Balloon Guided Cement Augmentation of Iliosacral Screws in the Treatment of Insufficiency Fractures of the Sacrum - Description of a New Method and Preliminary Results.

PURPOSE OF THE STUDY Fragility fractures of the pelvic ring in the elderly population are a serious problem in orthopaedics. The treatment options range from conservative treatment to diverse operative options. We present a balloon guided new technique of implanting cement augmented screws aiming at improved implant anchorage and reduced cement leakage. MATERIAL AND METHODS We describe a new technique of balloon- guided cement augmented iliosacral screws. After the balloon has been insufflated and contrast medium has been instillated for leakage detection, iliosacral screws can safely be placed with a relevant cement depot. RESULTS All patients (n = 8) treated in this way were allowed to weight bear on both legs and mobilisation was tolerated the next day after surgery. In the post-operative controls including X-ray and CT scan we noticed no cement leakage. Pain level as measured by the visual analog scale was significantly reduced to pre- surgery (mean 7.6 pre-operatively, mean 2.5 postoperatively). In addition pain medication could be reduced gradually soon after surgery. CONCLUSIONS The described procedure to address fragility fractures of the pelvic ring is a safe and easy to handle method. There are three advantages: First the osteoporotic S1 vertebral body can by stabilised by the amount of cement; second the cement leakage can be prevented by the balloon-compaction of the cancellous bone and the possibility to control the created cavity with contrast medium; third the bone - screw interface is much stronger compared to other procedures and is biomechanically superior against vertical shear stress. In contrast to sacroplasty, the cement application is guided by the previous use of a balloon. Key words:pelvic ring, fragility fracture, osteoporosis, elderly.

Delayed Fracture Healing in Diabetics with Distal Radius Fractures.

PURPOSE OF THE STUDY Diabetics may have an increased fracture risk, depending on disease duration, quality of metabolic adjustment and extent of comorbidities, and on an increased tendency to fall. The aim of this retrospective one-centre study consisted in detecting differences in fracture healing between patients with and without diabetes mellitus. Data of patients with the most common fracture among older patients were analyzed. MATERIAL AND METHODS Classification of distal radius fractures was established according to the AO classification. Inital assessment and followup were made by conventional x-rays with radiological default settings. To evaluate fracture healing, formation of callus and sclerotic border, assessment of the fracture gap, and evidence of consolidation signs were used. RESULTS The authors demonstrated that fracture morphology does not influence fracture healing regarding time span, neither concerning consolidation signs nor in fracture gap behavior. However, tendency for bone remodeling is around 70% lower in investigated diabetics than in non-diabetics, while probability for a successful fracture consolidation is 60% lower. CONCLUSIONS To corroborate the authors hypothesis of delayed fracture healing in patients with diabetes mellitus, prospective studies incorporating influencing factors like duration of metabolic disease, quality of diabetes control, medical diabetes treatment, comorbidities and secondary diseaseas, like chronic nephropathy and osteoporosis, have to be carried out. Key words: diabetes, delayed fracture healing, distal radius fractures, callus formation, blood glucose level, osteoblasts.

[Intramedullary nailing in diaphyseal clavicle fractures using minimally invasive percutaneous reduction]. / Die intramedulläre Nagelung der diaphysären Klavikulafraktur in minimal-invasiver Repositionstechnik.

OBJECTIVE: Closed reduction and intramedullary nailing is common in diaphyseal clavicle fractures. The aim of this report is to demonstrate a surgical method with minimally invasive percutaneous reduction in cases where closed reduction fails. The procedure is associated with good cosmetic results. INDICATIONS: Percutaneous reduction using two reduction forceps enables intramedullary nailing without an open procedure. CONTRAINDICATIONS: Open, multifragmented or non-dislocated fractures, oblique fractures due to postoperative dislocation or shortening risk, fracture having potential to become compound fractures, neurovascular complications, pseudoarthroses. SURGICAL TECHNIQUE: The patient is in beach-chair position. After an incision, the nail is entered from medial, two reduction forceps are mounted percutaneously at the lateral and medial fragment. After reduction the nail is pushed forward into the lateral fragment. Thereby, the fracture hematoma is not disturbed for the most part. POSTOPERATIVE MANAGEMENT: Early functional rehabilitation with maximal abduction and anteversion of 90° for 6 weeks. RESULTS: Anatomic reduction can be achieved with mild cosmetic impairment.

