[Fractures of the thoracic and lumbar spine in children and adolescents]. / Frakturen der Brust- und Lendenwirbelsäule im Wachstumsalter.

BACKGROUND: Only 1.5-2% of all fractures in children and adolescents are fractures of the thoracic and lumbar spine. Treatment is most often conservative. This study compares the own experience with the recent literature. MATERIAL AND METHODS: Over a 48 month period all patients with fractures of the thoracic and lumbar spine, younger than 16 years were included prospectively. Of the patients 67 underwent follow-up investigations after 3-36 months. RESULTS: The average age of the patients was 11.9 years. Sports (53%) and traffic (28%) accidents were most frequent. Fractures most often appeared in the mid-thoracic (47%) and thoracolumbar spine (41%). Operative treatment was performed in 9 cases (10.4%). Secondary loss of alignment was not observed neither after conservative nor operative treatment. Neurological deficits (n=2) did not completely improve. CONCLUSIONS: Most fractures of the thoracic and lumbar spine heal fast and without any sequelae. Unstable fractures of type B and C (exclusively occurring as a result of traffic accidents) need operative stabilization as in adults.

School-related injuries: a retrospective 5-year evaluation.

PURPOSE: Children and adolescents spend up to 50% of their time at school. The purpose of this study was to assess injury patterns of school accidents (along with their treatment) in the trauma center of a German university hospital, and to compare these data to those in the literature. METHODS: All school accidents treated in a level 1 pediatric trauma center over a five-year period were statistically analyzed in a retrospective manner by chart review. RESULTS: There were 1,399 school accidents that were treated in our department. Average age of the injured person was 11.8 years, with a boy:girl ratio of 3:2. Almost 40% of the injuries occurred during school sports. The most frequently injured region was the upper extremity, including the hand (36.8%). Distortion and contusion was the most frequent diagnosis among all injuries. Sixteen percent of the cases had to be treated surgically and/or under general anesthesia, and 16% of the patients had to be admitted to the hospital. CONCLUSION: It can be concluded that special attention must be paid during school sporting activities and breaks because they account for most of the accidents. Traffic education may reduce severe injuries. Specific knowledge of the growing long bones of the upper extremity and the hand is important for the diagnosis and treatment of school accidents.

[Traumatic rupture of the brachial artery due to a closed elbow joint dislocation]. / Traumatische Ruptur der A. brachialis durch eine geschlossene Ellenbogengelenkluxation.

A rare complication of a brachial artery rupture as a result of a closed elbow dislocation is presented. If vascular damage is suspected angiography must be carried out and if signs of ischemia are present on the affected arm an immediate operational intervention with vascular reconstruction is necessary. The problems associated with this type of injury are discussed on the basis of the current literature.

[Biochemical bone resorption markers during the healing of osteoporotic fractures]. / Biochemische Knochenresorptionsmarker in der Heilungsphase osteoporotischer Frakturen.

BACKGROUND: This study investigated the progression and clinical relevance of biochemical resorption marker values during fracture healing in osteoporosis. PATIENTS AND METHODS: In 44 patients with distal radius fractures and 29 patients without fractures, the blood and urine concentrations of pyridinoline (PYD), deoxypyridinoline (DPD), N-telopeptides (NTx), and bone sialoprotein (BSP) were recorded on the day of trauma as well as during further progression. All postmenopausal patients underwent bone density measurement. Accordingly, patients were divided into premenopausal, postmenopausal osteoporotic, and postmenopausal nonosteoporotic groups. RESULTS: Between the groups, PYD, DPD, and NTx showed significant differences in their initial values. However, their further relative progression was primarily affected by the chosen therapy. CONCLUSION: Bone resorption markers can diagnostically point to osteoporosis and are significant parameters in fracture healing.

[Autologous osteochondral transplants]. / Autologe osteochondrale Transplantate.

