The Surgical Treatment of a Bimalleolar Ankle Fracture - Tips and Tricks. / Die operative Versorgung einer bimalleolären OSG-Fraktur ­ Tipps und Tricks.

The ankle fracture - the most common fracture of the lower extremities - is usually due to pro- and supination trauma and is commonly challenging for junior doctors of orthopaedics and traumatology. To accomplish sufficient surgical results, it is necessary to have surgical experience, not only because of the surrounding fragile soft tissue, but also due to the specific anatomical structures surrounding the ankle joint and the postsurgical biomechanical stress to osteosynthesis. In the following video, the most relevant steps of surgery as well as some useful tips and tricks are mentioned. The intention of the video is to convey to junior orthopaedic surgeons the most important surgical steps for their clinical daily routine.

Improved gait parameters following surgical revascularization in patients with intermittent claudication.

Objective: Intermittent claudication (IC) is known to be associated with impaired gait parameters, with a higher incidence of falls and higher oxygen consumption due to uneconomic walking. However, the influence of arterial disobliteration in patients with IC on their gait pattern has rarely been investigated to date. The aim of this study was to examine the gait patterns before and after inflow revascularization by surgical disobliteration of pelvic and inguinal arteries (ie, common iliac artery, external iliac artery, common femoral artery, profound femoral artery, superficial femoral artery) in IC patients. Successful surgical disobliteration of inflow arteries (improvement of ankle brachial pressure index of ≥0.2 and patent common iliac, external iliac, common femoral, profound femoral, and superficial femoral arteries) is known to improve the painless walking distance for patients with IC due to peripheral arterial disease; however, its influence on gait parameters is unclear. We hypothesized that the gait parameters would also improve after surgery. Improved gait parameters can lead to a more economic walking process, lower oxygen consumption, a lower risk of falls, and a higher quality of life. Methods: In a single-center, exploratory, longitudinal study, we examined the gait parameters of 20 IC inpatients of our hospital before and after surgical disobliteration of pelvic and inguinal arteries. Spatiotemporal parameters such as range of motion of the hip and knee joint, stance phase, cadence, and foot rotation were obtained using the Diers 4Dmotion Lab (Diers International). The gait parameters were obtained under painful walking conditions preoperatively and with the patients walking pain free at the same speed postoperatively. Results: A total of 20 patients were examined. Surgical revascularization led to a higher walking cadence (mean, plus 7.88 steps; 95.5 steps/min vs 87.6 steps/min; P = .024), an increased range of motion of the hip joint (mean, plus 2.0°; 35.1° vs 33.1°; P = .038), and improved foot rotation (mean, plus 2.0°; 11.0° vs 9.0°; P = .02). