Effects of mesenchymal stromal cells versus serum on tendon healing in a controlled experimental trial in an equine model.

BACKGROUND: Mesenchymal stromal cells (MSC) have shown promising results in the treatment of tendinopathy in equine medicine, making this therapeutic approach seem favorable for translation to human medicine. Having demonstrated that MSC engraft within the tendon lesions after local injection in an equine model, we hypothesized that they would improve tendon healing superior to serum injection alone. METHODS: Quadrilateral tendon lesions were induced in six horses by mechanical tissue disruption combined with collagenase application 3 weeks before treatment. Adipose-derived MSC suspended in serum or serum alone were then injected intralesionally. Clinical examinations, ultrasound and magnetic resonance imaging were performed over 24 weeks. Tendon biopsies for histological assessment were taken from the hindlimbs 3 weeks after treatment. Horses were sacrificed after 24 weeks and forelimb tendons were subjected to macroscopic and histological examination as well as analysis of musculoskeletal marker expression. RESULTS: Tendons injected with MSC showed a transient increase in inflammation and lesion size, as indicated by clinical and imaging parameters between week 3 and 6 (p < 0.05). Thereafter, symptoms decreased in both groups and, except that in MSC-treated tendons, mean lesion signal intensity as seen in T2w magnetic resonance imaging and cellularity as seen in the histology (p < 0.05) were lower, no major differences could be found at week 24. CONCLUSIONS: These data suggest that MSC have influenced the inflammatory reaction in a way not described in tendinopathy studies before. However, at the endpoint of the current study, 24 weeks after treatment, no distinct improvement was observed in MSC-treated tendons compared to the serum-injected controls. Future studies are necessary to elucidate whether and under which conditions MSC are beneficial for tendon healing before translation into human medicine.

Incomplete burst fractures of the thoracolumbar spine: a review of literature.

PURPOSE: The purpose of this review was to analyze the biomechanical basis of incomplete burst fractures of the thoracolumbar spine, summarize the available treatment options with evidence from the literature, and to propose a method to differentiate fracture severity. METHODS: The injury pattern, classification, and treatment strategies of incomplete burst fractures of the thoracolumbal spine have been described following a review of the literature. All level I-III studies, studies with long-term results and comparative studies were included and summarized. RESULTS: Details of five randomized control trials were included. Additionally, three comparative studies and two studies with long-term outcomes were detailed in this review. The fracture severity reported in the included studies varied tremendously. Most classification used did not adequately describe the complexity of fracture configuration. A wide variety of treatment strategies were outlined, ranging from non-operative therapy to aggressive surgical intervention with combined anterior-posterior approaches. Thus, the treatment of incomplete burst fractures of the thoracolumbar spine is quite diverse and remains controversial. CONCLUSIONS: Incomplete burst fractures can differ tremendously regarding the degree of instability they confer to the thoracolumbar spine. Based on a detailed review of the literature, it is clear that good results can be obtained with both non-operative and operative strategies to treat these injuries. In the authors' opinion, the intervertebral disc plays a key role in determining the long-term clinical and radiological outcome. Thus, an incorporation of the intervertebral disc pathology into the existing classification systems would be a valuable prognostic factor.

[Seasonal distribution of clinical case codes (DOC study)]. / Saisonale Verteilung klinischer Kennzahlen (DOC-Study).

OBJECTIVES: The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management. METHODS: From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA. RESULTS: The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1). CONCLUSION: The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

[Partial Fasciectomy and Options of Reconstruction Using Local Flaps in Cases of Dupuytren's Disease]. / Partielle Fasziektomie und lappenplastische Deckungsoptionen beim Morbus Dupuytren.

Aim: Partial fasciectomy in cases of grade III-IV Dupuytren's contracture and coverage of the defect with local flaps. Indication: Dupuytren's contracture is a progressive disease of the hand associated with the formation of fascial cords, which may result in flexion and adduction contractures of the fingers leading up to complete dysfunction of the hands. Method: If several fingers are affected, partial fasciectomy is the gold standard in the treatment of Dupuytren's contracture. Ideally, the fingers reach the neutral position after the fibres causing the contracture are resected and arthrolysis is performed as needed. The skin deficits resulting from restored extension have to be covered by the use of Z-plasties, local or pedicled flaps of the hand. Conclusion: The resection of contracting cords in advanced cases of Dupuytren's contracture leads to large soft tissue defects. The microsurgical preparation of nerve and vascular structures is often difficult because of the fascial cords surrounding them. Exact preoperative planning of the extent of resection, as well as reconstruction options are essential and determine how incisions are made. To prevent a relapse, it is essential to reverse skin fibre direction using flaps and to insert intact skin with preserved subdermal adipose tissue.

