificed after six months, the other half after one year. The time periods to achieve weight bearing, meniscus healing, joint effusion (magnetic resonance imaging scan) and knee cartilage in the medial, lateral and patellofemoral compartments were evaluated in comparison to the opposite knee (control). Osteoarthritis (OA) was assessed by a modified Outerbridge classification and confirmed by scanning electron microscopy. Only one sutured meniscus remained completely adapted. In all other meniscus lesions, the rupture healed with a scar. In the PDS and sham-operated groups, OA was significantly higher in the medial knee compartment than in the lateral compartment and in controls (P < 0.001). In the operated groups, joint effusion was higher in the right hindlimb knee than in the normal left hindlimb knee (control) after six and 12 months (P < 0.001). Non-treated, displaced and even adapted sutured radial ovine meniscus tears produced intense OA within less than six months. Therefore, this animal model is suitable for assessment of new therapeutic regimens in meniscal surgery.

[Osteochondral fractures of the distal femur]. / Distale osteochondrale Femurimpressionsfrakturen.

BACKGROUND: Chondral or osteochondral avulsions of the lateral distal femur edge after luxation of the patella are well known. Less common are impression fractures of the retropatellar joint or the lateral trochlea. Furthermore, on standard knee X-rays these injuries may not be seen and thus not properly be treated. By presenting our cases we show clinical symptoms, diagnostic pathways and the therapeutic approach for osteochondral fractures of the distal femur. MATERIALS AND METHODS: The first patient had a large osteochondral impression fracture of the lateral femur trochlea and retropatellar surface. The second patient had a chondral depression of the lateral trochlea femoris after kicking a football. The further examinations showed no other knee injuries in the first case, but a rupture of the outer meniscus plus ACL rupture and distortion of the medial collateral complex in the other one. RESULTS: In both cases the whole degree of the injury was not seen on the standard X-rays, but only on MRI or CT scans. The clinical signs were also not so overwhelming, as both patients could walk with crutches, but suffered from haemarthrosis. Both patients were operated by arthroscopy first with surgery on the meniscus injury and ACL rupture. The impression was revised by an open procedure with elevation of the subchondral spongiosa. In the follow-up examination we saw no dissection of chondral flakes or local necrosis. CONCLUSION: Osteochondral lesions of the distal femur can be neglected, as it is an uncommon diagnosis and the radiological signs may not be impressing. The more important is a subtle anamnesis and further diagnostic regime via CT or MRI as it is a prearthrotic injury. Intraoperatively the impression must be elevated or in the case of a dislocation refixed. Further knee injuries have to be detected. In the follow-up one should check for signs of flake dissection or necrosis.

[Horner's syndrome after fracture of the first rib]. / Horner-Syndrom nach Fraktur der ersten Rippe.

Horner's syndrome after trauma is rare. After visual diagnosis, a search for the cause is urgent due to possible life threatening damage. Intracerebral bleeding and carotid dissection must be excluded. Traumatic Horner's syndrome often seems to be, as in the case described here, caused by a fracture of the first rib. As persistent symptoms are not described, conservative therapy is recommended.