[Medial fracture of the femoral neck with enclosed Küntscher nail]. / Mediale Schenkelhalsfraktur bei einliegendem Küntscher-Nagel.

We report about an 81-year-old male patient who suffered a medial femoral neck fracture after a fall on the left leg. A total hip arthroplasty was planned based on the appropriate indications. The planning was complicated by the presence of an intramedullary Küntscher femoral nail inserted after a motorcycle incident approximately 60 years ago. After fenestration of the proximal lateral femur, the nail was sawn off and a cemented total hip arthroplasty and plate osteosynthesis were performed.

Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature.

Experience with infected shoulder arthroplasty is limited. Treatment options are either one- or two-stage reimplantation, débridement with retention of the prosthesis, resection arthroplasty or arthrodesis. We retrospectively analysed ten patients with an infected shoulder prosthesis and evaluated the diagnostic and therapeutic management as well as the clinical outcome, assessed by the Constant score, Neer's criteria and the mean abduction ability. We identified an infecting organism before surgery in nine patients. Four patients were treated by two-stage exchange reimplantation, five by resection arthroplasty and one underwent serial débridement combined with vacuum-irrigation therapy. Infection was eradicated in all patients of this series. The mean Constant score in resected patients was 32.7, in patients treated by stage exchange 40.1 (no difference) and we measured 90 points in the patient with retention of the implant. In patients treated by resection arthroplasty, merely the mean abduction yielded a better result (63 vs 31°) than in patients treated by two-stage exchange-with the pain level being identical in both groups. Treatment of infected shoulder implants in patients who often have to deal with concomitant diseases remains unsatisfactory. Two-stage exchange procedures yielded only slightly better functional results than resection arthroplasty, which should be considered in cases of elderly or chronically ill patients because it offers good pain relief. Serial débridement combined with irrigation therapy is a new method which offers good clinical results, however with an unknown risk of persisting infection. The authors recommend isolating the infecting organism prior to surgery to allow the administration of organism-specific antibiotics as early as possible during surgery in order to efficiently eradicate the infection.

Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome.

BACKGROUND: Optimal timing of stabilization for thoracic spine injuries in multiply injured patients is still controversial because additional lung injury occurs frequently. Early operation might benefit clinical course and outcome in these patients. METHODS: We analyzed the German National Trauma Database (n = 8,057) and compared clinical parameters and outcome of patients with severe thoracic spine injuries (Abbreviated Injury Scale >2; n = 298) who underwent spine stabilization within 72 hours posttrauma (group I) or later (group II). RESULTS: In all, 95% of all patients had additional severe thoracic injuries such as lung contusion. In spite of comparable demographic data, patients in group I had a significant shorter intensive care unit (ICU) stay (median [range]: group I, 8 [0-237] days; group II, 16 [2-91] days; p = 0.001), shorter dependence on mechanical ventilation (group I: 2 [0-48] days; group II: 5 [0-91] days; p = 0.02), and shorter hospital stay (group I: 22 [1-255] days; group II: 31 [2-274] days; p = 0.048). Expected mortality calculated by Trauma and Injury Severity Score was significantly reduced in group I (calculated: 16%; documented: 6%; p < 0.05) but not in group II (19% versus 17%; p = NS). CONCLUSIONS: Almost 10% of all patients in the German National Trauma Registry had severe spine injuries. Severe thoracic injuries occurred in 95% of these patients with thoracic spine trauma. We provide further evidence that early stabilization of thoracic spine injuries in trauma patients reduces overall hospital and ICU stay and improves outcome. Thus early stabilization of thoracic spine injuries within 3 days after trauma appears to be favorable.

Surgical treatment of spondylodiscitis.

BACKGROUND: Spondylodiscitis is a rare bacterial infection of the vertebra and intervertebral discs with an inflammatory, destructive course. METHODS: To gain further information about the management and clinical course of spondylodiscitis, we retrospectively reviewed 32 patients in 2002 who had surgical interventions between 1992 and 2001. RESULTS: The mean age of patients was 61 years (29-78 years). The mean hospital stay was 47 days (+/- 5.6 days; 3-121 days), including 28 days (+/- 8.1 days; 2-112 days) in the ICU. In-hospital mortality was 6%. The cervical spine was affected in 20% of patients (6/32), the thoracic spine in 25% (8/32), and the lumbosacral spine in 55% (18/32). Abscesses occurred in 63% of patients (20/32) and destruction of the vertebral body in 71% (23/32). Neurological deficits were present in 17 patients, which improved by surgical intervention in 82% of those affected. Thirty-one patients underwent ventral resection of the focus, spondylodesis with a bone graft or titanium cage, and ventral stabilization with a plate. In 19% of patients (6/32), additional dorsal bridging instrumentation was performed. Complete healing was obtained in 94% (30/32) patients. At follow-up, 50% of patients (16/32) had no complaints. CONCLUSIONS: Spondylodiscitis requires immediate debridement of the focus, with decompression and stabilization through a ventral approach, when conservative management fails. Otherwise, severe complications occur, such as sepsis, vertebral body destruction, abscess, or neurological deficits.