Thermomechanical method for cement extraction in revision arthroplasty.

BACKGROUND: In joint revision surgery, bone cement extraction remains a major challenge which even today has not seen a satisfactory solution yet. We studied in an experimental setting the impact of heat sources on the mechanical properties and microstructure of bone cement and determined the glass transition temperature (T G) of bone cement. As a result, it would be possible to establish a thermomechanical method which makes use of the structural and material-specific property changes inherent in bone cement at elevated temperatures. METHODS: Prepared samples of polymerized bone cement were thermoanalyzed with a Netzsch STA 409 C thermal analyzer. Samples weighing approx. 55 mg were heated to 390 °C at a rate of 5 K/min. Both simultaneous differential thermal analysis and thermogravimetry were employed. The thermomechanically induced changes in the microstructure of the material were analyzed with a computed tomography scanner specifically developed for materials testing (3D-µXCT). RESULTS: The bone cement changed from a firm elastic state over entropy-plastic (air atmosphere 60-155 °C) to a plastic viscosity state (air atmosphere >155 °C). Between 290 and 390 °C, the molten mass disintegrated (decomposition temperature). CONCLUSION: Our study was able to determine the glass transition temperature (T G) of bone cement which was about 60 and 65 °C under air and nitrogen, respectively. Heating the dry bone cement up to at least 65 °C would be more than halve the strength needed to detach it. Bone cement extraction would then be easy and swift.

[Injuries of the thoracolumbar spine in children]. / Verletzungen der kindlichen thorakolumbalen Wirbelsäule.

BACKGROUND: Injuries of the thoracolumbar spine in children are rare and challenging for the treating physician. Besides knowledge of fracture treatment, the anatomical particularities of the spine in children are of great importance. METHODS: The article gives an overview of the diagnosis and therapy with the most common classification of injuries of the thoracolumbar spine. RESULTS: Taking into account the children's age and the fracture morphology most cases can be treated conservatively, especially because the young spine has great potential for remodelling. The older the child becomes, the more smoothly the transition to adult treatment occurs; thus, unstable fractures should be treated with surgery. CONCLUSION: The difficult indication and the specific characteristics of surgery necessitate treatment in a spine centre with experience with surgery on children.

[Treatment of chronic slipped capital femoral epiphysis : Use of dynamic epiphyseal telescopic screws]. / Behandlung der chronischen Epiphyseolysis capitis femoris : Einsatz der dynamischen epiphysären Teleskopschraube.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a multifactorial structural loosening in the area through the epiphyseal plate between the epiphysis and metaphysis accompanied by slippage of the femoral head in the mid-dorsal-caudal direction without additional adequate trauma. In this retrospective study, all patients with chronic SCFE were assessed who had been treated by implanting a dynamic epiphyseal telescopic (DET) screw. METHODOLOGY: All patients who had been treated at our hospital with a DET screw implant between December 2006 and November 2014 following diagnosis of chronic SCFE were included in the study. Clinical and radiological follow-up was carried out after 6 weeks, 12 weeks, and then every 6 months. RESULTS: In all patients, the SCFE proved to have been firmly fixed and no further slippage was observed in any patient on the side affected. None of the prophylactically treated hips showed secondary SCFE either. In all patients, the DET screw led to partial remodeling of the slippage. The average slippage angle according to Southwick (epsilon angle) was about 30° preoperatively and about 19° in the most recent radiological follow-up. The alpha angle according to Nötzli was about 91° preoperatively and about 62° in the most recent radiological follow-up. Most of the patients showed none treatment-related dysfunction. CONCLUSION: Surgical treatment with a DET screw seems to be a safe procedure for both the affected hip and the hip to be treated prophylactically. This method is an adequate alternative to the widespread technique of pinning with K­wires.