[Effects of a Pelvic Ring Injury on Earning Capacity]. / Auswirkungen einer Beckenringverletzung auf die Erwerbsfähigkeit.

Introduction: Pelvic ring injuries occur in 3-8 % of patients with fractures. They are rare, with an annual incidence of only 19-37 per 100,000 people annually. There have been publications on the generation of these injuries, as well as their diagnosis and treatment concepts, but there is little information on how these injuries impact the ability to work. Patients: The study covered all hospitalised patients between January 2003 and December 2011 with a pelvic ring injury, who had already been included in the data collection of the AG Becken III and who had had a work-related accident. Data acquisition was completed 12 months after the first cover letter. Data collection was supported by the statutory accident insurance institutions. Responses to the following questions were collected: Results: During the time period, 835 patients were admitted to our hospital with an injury to the pelvic ring or acetabulum. 632 patients (75.7 %) had a pelvic ring injury. 95 patients had a work-related accident, for which 67 records (70.5 %) could be evaluated. Seven patients were in retirement at the time. The average age was 48 years. In the patient population, we identified 9 type A, 16 type B and 42 type C injuries. The mean duration of incapacity for work was 9.5 months. 36 patients were able to return to their old work again, 22 patients did not. For two of these patients, this was due to cerebral haemorrhage. The mean reduction in earning capacity at the 1st and 2nd pension reports was 28 %. The individual rating of the degree of trauma lay between 0 % (B2.1) to 60 % (C1.2). Subgroup analysis was not performed, due to the small number of patients and their lack of homogeneity. As only hospitalised patients were included in the study group, there was excessive accumulation of pelvic B and C fractures in the patient group. The study shows that pelvic ring injuries can have a significant impact on the duration of the incapacity and the ability to work.

[Malnutrition in Elderly Trauma Patients - Comparison of Two Assessment Tools]. / Die Erfassung des Ernährungsstatus alterstraumatologischer Patienten ­ ein Vergleich zweier etablierter Screeningmethoden.

Background: The prevalence of malnutrition in hospitalised patients is reported to be between 16 and 55 % across disciplines. Within hospital care, screening for malnutrition is required. However, in orthopaedics and trauma surgery, there is still no generally accepted recommendation for the methods for such a data survey. In the present study, the following aspects are to be investigated with the help of two established scores: (1) the prevalence of malnutrition in the patient population of geriatric trauma care, and (2) the correlation between methods of data survey. Material and Methods: Between June 2014 and June 2015, a consecutive series of hospitalised trauma patients were studied prospectively with two validated screening instruments to record nutritional status. The study was carried out at a municipal trauma surgery hospital, which is a first level interregional trauma centre as well as a university hospital. The Nutritional Risk Screening (NRS) and the Mini Nutritional Assessment (MNA Short and Long Form) were used. All patients were divided into three age groups: < 65 years, 65-80 years, and > 80 years. The prevalence of malnutrition in geriatric trauma patients and the correlation between the screening instruments were determined. For a better comparison, prescreening and main assessment were applied to all patients. For statistical evaluation, both quantitative and semi-quantitative parameters were used. Furthermore, the Kolmogorov-Smirnov test, Spearman's correlation analysis and the chi-square test were applied. These tests were two-sided and had a level of significance of 5 %. The present study was partially funded by the Oskar-Helene-Heim Foundation. Results: 521 patients (43.8 % women, 56.2 % men), with a mean age of 53.96 ± 18.13 years, were statistically evaluated within the present study. Depending on the method of the data survey, malnutrition (NRS≥3) in geriatric trauma patients varied from 31.3 % (65-80 years) to 60 % (> 80 years). With MNA, 28.8 and 54.3 % of patients were at risk of malnutrition (MNA 17-23.5), while the fractions of patients already suffering from malnutrition (MNA < 17) were 5.4 and 8.6 %, respectively. The correlation between the NRS and MNA total scores increases with the age of the patients. The correlation coefficient for patients under 65 years is r = - 0.380, while among patients aged between 65 and 80, it is r = - 0.481, and for patients over 80 years, there is a medium to strong correlation of r = - 0.638 (each with a Spearman correlation of p < 0.001). For the total population as well as the different age groups, statistically significant correlations were recorded between the categorised scores (chi-square test for linear trend, p < 0.001). Summary: The present study demonstrates high prevalence of malnutrition among the geriatric trauma patients. Because of its easy and rapid application, the NRS has an advantage in clinical use. It was shown that the two methods of data survey were highly correlated.

