Non-invasive assessment of muscle compartment elasticity by pressure-related ultrasound in pediatric trauma: a prospective clinical study in 25 cases of forearm shaft fractures.

BACKGROUND: Soft-tissue swelling after limb fractures in pediatric patients is well known to be a risk factor for developing acute compartment syndrome (ACS). Clinical assessment alone is uncertain in specific cases. Recently, we proposed a non-invasive ultrasound-based method to objectify muscle compartment elasticity for monitoring. We hypothesize a strong correlation between the soft-tissue swelling after stabilization of upper limb fractures and the compartment elasticity objectified with a novel ultrasound-based approach in pediatric trauma. PATIENTS AND METHODS: In a prospective clinical study, children suffering forearm fractures but not developing an ACS were included. The muscle compartment elasticity of the m. flexor carpi ulnaris was assessed after surgical intervention by a non-invasive, ultrasound-based method resulting in a relative elasticity (RE in %) in both the control (healthy limb) and study group (fractured limb). Soft-tissue swelling was categorized in four different levels (0-3) and correlated with the resulting RE (%). RESULTS: The RE in the study group (15.67%, SD ± 3.06) showed a significantly decreased level (p < 0.001) compared with the control (22.77%, SD ± 5.4). The categorized grade of soft-tissue swelling resulted in a moderate correlation with the RE (rs = 0.474). CONCLUSIONS: The presented study appears to represent a novel approach to assess the posttraumatic pressure changes in a muscle compartment after fracture stabilization non-invasively. In this first clinical study in pediatric cases, our measurement method represents a low-cost, easy, and secure approach that has the potential to substitute invasive measurement of suspected ACS in muscle compartment conditions. Further investigations in lager cohorts are required to prove its daily clinical practicability and to confirm the expected reliability.

Effect of subsequent vertebral body fractures on the outcome after posterior stabilization of unstable geriatric fractures of the thoracolumbar spine.

PURPOSE: The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively. METHODS: Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters. RESULTS: Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01). CONCLUSION: Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender.

[Treatment strategies for pathological fractures of the spine]. / Versorgungsstrategien bei pathologischen Frakturen der Wirbelsäule.

BACKGROUND: Pathological fractures and instabilities of the spine are most often caused by primary tumors that hematogenously metastasize into the spine. In this context breast, prostate, kidney cell and bronchial carcinomas are the most relevant causative diseases. Furthermore, multiple myeloma is another frequent entity. Primary tumors of the spine are correspondingly rare and only make up a small proportion of all malignant processes in the spine. DECISION MAKING: The main symptom of pain is prognostically unfavorable in this context and is often associated with progressive instability or pathological fractures. To objectify the treatment approach the neurological status, an oncological assessment, the biomechanical stability and (systemic) general condition (NOMS criteria) of the patient have to be considered. Another major factor is the radiation sensitivity of the tumor. The spinal instability neoplastic (SIN) score is recommended to assess stability. Regardless of whether conservative or surgical treatment is carried out, interdisciplinary cooperation between the specialist departments must be guaranteed in order to achieve adequate treatment for the patient. TREATMENT: If a curative approach is followed an individualized and interdisciplinary surgical strategy must be performed to achieve an R0 resection, usually as a spondylectomy. In the case of palliative treatment, the goal of surgical treatment must be pain reduction, stability and avoidance or restoration of neurological deficits. This requires stabilization in a percutaneous or open technique, possibly in combination with decompression and local tumor debulking.

Non-invasive and reliable assessment of compartment elasticity by pressure related ultrasound: An in-vitro study.