[Pavlik harness for the treatment of congenital hip dysplasia types D III and IV]. / Pavlik-Bandage zur Therapie der kongenitalen Hüftdysplasie Typ D, III und IV.

BACKGROUND: Up to 4% of all neonates in Central Europe are born with congenital hip dysplasia (CHD), the most common congenital disease of the musculoskeletal system. However, in this retrospective analysis the outcomes of infants with CHD (type D, III or IV according to Graf) have been considered, with Pavlik therapy starting within the first 12 weeks of life. Connections between the start of therapy or the first finding according to Graf`s classification and the ultrasound result achieved, as well as the X-rays taken after 1 and 2 years, were evaluated. No repositioning under Pavlik treatment or side effects and their relevance have been evaluated, especially with regard to avascular necrosis (AVN) of the femoral head. MATERIALS AND METHODS: All infants treated using Pavlik treatment for CHD between 2010 and 2012 in our clinic were determined. A total of 62 patients with 79 pathological hips were included. The infants were classified into three groups to evaluate the influence of the start of therapy on the result: group I with the first investigation and start of treatment within the first 10 days of life, group II between the 11th day and the end of week 3, group III within preventive general examinations (U3) after the 4th week. Clinical examinations and the usual ultrasound scans were performed at an average of 1, 3, and 6 months. Furthermore, after 1 and 2 years clinical and radiological investigations were carried out, as well as further examinations depending on the findings. RESULTS: A failure of repositioning of the Pavlik treatment occurred in group I in 1 case (2.2%), in group II in 1 case (7.1%), and in group III in 2 cases (10%). This occurs in hips type D and type III in 1 case each (3.3%) and type IV in 2 cases (10.5%). Maturation disorders of the hips were found in 1 case (2.2%) in group I, 1 case (7.1%) in group II, and 3 cases (15%) in group III. Avascular necrosis of the femoral head was proven in 2 cases (4.4%) in group I, 0% in group II, and in 1 case (5%) in group III. All patients initially had femoral head necrosis of Graf type IV . All necrosis and maturation disorders were no longer visible on subsequent examinations after 2 years at the most. CONCLUSIONS: In summary, the study shows that even with a late treatment start (U3) good results could be achieved, but with a rising number of repositioning failures and femoral necroses. Ultrasound screening on U3 seems to be sufficient; however, for high-risk groups an additional screening in the first week of life should be performed, which does not replace a second evaluation at U3 if there are normal findings.

[Release of moveable segments after dorsal stabilization : Impact on affected discs]. / Freigabe von Bewegungssegmenten nach dorsaler Stabilisierung : Auswirkung auf die betroffenen Bandscheiben.

BACKGROUND: Bisegmental dorsal stabilization is a common treatment option for instable compression fractures of the thoracolumbar spine; however, it remains unknown to what extent bridging compromises intervertebral discs. OBJECTIVES: The purpose of this study was to determine the disc height and functional features in comparison to healthy intervertebral discs after removal of the dorsal fixator and particularly under consideration of the time span between dorsal stabilization and implant removal (IR). MATERIAL AND METHODS: The IR was performed in 19 patients after an average of 13 months (range 8-24 months) after dorsal stabilization of instable vertebral compression fractures of the thoracolumbar junction and lumbar spine. An additional ventral monosegmental spondylodesis was performed in 10 patients with incomplete burst fractures. Thus, a total of 28 intervertebral discs were temporarily bridged (bridged discs), with an adjacent endplate fracture in 10 (injured discs) and no adjacent bony lesion in 18 discs (healthy discs). The intervertebral discs superior and inferior to the instrumentation were selected as controls (control discs). Standardized conventional lateral radiographs were taken prior to and after IR as well as after 6 months. Additionally, standardized lateral radiographs in flexion and extension were taken. The intervertebral disc height (disc height) was determined by two independent board approved orthopedic observers by measuring the anterior, central and dorsal intervertebral disc spaces on all lateral radiographs as well as the intervertebral disc angles (disc angle) defined by the intervertebral upper and lower endplates in the flexion and extension views. Intradisc function (disc function) was defined as the difference between the disc angle in extension and flexion. The measurements were repeated after 12 months. Univariate analysis was performed using ANOVA and significance was set at p < 0.05. Interobserver and intraobserver comparisons of the disc heights and the disc angles were determined with intraclass correlation coefficients. RESULTS: No significant differences were seen in disc function and disc height between the controls and the bridged discs at all times of measurement; however, injured discs showed a significantly reduced disc height and disc angle in extension compared to healthy discs (p = 0.028 and p = 0.027, respectively). Additionally, patients with IR during the first 12 months had significantly reduced disc heights compared to those patients with delayed IR within the second postoperative year (p = 0.018). Interobserver and intraobserver agreement for disc function was 0.80 (95 % confidence interval CI: 0.68-0.88) and 0.85 (95 % CI 0.76-0.90), respectively. The interobserver and intraobserver correlations for disc height were 0.85 (95 % CI: 0.76-0.90) and 0.93 (95 % CI 0.88-0.95), respectively. CONCLUSION: Bridging of an intervertebral disc with IR within 24 months does not cause immediate loss of disc function or reduction of disc height; however, temporary bridging in combination with an adjacent endplate fracture causes significant reduction of disc height and loss of extension. Additionally, no beneficial effects could be seen by reducing the time span between stabilization and IR to below 12 months.