[Retrospective Analysis of Diabetics with Regard to Treatment Duration and Costs]. / Retrospektive Analyse von Diabetikern im Hinblick auf Behandlungsdauer und Behandlungskosten in einem überregionalen Traumazentrum.

Background: The increasing incidence of diabetes mellitus is also reflected in the patient population of a trauma and orthopaedic centre. Diabetics also exhibit more comorbidities than non-diabetics. In addition to surgical problems in these patients, hospitalisation is often accompanied by complications, which can prolong treatment and increase costs. The aim of this retrospective study is to analyse hospitalisation of diabetics compared to non-diabetics, as well as differences in treatment costs, depending on associated age and comorbidities. Patients/Material and Methods: 17,185 patients were treated at a transregional trauma and orthopaedic centre and were included in this retrospective analysis between 2012 and 2015. Comorbidities and hospitalisation of diabetics and non-diabetics were recorded. All costs charged by DRG were evaluated to calculate the cost per day and per patient, on the basis of the specific case rate. In this calculation, patient-related case rates were divided by the average residence time and the means of the calculated daily rates were calculated. Inclusion criteria were treatment within the various departments and a minimum hospitalisation of one day. Statistical analysis was performed with the SPSS program (version 22.0, SPSS Inc., Chicago, USA). Results: In comparison to non-diabetics (ND), diabetics (D) exhibited significantly more comorbidities, including: obesity, arterial hypertension, coronary heart disease, myocardial infarction (in the history), peripheral arterial disease, chronic kidney disease and hyperlipidaemia. Pneumonia in hospital was considerably commoner in diabetics (2.45 % [D] vs. 1.02 % [ND], p < 0.001). Time in hospital was significantly longer in diabetics (endoprosthetics 13.52 days [D] vs. 12.54 days [ND], p < 0.001; septic surgery 18.62 days [D] vs. 16.31 days [ND], p = 0.007; traumatology 9.82 days [D] vs. 7.07 days [ND], p < 0.001). For patients aged under 60 years, time in hospital was significantly longer for diabetics than for non-diabetics (9.98 days [D] vs. 6.43 days [ND] p < 0.001). Because of the longer time in hospital, treatment costs were higher by € 1,932,929.42 during the investigated time period. Conclusion: Because of their comorbidities, diabetics need to be categorised at an early stage as high-risk patients in traumatological and orthopaedic departments. Hospitalisation and the associated increased treatment costs, as well as postoperative complications, could be minimised in patients with diabetes by implementing an interdisciplinary treatment concept.

Acute MCL and ACL injuries: first results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction.