PURPOSE: The development of acute compartment syndrome is a serious threat to trauma patients. The clinical assessment alone is not reliable enough to determine the need for fasciotomy in many cases. The Physician´s assessment of the elasticity of the muscle compartment might be particularly important to objectively evaluate the pressure in this enclosed space. The purpose of this study was to determine the observer´s reproducibility, of compartment elasticity measurements by a novel ultrasonic approach. METHODS: Increasing intra-compartmental pressures (ICP) were simulated in a water filled in-vitro model. Pressure related ultrasound was used to determine the relative elasticity (RE) of soft tissue compartments. A pressure transducing probe head was combined with the ultrasonic probe to obtain cross section views of the simulated compartment and to detect the amount of applied pressure by the observer. In this model, the compartment depth without compression (P0) was set to be 100%. Changes of the compartment depth due to a probe pressure of 80 mmHg (P80) were correlated to P0 and an elasticity quotient as a value for RE (%) was calculated. Twelve blinded observers performed measurements for RE determination (%) under three pressure conditions. Reproducibility was calculated using intraclass correlation coefficient (ICC). RESULTS: Measurements (n = 432) revealed that the RE (%) in the control group was 17,06% (SD+/-2,13), whereas the RE of the group ICP30 significantly decreased to 12,66% (SD+/- 1,19) (p<0,001). The ICP50 group revealed a further significant decrease to 8,43% (SD+/- 0,67) (p<0,001). Repeated measurement of RE and ICP showed a high level of correlation (spearman correlation coefficient: roh=0,922). A RE <14% resulted in a sensitivity of 96% and a specificity of 90,3% for diagnosis of an ICP >30 mmHg. ICCinter was 0,986; 95%, CI: 0,977-0,992 (p<0,001). DISCUSSION: The presented ultrasound-based approach reliably assesses the elasticity in a simulated compartment model. In this pioneer study investigating the inter- and intra-observer reproducibility, this method of measurement appears to be of low cost in addition to being an easy and secure approach that may have the potential to substitute invasive measurement. Further investigations are required to improve its feasibility and to confirm the reliability under clinical conditions.

Non-invasive measurement of muscle compartment elasticity in lower limbs to determine acute compartment syndrome: Clinical results with pressure related ultrasound.

PURPOSE: Close monitoring of patients at risk to develop an acute compartment syndrome (ACS) is well known to be essential. There is a relevant risk that clinical assessment alone is not reliable enough. Reliable assessment of the elasticity of the muscle compartment might represent a helpful tool to assess the pressure in this enclosed space. Therefore, the purpose of this study was to determine the feasibility of muscle elasticity measurements by a non-invasive device. METHODS: In a prospective study, patients with elevated intra-compartmental pressure (ICP) were included. An ultrasound-based measurement approach was used to determine the relative elasticity (RE) of both, the affected and unaffected limb. A pressure transducing ultrasonic probe head was combined with the probe to obtain cross section views of the anterior tibial compartment and to detect the observer´s amount of pressure applied on the limb surface. The compartment depth without compression (P0) corresponds to 100%. The difference to the compartment depth with a probe pressure of 80mmHg (P80) on the limb (delta) related to P0 resulted in a value of relative elasticity (%). These values were compared with the invasive needle measurement (mmHg) regarding their intra-individual difference and correlation of the compartmental pressure. RESULTS: In six trauma patients the relative elasticity in their paired limbs showed a significant difference. The RE in the healthy compartments revealed a level of 17.95% (SD+/-5,4), whereas the RE of the affected limbs significantly decreased to a mean of 5,14% (SD+/-2,1) (p < 0,0001). The average values of the repetitively measured RE and the ICP showed a high level of correlation (spearman correlation coefficient: roh = 0,929). The RE less than 10,5% of the anterior tibial compartment had a sensitivity of 95,8% and a specificity of 87,5% to an appropriate diagnosis of ACS. DISCUSSION: The presented study appears to represent a promising approach to reliably assess the pressure in a muscle compartment. In this first clinical study, our measurement method represents a low cost, easy and secure approach that has the potential to substitute invasive measurement. Further investigations and development in lager cohorts are required to improve its practicality and to confirm the reliability.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]. / Die Chronische Symphyseninstabilität : Ätiologie, Diagnostik und Behandlungsmanagement.

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.

Impact of age on the clinical outcomes of major trauma.

PURPOSE: In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. METHODS: Review of the literature. RESULTS: Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. CONCLUSION: The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Open versus Percutaneous Stabilization of Thoracolumbar Spine Fractures: A Short-Term Functional and Radiological Follow-up.