[Delayed indications for additive ventral treatment of thoracolumbar burst fractures : What correction loss is to be expected]. / Zeitverzögerte Indikationsstellung zur additiv ventralen Versorgung thorakolumbaler Berstungsfrakturen : Welcher Korrekturverlust ist zu erwarten.

INTRODUCTION: There is a general consensus that unstable vertebral body fractures of the thoracolumbar junction with a B type fracture or a high load shear index need to be surgically stabilized, primarily by a dorsal approach. The authors believe that there are indications for an additional ventral spondylodesis in cases of reduction loss or a relevant intervertebral disc lesion in magnetic resonance imaging (MRI) 6 weeks after dorsal stabilization. However, in cases of unstable vertebral fractures it remains unclear if a delayed anterior spondylodesis will lead to unacceptable loss of initial reduction. MATERIAL AND METHODS: A total of 59 patients were included in this study during 2013 and 2014. All patients suffered from a traumatic vertebral fracture of the thoracolumbar junction and were initially treated with a dorsal short segment stabilization. All vertebral body fractures had a load shear index of at least 5 or were B type fractures. An x-ray control was carried out after 2 and 6 weeks and MRI was additionally performed after 6 weeks. An additional ventral spondylodesis was recommended in patients showing a reduction loss of at least 5° and in patients with relevant intervertebral disc lesions. The extent of the reduction loss was analyzed. Other parameters of interest were the fracture level, fracture classification, patient age and surgical technique (e.g. implant, index screw, laminectomy and cement augmentation). RESULTS: The patient collective consisted of 23 women and 36 men (average age 51 years ± 17 years). The mean reduction loss was 5.1° (± 5.2°) after a mean follow-up of 60 days (± 56 days). The reduction loss was significantly higher when polyaxial implants were used compared to monoaxial dorsal fixators (10.8° versus 4.0°, p < 0.001). There was a significantly higher reduction loss in those patients who received a laminectomy (11.3° versus 4.3°, p = 0.01) but there were no significant differences if an index screw was used (4.5° versus 5.3°). Additionally, there was a significantly lower reduction in the subgroup of patients 60 years or older who were stabilized using cement-augmented screws (3.9° versus 11.3°, p = 0.02). The mean reduction loss was 2.8° (± 2.5°) in patients treated with a monoaxial implant, cement-augmented if 60 years or older and without laminectomy (n = 39). There was no significant correlation between reduction loss and the other parameters of interest, such as fracture morphology with classification according to the working group on questions of osteosynthesis (AO) and McCormack or fracture level. CONCLUSION: Delayed indications for an additional ventral spondylodesis in patients with unstable thoracolumbar vertebral fractures and initial dorsal stabilization will cause no relevant reduction loss if monoaxial implants are used and laminectomy can be avoided. Additionally, cement augmentation of the pedicle screws seems to be beneficial in patients 60 years of age or older.

[Glomuvenous malformations]. / Glomuvenöse Malformationen.