BACKGROUND: There is an on-going discussion whether to operatively treat combined grade II and III lesions of the medial collateral ligament (MCL) with anterior cruciate ligament (ACL) in the acute phase rather than conservative treatment of the MCL lesion with a delayed unitary ACL replacement. Another issue is the question how to technically address these MCL lesions. The aim of this study was, therefore, to analyze the results of simultaneous ACL replacement (hamstrings) in a single-bundle technique with a simultaneous MCL ligament bracing procedure. METHODS: In this prospective non-randomized trial,, 16 patients were included with grade II and III lesions of the MCL. Surgical treatment was performed within 14 days (mean 10.4 days, SD ±2.3 days) by one single expert orthopedic surgeon using the semitendinosus tendon and Rigidfix® system for femoral and tibial fixation and 3.5 mm screws with one 1.3 mm PDS Cord for minimal-invasive MCL ligament bracing with screw fixation. Knee stability was measured with the Rolimeter® and KT-1000®. MCL stability was assessed in clinically and radiographically with valgus stress projections. RESULTS: The mean patient age was 36.4 with six female and ten male patients. There were no surgical complications such as infections or healing disturbances. Mean operation time was 64 ± 6 min. The arthrofibrosis rate was 0 %. Medial knee stability was normal in full extension for all cases with no intra-individual side-to-side difference. Radiological assessed MCL stability revealed Δ values with a mean of 1.1 ± 1.3 mm compared to the contra-lateral side. The Lachman Test revealed a side-to-side difference of 1.6 mm with the KT-1000® and 2.6 ± 0.9 mm when measured with the Rolimeter®. Subjective clinical assessment revealed good results with a mean Lysholm Score of 89.1 points. CONCLUSION: Acute ACL replacement and MCL ligament bracing with this novel technique revealed in this study good clinical results and objective restored knee stability without cases of knee stiffness or arthrofibrosis. The remarkable shortcoming is the small cohort number making further studies necessary.

[Surgical Treatment of Acetabulum Fractures with a New Acetabulum Butterfly Plate]. / Operative Versorgung von Azetabulumfrakturen mit der neuen Azetabulumflügelplatte.

Introduction: There have been significant increases in the number of acetabular fractures in elderly patients with primarily ventral pathology and medial protrusion of the femoral head. We have developed the "acetabulum wing plate", which is designed to facilitate repositioning, with its anatomically precontoured structure, and which offers full support of the quadrilateral surface, thus counteracting the force of the femoral head pushing inwards. Conventional plate osteosynthesis only provides insufficient support to the medial surface. After a successful series of biomechanical tests, we now report a clinical case series. Material and Methods: Between April 2012 and August 2013, a total of twelve patients underwent plate osteosynthesis using the precontoured plate described above. The patients (ten male, two female) were aged between 45 and 87 years, the average age being 62.5 years. We were able to perform all osteosynthesis with the modified Stoppa approach, in combination with the first window of the ilioinguinal approach (according to Letournel). In most patients, the plate was applied without complications, In some patients, it even supported repositioning. In six patients, the fractures were of the anterior collum and six fractures were fractures of both colla. The mean time span of follow-up was 13.1 months, the minimum being 4.5 and the maximum 23 months. Results: In most patients, the intra- and postoperative computed tomographic scans showed anatomically correct placement of the plate, thus confirming the correct repositioning of the bone. Routine follow-ups are part of the hospital's postsurgical care system for acetabular fractures; these revealed no secondary dislocation or loosening of the plate. The radiological examination showed consolidation of the fractures after a mean period of twelve weeks. A full year after the initial procedure, no implant-specific complications were observed. Revision surgery was necessary in one patient due to bleeding five days after surgery. In another patient, necrosis of the femoral head necessitated total hip replacement ten weeks after the first surgical intervention. In summary, the concept of the plate proved to be successful in its first case series. Summary: In spite of increasing surgical expertise and the refinements of standard approaches, there is a recognisable shift in acetabular fractures from mainly posterior fracture patterns to fractures of the anterior column. The new acetabulum wing plate takes these factors into account and is an implant designed to address the anterior aspects of the acetabulum. The outcome of the first application is promising and the acetabulum wing plate produces satisfactory results in our patients.

[The Pitch Angle of a Locked Plate Osteosynthesis Construct]. / Der Nickwinkel einer winkelstabilen Plattenosteosynthese.

UNLABELLED: The aim of the present study is to describe the biomechanical properties of the fracture motion of a locked plate construct. METHOD: The three dimensional fracture motion of a conventional and of a dynamic locked plate construct was observed using an optical measurement system. RESULTS: Fracture motion was described in terms of delta z (mean fracture motion in direction of force application) and the pitch angle (angle between the upper and lower cylinders of osteosynthesis). It could be shown that the fracture motion of a conventional locked plate construct is only possible through the bending of the plate. The ratio of pitch angle and mean fracture motion (delta z) is a measure of the necessary degrees of bending per millimeter fracture motion. At the same pitch angle, dynamic osteosynthesis gave greater fracture motion. CONCLUSION: With the parameters of pitch angle and mean fracture motion (delta z), it is possible to describe the whole fracture motion of locked plate fixation. Furthermore, it is possible to compare different locked plate constructs or fracture motions.