Osteochondral transplantation is a treatment option for restoring lesions of the cartilage surface and the underlying subchondral bone. For this technique, osteochondral cylinders are taken from less loaded regions of the knee joint and brought into the defect. It is based on press-fit implantation of osteochondral cylinders that are harvested from the mediocranial or laterocranial aspect of the patellofemoral joint with subsequent stable bony integration of the transplant. Indications for osteochondral transplantation must consider clinical, radiological, and magnetic resonance aspects, and concomitant pathologies of the joint should be eliminated. Isolated grade III and IV cartilage lesions in the load-bearing area of the medial or lateral femoral condyle are considered to be ideal indications for osteochondral transplantations. Further indications are retropatellar defects and lesions of the medial aspect of the talus. The technique is established for defects from 1 cm2 to 3 cm2. At this time, osteochondral transplantation is the only surgical method to achieve long-term coverage of the defect with hyaline cartilage. Donor site morbidity at the patellofemoral joint needs to be discussed because, particularly after the harvest of several cylinders, pain syndromes can develop. Therefore, the technique should be limited to two cylinders with a maximum diameter of 12 mm and one further cylinder with a smaller diameter.

[Necrotizing fasciitis caused by group G streptococci]. / Nekrotisierende Fasziitis durch Gruppe-G-Streptokokken.

Necrotizing fasciitis is a soft tissue infection which is highly lethal. Its lethality can only be reduced by early diagnosis and radical débridement. A delayed diagnosis will result in streptococcal toxic shock syndrome. Any surgery neglecting radical débridement up to amputation is inadequate and cannot reduce lethality. This paper reports on two cases of necrotizing fasciitis of the leg caused by group G streptococci.

Diagnosis of osteoporosis with vitamin k as a new biochemical marker.

Osteoporosis is a metabolic bone disease characterized by reduced bone quality and quantity. As a consequence, patients are at risk for fractures, subsequent immobility, and higher mortality especially among elder patients. Because of the high incidence of complications and the associated financial burden for the health system, new parameters for diagnostic and therapeutic purposes are urgently needed. In this regard, research focused on vitamin K as a biochemical bone marker has provided promising results. Vitamin K represents an important enzyme-cofactor for the posttranslational modification and activation of several proteins involved in bone metabolism. Vitamin K has been proven to be a valuable diagnostic as well as therapeutic parameter especially in osteoporosis. Patients with osteoporosis have been shown to have decreased levels of vitamin K. Further, regular intake of vitamin K may increase bone mineral density (BMD), thereby lowering the fracture risk. Yet vitamin K alone may not sufficiently indicate the mineral status of the bone. However, the usefulness of a combination of several biochemical bone markers as improved surrogate markers of bone metabolism has been shown recently. Therefore, this review will focus on the significance and importance of vitamin K for bone metabolism. Beyond this, aspects on the current and prospective use of vitamin K as well as other newly developed biochemical bone markers will be discussed.

[Medial dislocation of hip screw following internal fixation of a pertrochateric metastasis in the femur with gamma nails]. / Mediale Schenkelhalsschraubendislokation nach Gammanagelosteosynthese einer pertrochantären Femurmetastase.

If the standard technical guidelines are ignored so that the antirotation screw is not correctly placed during gamma nail osteosynthesis, dislocation of the hip screw is possible. In the rare cases of migration into the pelvis, the consequences may be lethal.

[Recurrent pulmonary embolism in cases of popliteal vein aneurism]. / Rezidivierende Lungenembolien bei Aneurysma der Vena poplitea.

Aneurysms of the popliteal vein usually occur within the context of angiodysplastic syndromes. The first symptom of an isolated aneurysm may be pulmonary embolism. Recurrent pulmonary embolism without thrombophilia requires more specific diagnostics. The rate of recurrent pulmonary embolism is high when no therapy is applied. Surgical treatment results in healing.

[Simultaneous rupture of a patellar tendon and contralateral quadriceps tendon]. / Gleichzeitige Patella- und kontralaterale Quadrizepssehnendurchtrennung.