SYMPTOMS: A patient presented suffering from neural pain in the medial foot for a period of over 20 years. DIAGNOSIS: Diagnostic showed a widely spread soft-tissue tumor consisting of confluent glomuvenous malformations that was responsible for the immense pain syndrome.The solitary or multiform-appearing knots are not compressible and manifest as the characteristic syndromes of regional pain, sensitivity to coldness, or local pressure pain. Alternatively, the patient could also be completely symptom-free. TREATMENT: Because of the dimension of the tumor and the degree of suffering, a radical resection with simultaneous microsurgical reconstruction was carried out. Twelve weeks postoperatively, healing of the flap stabilized, the foot is fully weight-bearing, and the patient is pain-free.

[Hip fracture prosthetics in German trauma surgery. State of the art]. / Frakturhüftendoprothetik in der deutschen Unfallchirurgie. Eine Standortbestimmung.

BACKGROUND: To improve patient safety and quality in joint arthroplasty a certification of arthroplasty centers (EndoCert©) and a German arthroplasty register (EPRD) have been implemented. This should guarantee a long-term improvement in documentation of arthroplasty in the future. Although the stages of operations in elective and trauma-associated joint arthroplasty are comparable, the surgical preconditions are often quite different. As required by the German Society of Trauma Surgery (DGU) this study analyzed the current situation with respect to the proportion of fracture-associated joint arthroplasties among the total volume carried out in Germany. MATERIAL AND METHODS: A uniform internet-based questionnaire was sent to all listed trauma centers in Germany by the central office of the DGU. In addition any information regarding hip joint arthroplasty in 2011 was collected from the Federal Statistical Office of Germany. RESULTS: The questionnaire was returned by 324 (47 %) out of 690 of the trauma centers contacted. A total of 34,135 total hip arthroplasties (THA) and 26,753 total knee arthroplasties (TKA) were carried out in 2011 by these clinics. The absolute numbers for total endoprosthesis replacement cited by the trauma centers were 5718 THAs and 3829 TKAs. According to the data from the Federal Statistical Office of Germany 131,966 hip fractures were registered in 2011, including 69,582 femoral neck fractures (patient age >19 years) and 62,384 pertrochanteric fractures. From a total number of THAs of approximately 200,000 in Germany 47,695 (approximately 25 %) of these were associated with trauma. DISCUSSION: The data analyzed in this study and the results obtained from known literature sources demonstrate that THA is the most frequently performed procedure in trauma management of femoral neck fractures. Because of the ubiquitous and high incidence and the need for emergency treatment due to correlated risks and complications of delayed treatment, a high and standardized around the clock (24 h and 7 days a week) treatment option is mandatory. Long waiting times to treatment or transfer are inacceptable due to the increased mortality and complications.

[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]. / Interdisziplinäres Traumamanagement : Update 3 Jahre nach Implementierung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung.

BACKGROUND: The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM: This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS: In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS: The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION: The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

[Implementation of a department of plastic surgery in a university clinic for trauma surgery]. / Implementierung einer universitären Abteilung für Plastische Chirurgie in eine Klinik für Unfallchirurgie.

BACKGROUND: Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department. OBJECTIVES: This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery. MATERIALS AND METHODS: Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery. RESULTS: A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case. CONCLUSION: The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

[Multiplanar reconstruction with mobile 3D image intensifier. Surgical treatment of proximal humerus fractures]. / Multiplanare Rekonstruktion mit mobilem 3D-Bildwandler. Operative Versorgung proximaler Humerusfrakturen.

PURPOSE: The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures. MATERIALS AND METHODS: In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications. RESULTS: In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients. CONCLUSION: Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.

[Indications and limitations of minimally invasive stabilization of metastatic spinal disease]. / Indikation und Grenzen der minimal-invasiven Stabilisierung der metastatisch befallenen Wirbelsäule.