New Method for Monitoring Partial Weight Bearing (PWB) of Outpatients with an Independent Insole Sensor System.

UNLABELLED: PURPOSE OF THE STUDY Partial weight bearing (PWB) is commonly prescribed post operatively following lower limb fractures and compliance with the weight bearing protocol is an essential element of the rehabilitation. So far it is unknown to what extent patients do comply with PWB during the healing process as instructed by the surgeon. Our aim is to assess a new device for real-time feedback and long-term measurement of PWB of outpatients. The device offers the possibility to monitor the outpatient's activity. The applicability, reliability and validity of the new device should be evaluated. MATERIAL AND METHODS 20 young, healthy subjects complete a course of 500 m that contained several stairs, with a PWB of 15 kg. During the entire test, the axial load, the acceleration and the temperature were measured with a novel insole sensor system. The results were compared with reference measurements performed with a force plate. RESULTS Altogether, the 20 subjects performed 11,106 steps during the completion of the walking circuit. In 23.6% of the steps, the subjects applied a PWB of 10 to 20 kg. In 5.5% of all steps, PWB was superior to 60 kg. The mean bias of the insole was 11,58 N. Limits of agreement were +/- 125 N and the interclass correlation coefficient was r = 0.945. CONCLUSIONS The presented sensor sole might be a useful tool to obtain more precise insight of outpatients' activity and load to the injured limb during the healing process. Furthermore, these results demonstrate that even young and healthy subjects are not able to keep the prescribed PWB. This raises the question, if patients who have been recently operated are able to follow the instructions concerning the PWB. KEY WORDS: partial weight bearing (PWB), insole sensor system, sensor sole, monitoring, outpatients.

[Pearls and pitfalls for the treatment of tibial head fractures]. / Outcome und Komplikationen nach proximalen Tibiafrakturen.

BACKGROUND: Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. In the last decade we have had a tremendous development, might it be the angular stable anatomical plates as well as new approaches to the proximal tibia. Nevertheless in the recent literature there are still many complications reported. Not only for sports professionals, recreational athletes or heavy load workers tibial plateau fractures affect leisure, all day activity and professional life. This article reports the treatment algorithm showing different cases, outlines the pitfalls and explains treatment strategies with a detailed x-ray follow-up. CONCLUSION: After a tibial plateau fracture patients are affected in their sporting activity due to an impaired knee function. Despite a long rehabilitation time and programs, physical activity changes to lower impact sports. Among the usual perioperative complications there are the specific complications of postoperative malalignment, implant infections, osteitis of the tibial head, compartment syndrome, secondary loss of reduction, avascular tibial head necrosis, secondary varus or valgus deformity, post-traumatic arthrosis and lesions of the peroneal nerve. In the literature in up to 43% of the cases complications have been noted. Despite surgery the majority of patients cannot return to their previous level of activity. However, overall about 70% of the patients return to sports after a tibial plateau fracture. For a beneficial outcome a detailed fracture analysis with CT scan and precise planning of the surgical strategies and approaches is mandatory.

Delayed Fracture Healing in Diabetics with Distal Radius Fractures.