The simultaneous bilateral rupture of the quadriceps tendon is a rare injury; only occasional reports exist about the bilateral simultaneous rupture of the patellar tendon. Degenerative changes of the tendon due to drugs or diseases lead to the rupture. We describe two cases of simultaneous rupture of the patellar and contralateral quadriceps tendons; only one patient had special risks. We report the management of therapy and the functional results using the Lysholm score and Knee Rating Scale.

[Dislocation of artificial cartilage (SaluCartialge)]. / Implantatdislokation bei künstlichem Knorpelersatz (SaluCartialge).

Treament of focal cartilage defects is challenging, and techniques of bone marrow stimulation or cartilage transplantation are not sufficient to reconstitute hyaline cartilage. Preliminary results of artificial cartilage repair are promising, but no long-term results are available. Here, we report on a case of graft dislocation 6 months after artificial cartilage repair (SaluCartilage). We conclude that this method is not fully developed and more long-term results are required.

Vitamin K in combination with other biochemical markers to diagnose osteoporosis.

The significance of a multiparametric classification approach of vitamin K is analysed to differentiate premenopausal (CTRL), postmenopausal non-osteoporotic (nOSP) and osteoporotic (OSP) women. Data records of women between 28 and 74 years of age were used for evaluation. Bone mineral density was determined by quantitative computed tomography of the lumbar spine using the T-score to diagnose osteoporosis. Vitamin K and biochemical markers of bone formation and resorption--alkaline phosphatase (AP), bone alkaline phosphatase (bAP), osteocalcin (OC), undercarboxylated osteocalcin (ucOC), procollagen type I carboxyterminal propeptide (PICP), pyridinoline (PYD), deoxypyridinoline (DPD), N-terminal cross-linked telopeptide of type I collagen (NTx) and bone sialo protein (BSP)--were analysed in all women on days 1 and 42. Vitamin K was significantly lower in the OSP group versus nOSP and CTRL. The odds ratio results revealed the following: vitamin K, 16.7; PYD, 7.5; NTx, 6.0; DPD, 2.7; and ucOC, 2.7. Vitamin K represented a sensitivity rate of 64% and a specificity rate of 82%. In the receiver operating curve analysis, vitamin K reached the highest area under curve (AUC) score. The combination of vitamin K and AP, bAP and PYD resulted in increased AUC scores (>0.9). The parameter combination of vitamin K/PYD and vitamin K/bAP demonstrated a sensitivity rate of 75-88%, with a specificity rate of more than 82%. The data suggests that a combination of vitamin K with other biochemical bone indices might be a useful tool for assessing bone metabolism, especially in metabolic bone diseases such as osteoporosis.

In vivo mechanisms of hydroxyapatite ceramic degradation by osteoclasts: fine structural microscopy.

In the present study the in vivo mechanism of calcium-phosphate (CaP) ceramic degradation has been investigated by means of transmission electron microscopy. The results revealed osteoclast-mediated degradation of hydroxyapatite ceramic implanted into sheep bone by simultaneous resorption and phagocytosis. After 6 weeks of implantation, osteoclasts were localized immediately beneath the ceramic surface. They had formed resorption lacunae and exhibited typical ultrastructural features, such as the ruffled border, the clear zone, and the dorsal microvilli. Their resorption capacity also had become evident by alterations of the electron density and the shape of the CaP crystals localized within the acidic microenvironment of the ruffled border. Moreover, the osteoclasts simultaneously were capable of phagocytosing the resorbed CaP crystals. The formation of endophagosomes was performed (1) by the uptake of particles into large intracellular vacuoles, which were generated by deep invagination of the membranes of the osteoclastic ruffled border, and (2) by the encircling of particles due to the development of pseudopodia-like plasmaprotrusions of the ruffled border. The formation of endophagosomes was followed by the in situ fragmentation of the inclusion material, which subsequently was released into the extracellular space and phagocytosed by macrophages.

[Operative treatment of extended peritendinous calcifications after open Achilles tendon repair-a case report]. / Operative Behandlung ausgedehnter peritendinöser Verkalkungen nach offener Achillessehnennaht-ein Fallbericht.

