[Type 2 dens fracture in the elderly and therapy-linked mortality : Conservative or operative treatment]. / Typ-II-Densfrakturen des alten Menschen und therapiebedingte Mortalität : Konservative oder operative Behandlung.

BACKGROUND: Type II fractures of the odontoid process of the axis are the most common injury of the cervical spine in elderly patients. Only little evidence exists on whether elderly patients should be treated conservatively or surgically. MATERIAL AND METHODS: The mortality and survival probability of 51 patients were determined in a retrospective study. The range of motion, pain and the neck disability index were clinically investigated. RESULTS: Of the 51 patients 37 were treated surgically and 14 conservatively. The conservatively treated group showed a higher mortality (64 % vs. 32 %). Kaplan-Meier analysis revealed a median survival of the conservatively treated group of 29 months, whereby during the first 3 months of treatment this group showed a higher survival probability and afterwards the surgically treated group showed a higher survival probability. The clinical examination of 20 patients revealed limited range of motion of the cervical spine. Additionally, moderate levels of pain and complaints were recorded using the neck disability index. CONCLUSION: Fractures of the odontoid process pose a far-reaching danger for elderly patients. A balanced assessment of the general condition should be carried out at the beginning of treatment of these patients. In the early phase following trauma no differences were found with respect to survival rates but for long-term survival the operatively treated group showed advantages; however, these advantages cannot be causally attributed to the choice of therapy.

[Conventional X-Rays of Ankle Joint Fractures in Older Patients are Not Always Predictive]. / Einschränkungen der Aussagekraft des konventionellen Röntgenbilds bei Sprunggelenksfrakturen im Alter.

Background: Ankle fractures are extremely common in the elderly, with an incidence of up to 39 fractures per 100,000 persons per year. We found a discrepancy between intraoperative findings and preoperative X-ray findings. It was suggested that many relevant lesions of the ankle joint in the elderly cannot be detected with plain X-rays. Methods: Complete data sets and preoperative X-rays of 84 patients aged above 60 years with ankle fractures were analysed retrospectively. There were 59 women and 25 men, with a mean age of 69.9 years. Operation reports and preoperative X-rays were analysed with respect to four relevant lesions: multifragmentary fracture pattern of the lateral malleolus, involvement of the medial malleolus, posterior malleolar fractures and bony avulsion of anterior syndesmosis. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and prevalence were calculated. Results: The prevalence of specific ankle lesions in the analyzed cohort was 24 % for the multifragmentary fracture pattern of the lateral malleolus, 38 % for fractures of the medial malleolus, 25 % for posterior malleolar fractures and 22.6 % for bony avulsions of the anterior syndesmosis. Multifragmentary fracture patterns of the lateral malleolus (sensitivity 0 %) and bony avulsions of the anterior syndesmosis (sensitivity 5 %) could not be detected in plain X-rays of the ankle joint at all. Fractures of the medial malleolus and involvement of the dorsal tibial facet were detected with a sensitivity of 96.8 % and 76.2 %, respectively, and specificity of 100 % in both cases. Conclusions: This study confirms that complex fracture patterns, such as multifragmentary involvement of the lateral malleolus, additional fracture of the medial malleolus, involvement of the dorsal tibial facet or bony avulsion of the anterior syndesmosis are common in ankle fractures of the elderly. Therefore, CT scans should be routinely considered for primary diagnosis, in addition to plain X-rays.

[The biomechanics of hyperextension injuries of the subaxial cervical spine]. / Biomechanik der Hyperextensionsverletzung der subaxialen Halswirbelsäule.

Hyperextension injuries of the subaxial cervical spine are potentially hazardous due to relevant destabilization. Depending on the clinical condition, neurologic or vascular damage may occur. Therefore an exact knowledge of the factors leading to destabilization is essential. In a biomechanical investigation, 10 fresh human cadaver cervical spine specimens were tested in a spine simulator. The tested segments were C4 to 7. In the first step, physiologic motion was investigated. Afterwards, the three steps of injury were dissection of the anterior longitudinal ligament, removal of the intervertebral disc/posterior longitudinal ligament, and dissection of the interspinous ligaments/ligamentum flavum. After each step, the mobility was determined. Regarding flexion and extension, an increase in motion of 8.36 % after the first step, 90.45 % after the second step, and 121.67 % after the last step was observed. Testing of lateral bending showed an increase of mobility of 7.88 %/27.48 %/33.23 %; axial rotation increased by 2.87 %/31.16 %/45.80 %. Isolated dissection of the anterior longitudinal ligament led to minor destabilization, whereas the intervertebral disc has to be seen as a major stabilizer of the cervical spine. Few finite-element studies showed comparable results. If a transfer to clinical use is undertaken, an isolated rupture of the anterior longitudinal ligament can be treated without surgical stabilization.