PURPOSE OF THE STUDY: Diabetics may have an increased fracture risk, depending on disease duration, quality of metabolic adjustment and extent of comorbidities, and on an increased tendency to fall. The aim of this retrospective one-centre study consisted in detecting differences in fracture healing between patients with and without diabetes mellitus. Data of patients with the most common fracture among older patients were analyzed. MATERIAL AND METHODS: Classification of distal radius fractures was established according to the AO classification. Inital assessment and follow-up were made by conventional X-rays with radiological default settings. To evaluate fracture healing, formation of callus and sclerotic border, assessment of the fracture gap, and evidence of consolidation signs were used. RESULTS: The authors demonstrated that fracture morphology does not influence fracture healing regarding time span, neither concerning consolidation signs nor in fracture gap behaviour. However, tendency for bone remodeling is around 70% lower in investigated diabetics than in non-diabetics, while probability for a successful fracture consolidation is 60% lower. CONCLUSIONS: To corroborate the authors hypothesis of delayed fracture healing in patients with diabetes mellitus, prospective studies incorporating influencing factors like duration of metabolic disease, quality of diabetes control, medical diabetes treatment, comorbidities and secondary diseases, like chronic nephropathy and osteoporosis, have to be carried out.

[Balloon osteoplasty as reduction technique in the treatment of tibial head fractures]. / Ballonaugmentation als Repositionstechnik bei der Versorgung von Tibiakopffrakturen.

BACKGROUND: Tibial plateau fractures requiring surgery are severe injuries of the lower extremities. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment.  AIM: This article reports on an innovative treatment concept to address split depression fractures (Schatzker type II) and depression fractures (Schatzker type III) of the tibial head using the balloon osteoplasty technique for fracture reduction. METHODS: Using the balloon technique achieves a precise and safe fracture reduction. This internal osteoplasty combines a minimal invasive percutaneous approach with a gently rise of the depressed area and the associated protection of the stratum regenerativum below the articular cartilage surface. This article lights up the surgical procedure using the balloon technique in tibia depression fractures. CONCLUSION: Using the balloon technique a precise and safe fracture reduction can be achieved. This internal osteoplasty combines a minimally invasive percutaneous approach with a gentle raising of the depressed area and the associated protection of the regenerative layer below the articular cartilage surface. Fracture reduction by use of a tamper results in high peak forces over small areas, whereas by using the balloon the forces are distributed over a larger area causing less secondary stress to the cartilage tissue. This less invasive approach might help to achieve a better long-term outcome with decreased secondary osteoarthritis due to the precise and chondroprotective reduction technique.

[Duration of inability for work and return to physical work after arthroscopic and open labrum refixation]. / Arbeitsunfähigkeitsdauer und berufliche Rehabilitation nach arthroskopischer und offener Labrumrefixation.

BACKGROUND AND INTRODUCTION: The duration of inability for work according to work load and the rate of successful return to work after open and arthroscopic Bankart repair (BR) due to anterior shoulder dislocation has not yet been examined with regard to validated work strain by the REFA classification. Thus, the objective of this study was to determine the duration of inability to work according to work load (REFA criteria) after open and arthroscopic BR as well as the rate of successful return to the original occupation. PATIENTS AND METHODS: A total of 93 patients (20 f/73 m) with isolated anterior arthroscopic or open BR due to posttraumatic anterior shoulder instability with no items of hyperlaxity were included in this study. There were 72 patients with arthroscopic and 21 patients with open BR. The postoperative aftercare was standardised and identical. The clinical assessment included the Constant and Murley scores, UCLA shoulder and the Rowe score for shoulder instability. Average follow-up time was 48.3 months (SD ± 23.6 months) with a mean age of 37.1 years (SD ± 14.4 years). The work load was classified according to the German REFA Association. Operation time, duration of inability for work and clinical outcome were analysed and compared according to the operation technique. RESULTS: Mean incapacity for work in the group of arthroscopic BR was 3.3 months (SD ± 2.5) and 2.7 months (SD + 2.3 months; p = 0.37) in the group of open BR demonstrating no statistical difference. Both mean time for surgery (p = 0.0003) and in-hospital stay (p = 0.0083) showed significant differences when comparing patients with low work load (REFA 0-1) and higher work load (REFA 2-4) irrespective of the surgical approach. Overall analysis showed an average time of 2.3 months (SD ± 1.5) to return to work for patients with low work load (REFA 0-1) and 4.2 months (SD ± 2.9) for individuals with high work load (REFA 2-4) revealing significant differences (p = 0.0006). The mean inability for work after arthroscopic BR for patients with REFA 0-1 was 2.4 months (SD ± 1.6) and 4.2 months (± 2,9; p = 0.0053) for patients with REFA 2-4 revealing a significant difference. The mean inability for work after open BR for individuals with REFA 0-1 was 1.8 months (± 1.0) and 4.3 months (± 3.3; p = 0.1196) for individuals with REFA 2-4. Two out of 35 patients (5.7 %) with low work load (REFA 0-1) and 10 out of 37 patients (27 %) with high work load (REFA 2-4) could not return to their original occupation after arthroscopic BR. One out of 14 patients (7.1 %) with low work load (REFA 0-1) and 4 out of 7 patients (57.1 %) with high work load (REFA 2-4) could not return to their original occupation after open BR. Comparing these results between arthroscopic and open BR, no significant differences were obtained (chi-square, Pearson). Recurrent shoulder dislocation occurred in the arthroscopic group in 14.3 % (REFA 0-1) and 8.1 % (REFA 2-4) compared to the open procedure group in 0 % (REFA 0-1) and 14 % (REFA 2-4) revealing no statistically significant differences. CONCLUSION: This study showed equivalent results after performing open and arthroscopic BR with significantly shorter operation times and in-hospital stays after arthroscopic BR. Higher work loads caused longer inability for work irrespective of the chosen surgical technique. On the basis of these results we recommend arthroscopic BR as the standard primary procedure, while the overall rate of return to work without restrictions of 81.7 % has to be improved in the future.