In the recent literature, there are only a few hints on spontaneous or postoperative heterotopic ossifications of the Achilles tendon region. The strategies of treatment are different, both conservative and operative. Postoperative calcifications are not mentioned as typical complications in the treatment of Achilles tendon ruptures. We describe the case of a 39 year old male suffering of an increasing, painful swelling and a decrease of loading capacity. In clinical, sonographic and radiological investigations,we found large peritendinous calcifications ventral to the intact heel tendon up to 36 mm in diameter. After operative resection of the calcifications and postoperative chemical prophylaxis, the patient has been without pain for 1 year. There was no relapse of the calcifications or re-rupture of the tendon.

[Minimal invasive cannulated screw osteosynthesis of Bennett's fractures]. / Minimalinvasive Hohlschrauben-Osteosynthese von Bennett-Frakturen.

PURPOSE OF THE STUDY: The current study presents a new technique and results of minimal invasive screw osteosynthesis in the treatment of Bennett's fractures and discusses its advantages and disadvantages. OPERATIVE TECHNIQUE: The Bennett's fragment has to be of sufficient size (at least one quarter of the articular surface) and closed reduction must be possible to achieve. Temporary fixation by K-wire is followed by minimal invasive osteosynthesis using a cannulated 3.0 mm screw in the lag screw technique. RESULTS: 18 patients underwent minimal screw osteosynthesis, of whom two were lost for follow-up. Average time of follow-up of the remaining 16 patients was 17.2 weeks. Fracture healing was achieved in all of the 16 patients. There were good to excellent results in 13 patients, fair results in one patient and poor results in two patients. CONCLUSION: Good results can be achieved by minimal invasive screw osteosynthesis in the treatment of Bennett's fractures. Correct indications and minute operation technique are indispensable preconditions for this new kind of treatment.

[Ultrastructural examination of cell-mediated degradation of a calcium phosphate ceramic]. / Ultrastrukturelle Untersuchungen zum zellvermittelten Abbau einer Calciumphosphatkeramik. Eine experimentelle Studie am Schaf.

Up to now little is known about cell-mediated degradation of biomaterial surfaces, especially as methodologically significant studies are not available. Therefore, the present study focused on ultrastructural details of cells involved in degradation of calcium phosphate ceramics. For the experimental procedure six adult sheep were used. At the medial aspect of the left hindlimb a cylindrical defect was created at the level of the proximal epiphysis of the tibia. Subsequently, a calcium phosphate paste was packed into the defect. Six weeks after implantation, specimens from the implants fixed by perfusion were examined histologically and by transmission electron microscopy. The results of light microscopy revealed substitution of the ceramic by newly formed lamellar bone. Electron microscopy indicated multinucleated cells localized at the implantation site and the bone surface, corresponding to osteoclasts. They formed resorption lacunae and revealed typical ultrastructural features such as the ruffled border and the sealing zone. Osteoclast-mediated degradation was performed by simultaneous resorption and phagocytosis. For the first time this degradation mechanism was documented in vivo. It confirms the notion that osteoclasts are members of the monocyte/macrophage family.

[Penetrating knife injury of the heart. Emergency management and definitive treatment: case report and review of the literature]. / Messerstichverletzung des Herzens. Notfallmanagement und definitive Versorgung--Fallbericht und Literaturübersicht.

The outcome of patients with penetrating heart injuries depends to a great extent on aggressive primary care and fast transport to the closest appropriate trauma center. There, after confirming the diagnosis, the injured victim has to be transferred without any delay to the operating room where the penetrating injury can be dealt with. The importance of resolute emergency management is shown based on a case presentation and a review of the current literature. The employment of extracorporal circulation (heart-lung machine) is rather subordinate in the primary care of these patients.

Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial.