[3D Fluoroscopy-Navigated Magerl Fusion of the 1st and 2nd Cervical Vertebra]. / Navigierte Fusion des 1. und 2. Halswirbelkörpers nach Magerl.

Background: Treatment of type II fractures of the odontoid process is still controversial. Besides conservative treatment, there are surgical options, including anterior screw fixation, as first described by Böhler and Magerl, or procedures using a dorsal approach. Many authors prefer dorsal fusion of C1 and 2, due to the reliable, biomechanical stability. In this context, pedicle screw fixation, as described by Harms, and transarticular screw fixation of the atlantoaxial joints, as described by Magerl, have to be mentioned. With the use of intraoperative fluoroscopic navigation, the risk of neurovascular lesions caused by abortive drilling or malposition of screws has been significantly decreased. In 1993, Eysel and Roosen established a subclassification of type II fractures of the odontoid process and gave treatment recommendations for each of the three subtypes. While there was an outcome for type A and B fractures treated by anterior screw fixation, the authors recommended performing dorsal stabilisation at type C fractures. Indication: In accordance with the recommendations of Eysel and Roosen, an 82 year old man, suffering from a type II C fracture of the odontoid process, underwent navigated, transarticular screw fixation of C1 and C2. Method: Once the 3D-fluoroscopy scan had been performed, the correct drilling direction in the axial, coronary and sagittal views of C1 and 2 was found using the navigated drillguide. After K-wires had been inserted in this direction on both sides, a second 3D-scan was performed to recontrol placement of the K-wires. Cannulated screws were introduced and the rods were installed, bearing the atlas hook to fixate the posterior atlas. Conclusion: In summary, dorsal, transarticular fusion of C1 and C2 is a successful treatment option, rarely leading to complications and is accompanied by reduced radiation exposure to the operating team.

[The Extended Deltoid-Split Approach for Plating Four-Part Proximal Humeral Fractures]. / Die Plattenosteosynthese bei proximaler 4-Fragment-Humerusfraktur über den erweiterten Deltoid-Split-Zugang.

The deltoideopectoral approach is established as the gold standard in the surgical treatment of proximal humeral fractures. As an alternative, we demonstrate the extended deltoid approach with an intraoperative video. A direct lateral incision is performed and the anterior parts of the axillary nerve are identified and preserved. In our experience, this approach allows improved visualisation of the greater tuberosity and easier positioning of locking plates. Clinically relevant neurological injuries cannot be seen in our patients or in the literature.

[3D-Navigated Implantation of Pedicle Screws in the Cervical Spine - Experience and Analysis of Complications]. / 3-D-navigierte Pedikelschrauben der Halswirbelsäule ­ Erfahrungen und Komplikationsanalyse.

Background: Placing transpedicular screws in the cervical spine is a special challenge for spine surgeons, due to the anatomical features of this part of the spine. During the last 15 years, computer-aided navigation systems have been developed to facilitate this procedure and to make it safer for patients. One option is navigation by intraoperatively acquired data sets with the use of an 3D C-arm. Patients/Material and methods: Our retrospective study evaluates transpedicular screws in the cervical spine placed by 3D C-arm navigation, within a 6 year period in a level 1 trauma centre. We recorded epidemiological data, operation time and especially general adverse events, as well as revision surgery, including reasons for revision. We used a C-arm Arcardis Orbic 3D (Siemens, Munich), connected to a navigation system (VectorVision, Brainlab, Munich). Results: Between July 2007 and July 2013, 207 transpedicular screws were placed in 58 patients. The main indications were trauma (69 %), rheumatic diseases (20.7 %) and tumour (8.6 %). The most commonly instrumented cervical spine segments were C2 (53.5 %)%), C7 (10.3 %) and C5 (8.6 %). In nearly 95 % of the cases, we performed an intraoperative 3D scan after screw or k-wire placement to control the screw position. We found unacceptable malposition in 7.2 % of patients. This was corrected at once. Ten patients had to be revised: seven times due to wound problems, twice because of implant failure and once for treatment of CSF leakage. Three screws (1.5 %) led to injuries of the vertebral artery, once with a lethal outcome. Analysis of these cases showed that the 3D scan gave reduced data quality, due to reduced bone density or anatomical factors. Conclusion: Intraoperative 3D C-arm navigation seems to be a reliable option for transpedicular screw placement in the cervical spine. Complication rates were comparable to published values. 7.2 % of all screws were corrected intraoperatively after a control scan. Therefore possible revisions could be avoided during primary surgery. Analysis of problematic cases led to a change in our treatment strategy: in patients with poor bone quality and/or anatomical problems which lead to 3D scans of poor quality, we avoid transpedicular screw placement in C6 or higher, in order to prevent injuries of the vertebral artery.