PURPOSE OF THE STUDY: A prospective cohort study evaluates the functional and radiological outcome of thoracolumbar spine fractures treated either with open or percutaneous dorsal instrumentation. In recent years, several studies advocate percutaneous stabilization of spinal fractures in patients without neurological deficits. However, it is still debated whether percutaneous stabilization is superior to open dorsal instrumentation in spinal trauma. MATERIAL AND METHODS: This study was performed between 2010 and 2012 at a Level 1 trauma center. Patients treated either with an open or a percutaneous dorsal instrumentation for traumatic fractures of the thoracolumbar spine (T11 to L2) were included. Fracture morphology, screw positioning and clinical parameters were analyzed. Standardized questionnaires (VAS-spine-score; Oswestry-disability-score; SF-36) and follow up radiographs were performed. RESULTS: Overall 72 patients (29 percutaneous; 43 open) could be included. The surgical and the early postsurgical course were similar between both groups. Furthermore the operative approach had no influence on the functional and radiological outcome one year after surgery, but the questionnaires showed moderate impairments within both groups. Also both groups showed a significant loss of reduction after the first postoperative month (p < 0.01). Within the open group a significantly higher amount of fracture reduction (p < 0.01) and a significantly reduced intraoperative radiation exposure was seen (open 105.9 sec.; percutaneous 143.1 sec; p < 0.05); whereas the percutaneous approach was associated with significantly reduced intraoperative blood loss (open 2.2 g/dl; percutaneous 1.2 g/dl; p < 0.001). CONCLUSION: The functional and the radiological outcome of both groups was comparable one year after trauma. Minor advantages of the percutaneous system was less blood loss, whereas the open approach was associated with a significantly higher amount of initial reduction and significantly less intraoperative radiation exposure. Independent from the type of posterior fixation loss of reduction was already significant in the early postoperative course.

Measurement of compartment elasticity using pressure related ultrasound: a method to identify patients with potential compartment syndrome.

PURPOSE OF THE STUDY Decision-making in treatment of an acute compartment syndrome is based on clinical assessment, supported by invasive monitoring. Thus, evolving compartment syndrome may require repeated pressure measurements. In suspected cases of potential compartment syndromes clinical assessment alone seems to be unreliable. The objective of this study was to investigate the feasibility of a non-invasive application estimating whole compartmental elasticity by ultrasound, which may improve accuracy of diagnostics. MATERIAL AND METHODS In an in-vitro model, using an artificial container simulating dimensions of the human anterior tibial compartment, intracompartmental pressures (p) were raised subsequently up to 80 mm Hg by infusion of saline solution. The compartmental depth (mm) in the cross-section view was measured before and after manual probe compression (100 mm Hg) upon the surface resulting in a linear compartmental displacement (Δd). This was repeated at rising compartmental pressures. The resulting displacements were related to the corresponding intra-compartmental pressures simulated in our model. A hypothesized relationship between pressures related compartmental displacement and the elasticity at elevated compartment pressures was investigated. RESULTS With rising compartmental pressures, a non-linear, reciprocal proportional relation between the displacement (mm) and the intra-compartmental pressure (mm Hg) occurred. The Pearson's coefficient showed a high correlation (r2 = -0.960). The intraobserver reliability value kappa resulted in a statistically high reliability (κ = 0.840). The inter-observer value indicated a fair reliability (κ = 0.640). CONCLUSIONS Our model reveals that a strong correlation between compartmental strain displacements assessed by ultrasound and the intra-compartmental pressure changes occurs. Further studies are required to prove whether this assessment is transferable to human muscle tissue. Determining the complete compartmental elasticity by ultrasound enhancement, this application may improve detection of early signs of potential compartment syndrome. Key words: compartment syndrome, intra-compartmental pressure, non-invasive diagnostic, elasticity measurement, elastography.

[The Anterior "Triple-/Quadruple" Technique for C1/C2 Trauma in the Elderly: First Experience with 16 Patients]. / Die ventrale "Triple-/Quadruple"-Schraubenosteosynthese für die traumatische C1-C2-Kombinationsverletzung des geriatrischen Patienten: erste operative Erfahrungen mit 16 Patienten.