Gene expression changes in cancellous bone of type 2 diabetics: a biomolecular basis for diabetic bone disease.

PURPOSE: Diabetes mellitus type 2 (2DM) is associated with altered bone quality. In order to analyze associated changes on a molecular level, we investigated the gene expression of key factors of osteoblast metabolism in type 2 diabetics. METHODS: Total mRNA and protein of bone samples from 2DM patients and non-diabetic patients were isolated, and subsequently, reverse transcription polymerase chain reaction (RT-PCR) or Western blot was performed. Furthermore, pro- and anti-inflammatory serum cytokine levels were determined using a cytokine array. RESULTS: Expression of runt-related transcription factor 2 (RUNX2) was increased by 53 %. Expression of the bone sialoproteins, secreted phosphoprotein 1 (SPP1; osteopontin), and integrin-binding sialoprotein (IBSP), was elevated by more than 50 %, and activating transcription factor 4 (ATF4) expression was 13 % lower in the investigated diabetes group compared to the control group. Similarly, the expression of versican (VCAN) and decorin (DCN) was upregulated twofold in the diabetic group. At the same time, 2DM patients and controls show alterations in pro- and anti-inflammatory cytokine levels in the serum. CONCLUSIONS: This study identifies considerable changes in the expression of transcription factors and extracellular matrix (ECM) components of bone in 2DM patients. Furthermore, the analysis of key differentiation factors of osteoblasts revealed significant alterations in gene expression of these factors, which may contribute to the dysregulation of energy metabolism in 2DM.

[Use of Bone Morphogenetic Proteins (BMPs) for the Treatment of Pseudarthroses - Efficiency and Therapy Failure]. / Einsatz der Bone morphogenetic Proteins (BMPs) zur Behandlung von Pseudarthrosen - Effizienz und Therapieversagen.

In the therapy for pseudarthroses of the proximal tibia, the human recombinant bone morphogenetic proteins (BMP-2 and BMP-7) have been used for several years. Despite their limited and specified use as local mediators of bone healing, no conclusions regarding the therapeutic success can be made beforehand. The regulatory mechanisms have turned out to be much more complex and patient-specific than had been assumed before. To help understand the cell biological processes (signalling) and the current possibilities of predicting a successful use of BMP, this article summarises the relevant findings.

[Patella dislocation: an algorithm for diagnostic and treatment considering the rotation]. / Patellaluxation: Diagnostik- und Behandlungsalgorithmus unter Berücksichtigung der Torsion.