[Shortening deformities of the clavicle after diaphyseal clavicular fractures : Influence on patient-oriented assessment of shoulder function]. / Verkürzungsfehlstellung des Schlüsselbeins nach diaphysären Klavikulafrakturen : Einfluss auf die patientenorientierte Bewertung der Schulterfunktion.

OBJECTIVE: The aim of this study was the evaluation of patient-oriented outcome scores for shoulder function and residual complaints after diaphyseal clavicular fractures with respect to shortening deformities. MATERIAL AND METHODS: The analysis was based on data of 172 adult patients (mean age 39 ± 14 years) with healed clavicular fractures treated operatively (n = 104) or conservatively (n = 67). The control population consisted of 35 healthy adults without shoulder problems and 25 patients with nonunion after conservative treatment. The subjective estimation of the level of pain was collated on a visual analog scale (VAS 1-100 points), together with the relative Constant and Murley score, the Cologne clavicle score, the disabilities of the arm, shoulder and hand (DASH) score and a bilateral comparison of the length difference of the clavicles. RESULTS: Patients with a clavicular length difference of > 2 cm had significantly (p < 0.001) more pain, a greater loss of mobility and significantly lower values in the scoring system of Constant and Murley, the DASH and Cologne clavicle scores compared to patients with clavicular length differences < 0.5 cm and healthy controls (p < 0.001). CONCLUSION: The results of this study showed that shortening deformities after clavicular fractures in adults have a large impact on the functional result and patient-oriented outcome scores. The aim of the therapy of diaphyseal clavicular fractures should therefore concentrate on reconstruction of the anatomical length of the clavicle.

The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine.

PURPOSE: Due to better primary stability and repositioning options, pedicle screws are increasingly used during posterior stabilization of the cervical spine. However, the serious risks generally associated with the insertion of screws in the cervical spine remain. The purpose of this study is to examine the accuracy of pedicle screw insertion with the use of 3D fluoroscopy navigation systems, also accounting for various spine levels. METHODS: Data of 64 patients were collected during and after screw implantation (axial and subaxial) in the cervical spine. 207 screws were implanted from C1 to C7 and analyzed for placement accuracy according to postoperative CT scans and following the modified Gertzbein and Robbins classification. RESULTS: The accuracy of most of the inserted screws was assessed as grade 2 according to the modified Gertzbein and Robbins classification. 93.9% of the screws implanted at C1 or C2, and 78.51% of the screws implanted at levels C3-C7 showed placement accuracy grade 2 or better, indicating pedicle wall perforation of <2 mm. Overall, seven complications were observed. In three cases, the vertebral artery was affected, leading to one fatality. Surgical revision was necessary once because of Magerl screw misplacement and three times due to impaired wound healing. No radicular symptoms resulted from screw malposition. CONCLUSION: Axial and subaxial screws can be inserted with a high grade of accuracy using 3D fluoroscopy-based navigation systems. Nevertheless, while this useful innovation helps to minimize the risks of misplacement, the surgery is still a challenge, as arising complications remain severe.

[Intramedullary stabilisation of clavicula fractures]. / Intramedulläre Stabilisierung von Klavikulafrakturen.

With an incidence of 64/100,000, clavicular shaft fractures are one of the most common fractures. Intramedullary fixation with Prevot nails was initially reported in the late 1990s. This procedure offers minimally invasive stabilization of the fracture, thus enabling immediate mobilization and rapid loading capacity. Using a case study, the positioning and procedure are demonstrated on video. The intramedullary implant accommodates the varying tension loading of the clavicle. This treatment is ideal for clavicular fractures with 2-3 fragments. Compared to patients treated conservatively, operated patients achieve more rapid and improved mobility. Employment disability is shorter, and malunion occurs less frequently.