BACKGROUND: Current methods used to restore the joint surface in patients with localized articular cartilage defects include transplantation of an autologous osteochondral cylinder and implantation of autologous chondrocytes. The purpose of this study was to evaluate the clinical and histological outcomes of these two techniques. METHODS: We performed a prospective clinical study to investigate the two-year outcomes in forty patients with an articular cartilage lesion of the femoral condyle who had been randomly treated with either transplantation of an autologous osteochondral cylinder or implantation of autologous chondrocytes. Biopsy specimens from representative patients of both groups were evaluated with histological staining, immunohistochemistry, and scanning electron microscopy. RESULTS: According to the postoperative Lysholm score, the recovery after autologous chondrocyte implantation was slower than that after osteochondral transplantation at six months (p < or = 0.015), twelve months (p < or = 0.001), and twenty-four months (p < or = 0.012). On the basis of the Meyers score and the Tegner activity score, the results were equally good with the two methods two years after treatment. Histomorphological evaluation of biopsy specimens within two years after autologous chondrocyte implantation demonstrated a complete, mechanically stable resurfacing of the defect in all patients. The tissue consisted mainly of fibrocartilage, while localized areas of hyaline-like regenerative cartilage could be detected close to the subchondral bone. Although a gap remained at the site of the transplantation in all five biopsy specimens examined as long as two years after osteochondral cylinder transplantation, histomorphological analysis and scanning electron microscopy revealed no differences between the osteochondral transplants and the surrounding original cartilage. CONCLUSIONS: Both treatments resulted in a decrease in symptoms. However, the improvement provided by the autologous chondrocyte implantation lagged behind that provided by the osteochondral cylinder transplantation. Histologically, the defects treated with autologous chondrocyte implantation were primarily filled with fibrocartilage, whereas the osteochondral cylinder transplants retained their hyaline character, although there was a persistent interface between the transplant and the surrounding original cartilage. Limitations of our study included the small number of patients, the relatively short (two-year) follow-up, and the absence of a control group.

[Vacuum mixing systems for bone cement completion - comparison of different systems]. / Vakuummischsysteme zur Knochenzementfertigstellung - Ein Vergleich unterschiedlicher Systeme.

INTRODUCTION: The use of vacuum mixing systems when mixing bone cement reduces its porosity and hereby significantly improves the features of the material. The currently available mixing systems are compared with regard to handling, mechanical properties and economical aspects. METHODS: In 8 vacuum mixing systems the handling, pump performance, system tightness, the used air volume, the filter efficiency, the remaining amounts in the mixing system and the porosity of the cements are shown in comparison. RESULTS: All vacuum mixing systems reduce the porosity of the cement in comparison to hand mixed cements significantly if used correctly. The individual examinations, though, show enormous differences, which can be of significance to the user in the individual choice of system and, depending on the individual circumstances, can influence the quality of the mixed cement. CONCLUSION: The results enable the user to choose and handle a vacuum mixing system which is optimally suitable for the individual circumstances in respect to the characteristics examined.

["Biorigid" interlocking after unreamed intramedullary nailing of tibial shaft fractures]. / Die "biorigide" Rinnenverriegelung nach unaufgebohrter Marknagelung von Tibiaschaftfrakturen Eine retrospektive Untersuchung an 76 Patienten.

Between April 1996 and December 1999, 76 tibial shaft fractures were treated at the Department of Trauma Surgery of the Justus-Liebig-University in Giessen, Germany and the Department of Orthopedic Surgery of the University of Louisville, USA with a newly developed, unreamed, solid, small diameter tibial nail interlocked "biorigidly" with screws in grooves of the nail. 69 Patients were reviewed with a minimal follow-up period of 16 months. In 65 patients, the fractures united without exchange nailing, although four of these fractures showed a delay of healing. In further four cases, non-union occurred, one of which was associated with the only break of a nail located at a distal interlocking groove of the nail. In one patient, a late medullary infection so far has not recurred following treatment. In 358 implanted interlocking screws, no implant failure was observed. First clinical experience suggests that, especially due to the low rate of material fatigue, the biorigid nail is an alternative to other implants for unreamed intramedullary nailing of the tibia.