Treatment of Dens Fractures with Anterior Screw Fixation.

INTRODUCTION: Direct anterior screw fixation of the dens preserves C1-C2 rotation, and the reported fusion rates range from 88% to 100%. STEP 1 POSITIONING OF THE PATIENT: Exact positioning of the patient and use of image intensifiers are mandatory to obtain perfect anteroposterior and lateral views of the axis. STEP 2 SURGICAL APPROACH: The surgical approach is standardized, and the pretracheal layer can be exposed without violating any essential anatomic structures. STEP 3 ENTRY POINT OF THE SCREW: The perfect entry point is directly anterior-inferior at the base of C2; therefore, the anterior rim of the C2-C3 intervertebral disc must be penetrated. STEP 4 SCREW INSERTION: We use a single cannulated screw in most cases: insert the screw in the center of the dens with its tip perforating the cranial, cortical bone of the dens just posterior to the apex. STEP 5 WOUND CLOSURE: Precise and anatomic closure of the platysma determines the quality of the scar that will be visible after the operation. STEP 6 FOLLOW-UP: The patient wears a rigid collar for six weeks, removing it for body care; radiographic evaluations should be performed regularly. RESULTS: In a study of sixty-nine patients with a fracture of the dens, three of the thirteen patients who underwent direct anterior screw fixation had persistent instability and nonunion of the dens four months after surgery. Indications Contraindications Pitfalls & Challenges.

Treatment of Dens Fractures with Posterior Transarticular Fixation.

INTRODUCTION: Treatment of unstable dens fractures with posterior transarticular C1-C2 arthrodesis provides a biomechanically stable construct, even when poor bone quality is present, and a low rate of complications even in elderly patients; however, when this method of fixation is performed, cervical spine rotation is substantially reduced as compared with that associated with alternative fixation techniques. STEP 1 POSITIONING: Exact positioning of the patient and use of image intensifiers are mandatory to obtain appropriate anteroposterior and lateral views of C1 and C2. STEP 2 SURGICAL APPROACH: Use the modified technique of Magerl and Seemann, as it allows a less extensive approach to C1 and C2, and the drill can enter through two incisions at the level of T1. STEP 3 INSERTION OF SCREWS: Use smooth 2.0-mm Kirschner wires to prepare the canal for the screws, and subsequently replace them with 3.0-mm self-tapping screws. STEP 4 GALLIE FUSION: Perform a modified Gallie fusion, in addition to the transarticular screw fixation, to increase stability and osseous fusion between C1 and C2. STEP 5 WOUND CLOSURE: Perform meticulous closure of the wound to avoid wound-healing complications. RESULTS: In our original study, we treated twenty-five patients with posterior transarticular fixation.IndicationsContraindicationsPitfalls & Challenges.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]. / Ablauforganisation - unfallchirurgisches und anästhesiologisches Management bei Hüftfrakturen.

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Rehabilitation after hip fracture.

Low-trauma hip fracture in old age leads to impairment, increased need of care and mortality. Rehabilitation should start in the department for traumatology and accompany the patient through different settings until the pretraumatic status is reached. Besides the surgical procedure and the medical management of an aged person with complex disease and polypharmacy, the multidisciplinary rehabilitation process is an important factor for regaining ability for self-care and autonomous decisions. Pain management supports the process. The ideal setting is not clear yet. Besides established rehabilitation facilities for elderly people, including the departments for 'Akutgeriatrie/Remobilisation', the 'Outreach Geriatric Remobilisation' project offers new perspectives. It was designed to remobilise patients with multimorbidity in their own homes.

Treatment algorithm for dens fractures: non-halo immobilization, anterior screw fixation, or posterior transarticular C1-C2 fixation.

BACKGROUND: The appropriate treatment of dens fractures is unclear. We established a staged treatment protocol for dens fractures and conducted a prospective study to evaluate the outcome of treatment based on this protocol. METHODS: We prospectively evaluated sixty-nine consecutive patients who presented to our institution with a dens fracture. The mean duration of follow-up was 9.7 months (range, six to fifty-eight months). Fractures were categorized as stable or unstable. Stable fractures were treated by immobilization in a rigid collar. Patients seventy-five years or older with unstable fractures, patients with a neurological deficit, and patients with Anderson and D'Alonzo type-III fractures underwent posterior transarticular C1-C2 stabilization. Unstable fractures in patients younger than seventy-five years were stabilized with direct anterior screw fixation. Thirty-one patients were treated with a Philadelphia collar, twenty-five with posterior transarticular fixation, and thirteen with direct anterior screw fixation. RESULTS: Fracture-healing or solid fusion of C1-C2 was documented in sixty-eight of sixty-nine treated patients at final follow-up. The remaining patient had a stable nonunion of the dens. Secondary procedures were performed in five patients. CONCLUSIONS: Our treatment algorithm based on dens fracture type, fracture stability, and patient age was associated with a high success rate. Evaluating fracture stability is crucial when considering nonoperative treatment. External stabilization with a rigid cervical collar was adequate for stable fractures of the dens and was associated with a high healing rate. Posterior transarticular screw fixation of C1-C2 was associated with a high success rate, including in elderly patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Free microvascular transfer of segmental corticocancellous femur for the treatment of scaphoid nonunion]. / Das freie mikrovaskuläre Knochentransplantat vom medialen Femurkondylus zur Behandlung der Kahnbeinpseudarthrose.