BACKGROUND: Patella dislocation and re-dislocation are common diseases. Although patella dislocation is frequent, it always poses a challenge concerning diagnostics and therapy. Mixed forms of pathological disorder in the patellofemoral joint make the analysis of the malalignment and the choice of the correct treatment more difficult. MATERIAL AND METHODS: By reviewing the available literature of the last few years and taking into account considerations concerning the malalignment, an overview of the necessary diagnostics can be given. Radiographs and MRI are essential parts of the diagnostics after a traumatic patella dislocation. After re-dislocation, more extensive diagnostics are required to determine all pathological aspects of the malalignment. In this situation, a CT scan for measuring the torsion of the femur and the tibia as well as the TT-TG distance (tibial tubercle - trochlea groove), and the full weight-bearing long leg standing radiograph are part of the fundamental diagnostics. RESULTS: The results that are presented in the literature provide some indications for a successful treatment. In consideration of the thorough analysis of the malalignment, the torsional correction of the femur and/or the tibia gains a new importance in the patellofemoral joint. The presented algorithm for diagnostics and treatment should make the decision for the best treatment easier. CONCLUSION: The proposed algorithm for diagnostics and treatment is only partially founded on evidence-based results. Moreover, it takes into consideration reflections concerning the biomechanics of the patellofemoral joint and the realignment of this joint.

[Dynamic locking screw 5.0--first clinical experience]. / Dynamic Locking Screw 5.0--erste klinische Anwendung.

The principle of "biological" plate osteosynthesis describes the optimum interaction between mechanics and biology with the aim to achieve an uneventful consolidation of the fracture by secondary bone healing. The preservation of soft tissue and blood supply are central points in this context. Empirical values show that a too rigid internal fixation can suppress callus formation. The dynamic locking screw - DLS - allows for a decrease of the rigidity of a plate osteosynthesis. The fracture motion is positively affected. The advantages of the angular stability are not affected. In the Trauma Centre Tuebingen 35 patients were treated with the DLS5.0 in the time between November 2011 and October 2012. These first clinical cases with the use of the large fragment DLS showed good results. Handling the DLS5.0 is comparable to the conventional locking screw - LS5.0. Complications were not caused by the DLS and their application.

[Fractures of the lower extremity in the emergency room. Analysis of a new immobilization and x-ray splint]. / Frakturen der unteren Extremität in der Notaufnahme. Anwendungsanalyse einer Lagerungs- und Röntgenspezialschiene.

BACKGROUND: Fractures of the lower extremity are a common reason for presentation to an emergency room. The aim of this study was to evaluate a new immobilization and x-ray splint (Andante®, ForMed) in the emergency room. METHODS: From April 2010 to August 2010 all patients presenting with a fracture of the lower extremity were included in the study. Pain perception (visual analog scale; VAS) was measured before and after splint application. The handling of the splint during radiography was assessed and the quality of the diagnostic x-ray was evaluated. RESULTS: The study comprised 61 patients. Subjective pain perception was reduced significantly (3.96±1.9 vs. 6.38±2.2; p<0.001). The handling of the splint was graded at 1.73±0.96 (1, very good; 5, poor). There was no difference in the diagnostic quality of the x-rays between the Andante® and the control group; however, significantly poorer results were found for x-rays of ankle fractures (p<0.038). CONCLUSION: The Andante® splint is a useful tool in the emergency room that combines simple handling and pain relief due to immobilization. However, the quality of the diagnostic x-rays was not better compared with the control group.

[Insufficiency fractures of the pelvic ring]. / Insuffizienzfrakturen des Beckenrings.

The demographic changes in society automatically lead to an increase in specific diseases and injuries in the older generation. Therefore, the proportion of osteoporotic and fatigue fractures increases in total and also the absolute number of insufficiency fractures of the pelvic ring. In younger people pelvic ring fractures are mostly due high speed trauma. In the elderly this often occurs by low energy trauma or even with no trauma which is then designated as insufficiency fracture. The problematic of such fractures is insufficiently covered in the conventional classification. Conventional radiological diagnostics must often be supplemented by slice imaging procedures. The therapy forms must be more closely adapted to the general condition and physical health of the patient than by classical fractures and the substantially reduced sustainability of osteosynthesis in altered bones must be taken into consideration.