[A simple clavicle score. An effective and reliable classification for outcome assessments of midclavicular fractures]. / Ein einfacher Klavikulascore. Bewertungssystem zur Beurteilung der Behandlungsergebnisse nach Frakturen des mittleren Klavikuladrittels bei Erwachsenen.

BACKGROUND: To compile an evaluation system (score) for post-treatment outcomes of midclavicular fractures, 172 patients were studied on average 15 months post-injury. As a control group 45 healthy volunteers were examined. The most relevant elements were filtered out for use in a new classification system, the Clavicle Score (CS). METHODS: The CS is based on a system of three partnered objective/subjective items as well as radiographic assessment of fracture healing. For the partnered items, subjective responses with the most significant correlation to the specific objective parameters were selected. Total score cutoff values (very good, good, moderate, poor) were established to keep interpretation simple. To validate the system, linear regression analysis was performed comparing the CS to two established assessment systems (Constant Score and the DASH Score). ERGEBNISSE: The correlation coefficients R=0.756 (Constant) and R=0.687 indicated that the conclusions were comparable and therefore valid. The reliability coefficient Cronbach's alpha was calculated at 0.8241, indicating high reliability. CONCLUSION: The CS is a simple, valid and reliable instrument to assess outcomes post-midclavicular fracture.

[Classification and treatment of patella fractures]. / Einteilung und Therapie der Patellafraktur.

Patella fractures are rare and account for approximately 1% of all fractures. They are classified regarding their localization (proximal, distal) and appearance. The aim of any treatment is reconstruction of the extensor mechanism and joint surface. If dislocation and cartilage steps are less than 2 mm, conservative treatment may be indicated. Operative treatment is only necessary if a dislocation is more than 2 mm or when the extensor mechanism is unstable. Depending on the shape of the fracture, tension band wiring, interfragmentary screw fixation and combinations are the main techniques. Because patellectomy has functionally the worst result it should be avoided. Sleeve fractures (children) need exact reconstruction of the joint surface. In elderly patients conservative treatment or surgical patella-enclosing wiring techniques for stabilization are the best options due to low bone quality.

[Appearance of complex regional pain syndrome after intramedullary nailing of a clavicle fracture]. / Auftreten eines Complex-regional-pain-Syndroms nach intramedullärer Nagelung einer Klavikulaschaftfraktur.

After operative correction of a clavicle fracture using an elastic stable intramedullary nail the patient presented signs of delayed fracture healing after 2 months. During the sixth postoperative month the 28-year-old obviously pain-ridden female patient showed dystonia of the shoulder girdle and allodynia surrounding the operation field. Upon these findings, we decided - as a result of the complex regional pain syndrome that had not been previously described in this location - to treat the patient by administering bisphosphonates, multimodal analgetic therapy, physiotherapy and occupational therapy. Fourteen months after surgery, the patient showed no remaining symptoms, and the fracture had consolidated at that time.

[Non-union of the clavicle after intramedullary nailing with a steel Kirschner wire]. / Pseudarthrose nach intramedullärer Nagelung der Klavikula mit einem Stahl-Kirschner-Draht.

Elastically stable intramedullary nailing is a safe surgical procedure used to treat mid-shaft clavicular fractures of types A and B according to the Orthopaedic Trauma Association (OTA) classification. In the case reported intramedullary fixation with a Kirschner wire and an incorrectly performed surgical technique led to pseudoarthrosis (non-union). After revision surgery with an elastically stable titanium nail and a correct surgical technique, fracture healing was achieved.

[Cleavage lines and incisions in foot surgery]. / Die Hautspaltlinien und die Schnittführung bei Fussoperationen.

BACKGROUND: In the constantly evolving, increasingly important field of foot surgery, the question arises as to whether the incision types currently in use are adequate. Whether Langer's lines should be considered during the operative approach to the foot is examined here. The goal of the current study was to investigate the pattern of skin cleavage lines of cadaveric feet and to establish the optimal incision type for surgical approaches to the foot. MATERIALS AND METHODS: Twelve feet from older deceased subjects were examined. The samples were fixed. The cleavage lines of the individual skin regions were outlined and evaluated. To emphasize the significance of the investigative findings, the cleavage lines and the current, relevant operative approaches were compared. RESULTS: Standard current approaches often ignore skin cleavage lines, understandably resulting in cosmetically unsatisfactory scars. A chart with ideal incision types for individual operations was created. CONCLUSION: The ideal incision should run parallel to skin cleavage lines. If this is not completely possible due to operative requirements, then at least a large part of the incision should follow these lines.