OBJECTIVE: Reconstruction of the scaphoid in length and form. Revitalization of the proximal fragment in case of avascular necrosis. INDICATIONS: Nonunion of the scaphoid, especially with avascular necrosis of the proximal pole. Persisting nonunion of the scaphoid after operative treatment. CONTRAINDICATIONS: Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Low compliance. Reduced general health. SURGICAL TECHNIQUE: Reconstruction of the scaphoid in correct dimension and angulation with use of a vascularized microvascular corticocancellous bone graft from the medial distal femur. Anastomoses to the radial artery or its palmar branch. Fixation by a cannulated scaphoid screw or Kirschner wires. POSTOPERATIVE MANAGEMENT: Postoperative immobilization in a short cast with thumb support for 6 weeks followed by a removable splint for another 6 weeks. Physiotherapy after cast removal. RESULTS: 15 patients with avascular necrosis of the scaphoid were treated with this technique after a mean of 128 weeks following trauma. In five patients, one to three previous operations had already been performed. 6 months after surgery, osseous healing of the nonunion was registered in all patients. The carpal height ratio according to Nattrass was increased by 0.07. The scapholunate angle had decreased by 10.7 degrees on average. 14 patients had a mean improvement of the Mayo Wrist Score of 13.3 points.

Traumatic manubriosternal dislocation.

Manubriosternal dislocation is an extremely rare occurrence, especially as the result of an indirect compression injury. Manubriosternal dislocations are divided into two types: In a Type I dislocation, the body of the sternum is displaced in a dorsal direction; in Type II dislocation, the body is displaced to the ventral side of the manubrium. A manubriosternal dislocation may be caused by direct or indirect trauma. Direct injury is generally a collision injury occurring in the context of a road accident. Resulting may be in either a Type I or Type II dislocation. Indirect trauma always leads to a Type II dislocation due to a flexion-compression mechanism in the region of the spine. Rheumatic arthritis and obvious kyphosis are predisposing factors in manubriosternal dislocation due to the indirect compression injury. Non-operative treatments after reduction, e.g. correction tape or plaster bandage, symptomatic pain treatment, application of ice, and several weeks without sports, are associated with a not inconsiderable rate of subluxations or reluxations, especially due to insufficient patient compliance. These disorders can lead to chronic pain, periarticular calcification with ankylosis, and progressive deformity. It has not been possible to establish an optimal, standardized operative procedure so far because of the small number of cases. We have achieved very good, postoperative long-term outcomes after plate osteosynthesis of manubriosternal dislocations in two patients.

Non-rigid immobilisation of odontoid fractures.

Despite various reports on the management of odontoid fractures, there is no consensus on the subject, and the appropriate treatment still remains controversial. While untreated fractures or fractures treated only with a cervical orthosis seem to have the highest rate of non-union, the need for rigid external stabilisation has never been substantiated. In a retrospective analysis we reviewed 26 patients with acute type II and III fractures of the odontoid, treated with a cervical orthosis only. Study inclusion was limited to fractures that had a fracture gap of less than 2 mm, an initial antero-posterior displacement of less than 5 mm and angulation of less than 11 degrees, less than 2 mm displacement on lateral flexion/extension views, and were without neurological deficits. These fractures were defined as stable. There were 19 (73.1%) type II and 7 (26.9%) type III fractures; in 10 (38.5%) of these fractures the odontoid was displaced and/or angulated. The overall complication rate was 11.4% ( n=3). One patient suffered from pulmonary embolism, in two patients (7.7%) with initially minimally displaced fractures, secondary internal stabilisation had to be performed because of persistent instability. In 20 (77%) of the remaining fractures healing was uneventful. In 4 nondisplaced fractures (15%) fibrous union was documented. Three of these patients were over 65 years old. The overall fusion rate was 73.7% for type II and 85.7% for type III fractures. At follow-up 39% of the patients were free of symptoms; however, the clinical outcome did not correlate with the radiological findings. According to our findings, stable type II and type III fractures of the odontoid can be successfully treated with non-rigid immobilisation, even if they are displaced. A thorough assessment of the stability of the odontoid with lateral flexion/extension views or dynamic fluoroscopy is recommended to evaluate the appropriate treatment. Non-rigid immobilisation may be an option in selected cases with stable injuries.