The number of patients with symptomatic metastases increases from year to year. Especially spinal metastases often lead to severe pain which often cannot be treated adequately by conservative treatment. Surgeons are confronted with the risk of instability, pathological fractures and neurological failure and the surgical treatment necessary in most cases is nowadays becoming an even greater challenge. The surgical procedure has changed considerably in recent years. The therapy is patient-individualized, the selection of implants and technology is adapted to the physical condition of the patient and the progression of the underlying disease. The main targets of the surgical treatment of spinal metastases have to be sufficient pain reduction with restoration of mobility as well as with the prevention of neurological deficits caused by progressive osteolysis. There are two minimally invasive stabilization procedures which can basically be applied. Under certain circumstances a single kyphoplasty/vertebroplasty procedure can be sufficient, in contrast to the possibility of short or long percutaneous posterior stabilization in combination with selective decompression of neural structures. These percutaneous surgical procedures currently have an important place in the surgical treatment of spinal metastases. The advantages are a less traumatic intervention for patients with advanced malignant diseases and poor general condition. Low intraoperative loss of blood means less intraoperative stress for the patient and minor surgical approaches lead to rapid mobilization and effective pain relief. As a result the hospital stay is shorter, adjuvant therapy can be started earlier and patients can be discharged sooner.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]. / Polytrauma mit Beckenfraktur und schwerem Thoraxtrauma: Hat der Zeitpunkt der definitiven Beckenfrakturstabilisierung Einfluss auf den klinischen Verlauf?

BACKGROUND: The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function. METHODS: A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay. RESULTS: The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01). CONCLUSIONS: In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

[Influence of the general data protection regulation on data quality in registry data collection : Selection bias due to data protection requirements and the impact on key indicators for measuring the quality of care in a level 1 trauma center]. / Einfluss der Datenschutz-Grundverordnung auf die Datenqualität bei der Erhebung von Registerdaten : Selektionsbias aufgrund datenschutzrechtlicher Anforderungen und dessen Auswirkungen auf Kennzahlen zur Messung der Versorgungsqualität am Beispiel eines überregionalen Traumazentrums.

BACKGROUND: Due to the new general data protection regulations (GDPR), the requirements for correct patient information on the documentation of pseudonymized data in a registry have increased enormously. In particular, written consent applies to the TraumaRegister DGU® as it is not always possible to get written permission from severely injured patients in acute situations. Therefore, the study aimed to investigate the influence of undocumented cases due to a lack of clarification on the standardized mortality rate (SMR). MATERIAL AND METHODS: In 2019, 274 patients meeting the criteria of the baseline dataset were retrospectively recorded. In the remaining 197 patients, the RISC II score could be calculated in all cases. In addition, due to state-specific law, all deceased patients were documented in our trauma center. RESULTS: In this study with 197 primary care patients (72% male), 147 (74,6%) were informed and gave permission or died and were subsequently documented. The predicted mortality, actual mortality and SMR were 18.5%, 19.0% and 1.03, respectively. For patients who were not informed (n = 50), the predicted mortality, actual mortality, and SMR were 7.0%, 0% and 0. When these cases are included, the SMR is significantly more favorable at 0.93. CONCLUSION: Due to the lack of written consent from surviving patients, only about 75% of all patients at Leipzig University Hospital could be documented for the TraumaRegister DGU®. On the other hand, since the local legal situation permits registry documentation of deceased patients, this has a detrimental effect on the standardized mortality rate (SMR), which is about 10% higher in our collective than it actually is.

An efficient and accurate prediction of the stability of percutaneous fixation of acetabular fractures with finite element simulation.

Posterior wall fracture is one of the most common fracture types of the acetabulum and a conventional approach is to perform open reduction and internal fixation with a plate and screws. Percutaneous screw fixations, on the other hand, have recently gained attention due to their benefits such as less exposure and minimization of blood loss. However their biomechanical stability, especially in terms interfragmentary movement, has not been investigated thoroughly. The aims of this study are twofold: (1) to measure the interfragmentary movements in the conventional open approach with plate fixations and the percutaneous screw fixations in the acetabular fractures and compare them; and (2) to develop and validate a fast and efficient way of predicting the interfragmentary movement in percutaneous fixation of posterior wall fractures of the acetabulum using a 3D finite element (FE) model of the pelvis. Our results indicate that in single fragment fractures of the posterior wall of the acetabulum, plate fixations give superior stability to screw fixations. However screw fixations also give reasonable stability as the average gap between fragment and the bone remained less than 1 mm when the maximum load was applied. Our finite element model predicted the stability of screw fixation with good accuracy. Moreover, when the screw positions were optimized, the stability predicted by our FE model was comparable to the stability obtained by plate fixations. Our study has shown that FE modeling can be useful in examining biomechanical stability of osteosynthesis and can potentially be used in surgical planning of osteosynthesis.