INTRODUCTION: In geriatric patients the management of odontoid type II fractures is complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2) with an increased lever arm. Furthermore, a few of the odontoid fractures are accompanied by an atlas fracture resulting in the "atlantoaxial unhappy triad". Posterior C1/C2 spondylodesis with bilateral Magerl screws and C1 hooks is a strong biomechanical construct, however, the posterior approach is associated with several drawbacks such as increased risk of infection and increased blood loss. In contrast, the anterior bilateral C1/C2 transarticular screw fixation with additional odontoid screw fixation is also a known technique. Advantages of the anterior approach are shorter surgery time, lower intraoperative blood loss and lower risk of infection. MATERIALS AND METHODS: In this retrospective study, all geriatric patients with an atlantoaxial arthritis and odontoid or combined atlantoaxial fracture treated at our institution between 01/2012 and 12/2014 with an anterior screw fixation were included. Following closed reduction, the surgical management was performed over a standard right anterior approach. At the end of surgery, operation time and blood loss were documented. During the hospital stay radiological follow-up of the upper cervical spine were performed to analyse the screw position. We also report the length of stay on intensive care unit, the hospital course and demographic data of the patients. Follow-up was planned after 6 weeks, 6, 12 and 18 months. During follow-up COMI evaluation and X-rays of the cervical spine were made. RESULTS AND CONCLUSION: This study included 16 patients who underwent surgery for C1-C2 lesions. There were 9 females and 7 males. Median age at the time of operation was 76 years. At the time of surgery, fractures were classified as follows: 8 patients showed an "atlantoaxial unhappy triad", 8 patients had a type II odontoid fracture complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2). Average time for operative treatment was 100 ± 36.35 minutes with a median intraoperative fluoroscopy time of 161 seconds. The intraoperative blood loss was minimal (45 ± 22.80 ml). Length of stay was documented with 10 (± 4.60) days whereby the patients spent on average 0.8 days in the intensive care unit postoperatively. No serious morbidities, such as esophageal perforation, carotid artery laceration, neurological deterioration, and airway obstruction were reported. All cases of transient dysphagia resolved gradually and spontaneously without therapy. In 4 cases (25 %) we detected a penetration of the atlantooccipital joint without functional impairment. In one case we have seen an implant failure. The technique of anterior screw fixation of odontoid and bilateral transarticular C1-C2 anterior screw fixation provides a fast surgery without higher morbidity. Based on our findings, this technique and its feasibility is an alternative to known posterior C1/C2 spondylodesis in the elderly.

Biomechanical properties of different external fixator frame configurations.

PURPOSE: External fixators are easy to apply and maximize soft tissue preservation. However, frames need providing an adequate stiffness in order to avoid excessive interfragmentary movement during the healing period. We characterized the stiffness of four different configurations of the newly developed Hoffmann 3 external fixation system. METHODS: A synthetic fracture gap model was stabilized using four different frame configurations: a double-∅ 11 mm rod configuration (group DR), a hybrid double-∅ 8 mm rod configuration (group H), a single ∅ 11 mm rod direct link configuration (group DL) and a single ∅ 11 mm rod side arm configuration (group SA). The stiffness of each configuration was measured under anterior-posterior bending, medial-lateral bending and axial torsion loading directions and the results statistically compared. RESULTS: The basic frame construct (group DR) showed the highest bending and torsional stiffness properties while the single rod side arm configuration (group SA) the lowest. CONCLUSIONS: The diameter and the amount of used connecting rods as well as the adequate placement of these rods towards the main loading directions determine the construct stiffness. These results could help the surgeons estimating how different frames can potentially affect the interfragmentary motion. This information might help in choosing specific configuration when treating different fracture types on given patients.

Reconstruction of a quadriceps tendon tear using Polyvinylidene fluoride sutures and patellar screw fixation: A biomechanical study.

