Anterior management of C2 fractures using miniplate fixation: outcome, function and quality of life in a case series of 15 patients.

PURPOSE: The classification systems by Anderson and D'Alonzo, Effendi, Benzel and others have limitations when it comes to morphologically categorising fractures of the second cervical vertebral body (C2) that present with or without an additional fracture of the dens or with or without an extension of the fracture line into the vertebral arch and displacement. Currently, there are no definitive recommendations for the treatment of fractures at the junction of the dens with the vertebral body of C2 on the basis of outcome and stability data. Depending on patient anatomy, either anterior or posterior approaches can be used to fuse C1 and C2 and to achieve definitive surgical stabilisation. The anterior management of C2 fractures without C1-C2 fusion has the theoretical advantage that it preserves rotational motion at this motion segment and that the anterior approach is associated with lower morbidity. In the study presented here, we followed up a group of our patients who underwent anterior miniplate fixation for C2 fractures. METHODS: Fifteen patients underwent fixation of C2 fractures with titanium miniplates (Medartis Hand fixation system, 2.0 or 2.3 mm) that were placed using a submental approach. To our knowledge, this construct has not yet been described in the literature. Where necessary, this procedure was combined with screw fixation of the dens as described by Böhler. We retrospectively analysed operative reports and medical records, evaluated the patients' health status using the Short Form (36) Health Survey (SF-36), and performed clinical follow-up examinations. RESULTS: From January 2009 to June 2015, 226 traumatic lesions of the cervical spine were managed at our institution in the inpatient setting. Ninety-two patients underwent conservative treatment. Of the 134 cases that required surgery for fractures and instability, 67 involved the C0-C3 motion segments. In 15 patients, stability was achieved using an anterior miniplate or miniscrews alone (n = 4) or in addition to other techniques (n = 11). Anderson and D'Alonzo type II and III dens fractures with involvement of the body or lateral mass of C2 accounted for eight cases. Effendi type II body fractures with or without instability were seen in four cases. There was no perioperative mortality and morbidity in this patient group. All fractures healed and stability was achieved in all cases. No patient had neurological deficits or required revision surgery. An assessment of postoperative quality of life showed that 11 patients (7 men, 4 women) with a mean age of 57 (± 5.3) years reached an SF-36 score that was normal for their age group after a mean period of 33 (± 6.3) months following their injury. Compared to a group of healthy subjects, the patients had a range of motion that was limited only at the extremes. CONCLUSIONS: In patients with appropriate indications, anterior fixation with miniplates alone or additionally is a further useful treatment option in the management of fractures at the junction of the dens with the vertebral body of C2. Since this type of treatment preserves motion at the C1-C2 motion segment after fracture healing and since an anterior approach is associated with less surgical trauma than posterior instrumentation, the technique presented here should be included in a discussion on (surgical) treatment options. These slides can be retrieved under Electronic Supplementary Material.

Management of Soft-Tissue and Bone Defects in a Local Population: Plastic and Reconstructive Surgery in a Deployed Military Setting.

OBJECTIVE: Gunshot injuries, blast injuries, and major contusions can cause extensive extremity defects. In countries with damaged or destroyed infrastructure, local national patients with these injuries pose a challenge. Deployed medical facilities of the German Armed Forces provide medical care to these patients as part of their humanitarian activities. Reconstructive techniques, for example, microvascular free tissue transfer, can be used only to a limited extent in such settings, which require safe and simple (outpatient) procedures. The focus of treatment is not on cosmetic aspects but on rapidly restoring function. Low-resource settings require ethical and medical compromises. It is still a topic of the discussion which reconstructive surgical procedures could be performed in a deployment mission and which should be in the portfolio of the deployed surgeon. METHODS: We conducted a retrospective analysis of a sample of 550 patients who received definitive treatment from seven surgeons from a single German Armed Forces hospital during a total of 47 tours of duty (i.e., 94 months) with the International Security Assistance Force in Feyzabad, Kunduz, and Mazar-i-Sharif in Afghanistan. The deployed surgeons (authors) were given an Excel spreadsheet and were asked to enter details on the surgical procedures they had performed in the deployed setting on the basis of operative reports. RESULTS: Local and pedicled flaps were used in 73 cases to cover extensive soft-tissue defects and preserve the affected limbs. Improvised distraction osteogenesis was used in 18 patients to manage large bone defects. In 13 cases, bone defects were temporarily filled with a cement spacer (Masquelet technique). Fourteen patients required a combination of soft-tissue and bone reconstruction. CONCLUSIONS: Simple surgical reconstructive procedures are available that enable surgeons to preserve the shape and function of an injured limb with limited resources. This emphasizes the need either to make these techniques a mandatory part of training not only for surgeons who are deployed to combat zones and disaster areas but also for surgeons working for civilian relief organizations or to ensure that surgical teams are composed in such a way that these techniques are available.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®).

PURPOSE: The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome. MATERIAL AND METHODS: In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock. RESULTS: Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation. CONCLUSION: This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Masquelet technique for reconstruction of osseous defects in a gunshot fracture of the proximal thigh--a case study.

Treatment of osseous defects of the extremities is a constantly recurring challenge in modern reconstructive surgery. This applies, in particular, to military surgery, especially to the sequelae of gunshot and blast injuries. Severe soft-tissue damage and inevitable contamination lead to an increased rate of infection. Repetitive surgical debridement involving the bone must be performed at regular intervals. Frequent outcomes are osseous defects that call for a consistent therapeutic concept adapted to the individual patient. The Masquelet technique is an additional bone reconstruction method with which to sufficiently treat initially infected long bone defects in multiple operations. Following radical debridement, the resulting bone defect is completely filled with a bone cement spacer loaded with antibiotics. At the boundary layer between the spacer and soft tissue, a membrane expressing growth factors will develop over several weeks. This has a favorable effect on the successful transplantation and ossification of autologous cancellous graft following spacer removal. This technique will be illustrated by a case study. Since this technique has already proved successful in reconstructing defects of up to 25 cm, it is an alternative to various callus distraction methods as well as vascularized bone transfer.