[Implantation of matrix-free cartilage transplants in standardized defects in sheep knee joints]. / Die Implantation von matrixfreien dreidimensionalen Knorpeltransplantaten in standardisierte Knorpeldefekte am Schafskniegelenk.

The goal of the current investigation was to make a comparative analysis of regenerative tissue after autologous de novo cartilage transplantation on the femoral condyles of sheep after a chondral defect. One chondral defect measuring 4 mm in diameter was placed in the center of one medial femoral condyle of each of 48 Suffolk sheep. Twelve defects were left to heal spontaneously, 16 defects were covered with periosteal flaps, and 20 defects were filled with autologous de novo cartilage graft. Macroscopic and microscopic assessments were performed at 26 and at 52 weeks. Regeneration was significantly better (p<0.05) in the transplant group than in the control groups at both 26 weeks and 52 weeks. The differences were most evident in the grade of defect filling, cartilage stability, cell distribution, and matrix assessments. Transplantation of immature, autologous de novo cartilage leads to qualitatively better regeneration both macro- and microscopically than does periosteal flap placement alone. The transplanted, immature cartilage tissue undergoes maturation in vivo. The regenerated tissue has hyaline-like features.

[Lecture disasters - and how to prevent them]. / Der grottenschlechte Vortrag - oder wie geht es auch besser.

Presentations at medical conferences can sometimes confuse or compromise understanding of current topics. Although considerable time and financial costs may be taken to be present at such events, all too often one must go through inferior presentations that are poorly structured and do not contribute to one's understanding of the topic at hand. A good presentation is distinguishable by the clear intentions of the speaker to give a good lecture. The presenter has worked extensively with his topic and is familiar with the audience. The presentation has a clear structure and finishes with a take-home message. The speaker takes the listener from his previous level of knowledge to a new understanding. To do so, both voice and body language are used. The supporting slides are simple and direct, and not overloaded with information. The speech conforms exactly with the pre-determined time limit.

[Multislice CT in diagnostic work-up of polytrauma]. / Multislice-Spiral-CT zur Diagnostik beim Polytrauma.

BACKGROUND: In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized. QUESTION: Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner? MATERIAL AND METHODS: Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3-81 years) were evaluated retrospectively. The average ISS score was 32.8+/-12 points (range: 17-75 points). RESULTS: The average time in the ED, prior to CT, was 33+/-14 min. The CT scans lasted 16+/-5 min and the total diagnostic time was 48+/-14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days. CONCLUSION: The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.

[Treatment of mid-clavicular fractures in adults. Early results after rucksack bandage or elastic stable intramedullary nailing]. / Die Behandlung der diaphysären Klavikulafraktur. Vergleich der Frühergebnisse nach Rucksackverband und elastisch stabiler intramedullärer Nagelung.

OBJECTIVES: The aim of this prospective study was to compare the results achieved in two groups of patients treated for mid-clavicular fracture. METHODS: The first group of 27 patients was treated nonoperatively with a rucksack bandage, whereas the second group underwent intramedullary fixation with a titanium pin, using a minimally invasive technique. Within the follow-up period of 6 months, results were evaluated seven times. RESULTS: During the whole period significantly (p<0.05) better results were observed in the group of operated patients concerning shoulder function, Constant score, DASH score, personal satisfaction, pain, and cosmetic result. In the second group return to work occurred in less than half the time of the first group. CONCLUSION: Intramedullary nailing of mid-clavicular fractures is a safe and minimally invasive operation technique. Early functional and cosmetic results are not worse than results after nonoperative treatment with a rucksack bandage.

[ Intramedullary nailing (ESIN) in clavicular pseudoarthroses. Results of a prospective clinical trial]. / Die intramedulläre Nagelung (ESIN) von Klavikulapseudarthrosen. Ergebnisse einer prospektiven Anwendungsbeobachtung.

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: <18 years or >70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p<0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

[Experience with elastic stable intramedullary nailing (ESIN) of shaft fractures in children]. / Erfahrungen mit der elastisch stabilen intramedullären Nagelung (ESIN) diaphysärer Frakturen im Kindesalter.

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.