BACKGROUND: Acute quadriceps tendon tears are infrequent injuries requiring surgical treatment. Improved stability after surgical repair may allow for earlier weight-bearing and range of motion. Therefore, a new implant was tested and compared with the "gold standard", using transosseous sutures. METHODS: Quadriceps tendon tears were constructed using a cadaveric model of 12 fresh matched-pair specimens (aged 61-97; mean age: 82 years). The biomechanical testing compared non-absorbable suture anchors (Polyvinylidene fluoride) versus transosseous absorbable sutures (Polydioxanon). Following anatomic reconstruction, the repaired specimens were loaded until they failed (testing machine: Hounsfield H10KM, Redhill, United Kingdom; maximum force: 1000 N; load speed: 25 mm/min; maximum test length: 150 mm; pre-load: 5 N). Values for load until tear displacement, maximum load until complete failure of the construct (pullout or breakage of the sutures or anchors) and stiffness of the reconstruction were recorded. RESULTS: The stiffness found in the Polyvinylidene fluoride reconstruction (mean 9.83 N/mm) (standard deviation (SD) 7.75) showed a significant increase compared to the Polydioxanon reconstruction (mean 6.66 N/mm (SD 3.32); P=0.045). Transosseous fixation showed comparable results to the suture anchor system. There was no significant difference found in the maximum load to tear displacement (PVDF: 290.88 N (SD 106.01) vs. PDS: 266.75 N (SD 82.61); P=0.358). CONCLUSIONS: Using the Polyvinylidene fluoride thread showed comparable results to the established method in reconstruction of ruptured quadriceps tendon. Stiffness of the Polyvinylidene fluoride thread reconstruction was even greater than Polydioxanon thread. CLINICAL RELEVANCE: Improved stiffness may facilitate healing and is suggested as clinical relevance in reconstruction.

[Percutaneous stabilization of the thoracic and lumbar spine with active intraoperative reduction]. / Perkutane dorsale Stabilisierung der Brust- und Lendenwirbelsäule mit aktiver intraoperativer Repositionsmöglichkeit.

OBJECTIVE: Operative treatment of vertebral fractures is focused on stabilization of the spine and decompression of the spinal cord and nerves. In German-speaking countries, it is common to restore the sagittal profile by fracture reduction. The use of percutaneous systems has been limited due to inferior reduction possibilities compared to open systems. The improved reduction options offered by newer percutaneous systems extend their application to highly deformed fractures. INDICATIONS: Unstable thoracic, lumbar and lumbosacral spine fractures; unacceptable spinal deformities. CONTRAINDICATIONS: Need for open decompression or cross-bracing; relative contraindication: obesity or cachexia. SURGICAL TECHNIQUE: 3 cm skin incision 1.5 cm lateral to the radiological border of the pedicle. Incision of the fascia and blunt preparation to the facet joints. Guidewire placement via fluoroscopy. Tapping and cannulated screw setting. Insertion of the longitudinal rods and reduction using special reduction tools. Rod fixation with locking caps, wound closure, dressing. POSTOPERATIVE MANAGEMENT: Pain-related mobilization, physiotherapy, indication for anterior fusion to be considered. RESULTS: In 2012, 80 patients (42 female, 38 male) with a mean age of 59.7 years received posterior stabilization (27 open, 53 percutaneous). Intraoperative radiation was significantly higher in the percutaneous group compared with the open group (percutaneous: 212 s; open: 146 s; p < 0.05), while the length of surgical treatment was significantly shorter (percutaneous: 107 min; open: 143 min; p < 0.05). Accuracy of screw positioning and the amount of reduction was similar in both groups. Major complications did not occur.

[Biomarkers in pediatric polytrauma]. / Biomarker beim kindlichen Polytrauma.

BACKGROUND: Trauma represents one of the leading causes of death in children. Beside an injury pattern that differs from adult trauma patients, children seem to develop multiple organ dysfunction syndrome (MODS) less frequently. Compared to adult MODS, pediatric MODS has also been described to occur earlier in the posttraumatic course. METHOD: Biomarkers for early identification of patients at high-risk for posttraumatic complications are of high clinical relevance. However, little is known from clinical studies about the relevance of biomarkers during the posttraumatic course. AIM: Therefore, the purpose of this review is to summarize current knowledge on this topic in order to investigate the prognostic significance of different parameters.

A meta-analysis of operative versus nonoperative treatment in 463 scapular neck fractures.

BACKGROUND AND AIMS: Treatment of scapular neck fractures remains controversial. Advantages of surgical treatments, such as anatomical restoration of fracture displacement, are counterbalanced by approach morbidity. We conducted a meta-analysis of 463 scapular neck fractures and compared clinical, functional, and radiographical outcomes in operatively and nonoperatively treated scapular neck fractures. MATERIAL AND METHODS: A literature search was conducted, including the databases PubMed/MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Manuscripts were included if they reported a precise description of treatment, complications, functional outcomes, and/or radiographic evaluation. Data about day-to-day activities, level of pain-freeness, range of motion, functional grading, and radiographical assessment were pooled and compared using fixed effects models. RESULTS AND CONCLUSIONS: A total of 22 manuscripts were relevant, including 1 prospective cohort study and 21 retrospective studies. The studies showed a high heterogeneity in the result assessment. Most patients had concomitant injuries. In total, 234 out of the 463 fractures were treated operatively. Pain-freeness and radiographic outcome measurements were significantly better in the operatively treated group, whereas range of motion was significantly improved in the nonoperative treated patients. Complication rate for surgical treatment was about 10%. From the achievable data, there was no bias detected when comparing the two treatment groups. However, those data could not be analyzed for all included studies. For the same reason, the role of additional surgical treatment for concomitant injuries to the shoulder girdle could not be cleared completely. Caution should be exercised, and individual injury patterns have to be taken into consideration when considering the best treatment options.

[Therapy of chronic osteomyelitis: soft tissues as "key to success"]. / Therapie der chronischen Osteomyelitis: Die Weichteile als "Schlüssel zum Erfolg"

Chronic osteomyelitis is a severe complication characterized by soft tissue and bone pathogenic infection resulting in osseous destruction. Surgical management is demanding and poses a challenge in achieving the goals of treatment, which are control of infection, bone healing as well as satisfactory functional outcome. Therapeutic strategies are based on a combined application of radical surgery and systemic antibiotic therapy. The bony defects which remain after extensive debridement have to be reconstructed with bone grafting after soft tissue coverage and the healing process is decisive for a successful outcome.

[The reamer-irrigator-aspirator (RIA) System]. / Das Reamer-Irrigator-Aspirator (RIA)-System.

PROBLEM: Autologous bone transplantation is a treatment of choice in patients with large bone defects. However, the iliac crest bone graft harvest is associated with numerous limitations: low volume of graft, long operation times, acute and chronic pain. SOLUTION: The reamer-irrigator-aspirator (RIA) system is used to harvest large volumes of intramedullar bone graft for surgical procedures that require bone graft, including non-unions, delayed union, and bone loss. SURGICAL TECHNIQUE: The RIA device should be assembled prior to the surgical procedure. The greater trochanter is used as entry point. Following the opening of the trochanteric region, a guide wire should be centrally positioned within the bone canal. Frequent fluoroscopic evaluation should be performed to assure the central position of the guide wire. Apply the advance/withdraw/pause/advance technique to maximize irrigation flow through the RIA. The guide wire could be placed in newly desired position within the condyle of the femur if more bone graft is required. While reaming, monitor the reaming head passage on both the anteroposterior and lateral planes to avoid bone perforation or excessive thinning. Remove the intramedullary bone graft from the graft filter. POSTOPERATIVE MANAGEMENT: Cautious ambulation on the 2nd postoperative day. In case of excessive bone thinning of the femur, partial weight bearing for 4-6 weeks is recommended. RESULTS: The RIA system allows large amounts (25-90 cm3) of high quality bone graft to be harvested. This alternative technique is associated with less donor site morbidity and lower rates of minor and major complications when compared with conventional harvest methods (iliac crest).

[Kyphoplasty and vertebroplasty. Indications, techniques, complications and results]. / Kyphoplastie und Vertebroplastie. Indikationen, Techniken, Komplikationen und Ergebnisse.

The indications, technical principals, and results after vertebroplasty and kyphoplasty are presented in detail. We focus on the complications of both procedures. The benefit of vertebroplasty has been fundamentally questioned by two papers which have recently been published in the New England Journal of Medicine. Our paper discusses the present knowledge and policy about indication. The contradictory results from different studies are presented. In general, there is a lack of randomized clinical trials. Therefore, a final judgement of these two techniques is not possible. New procedures like stent-kyphoplasty or lordoplasty are briefly described. However, at present an assessment of these new techniques is impossible. A similar situation is give for the application of resorbable bone cements.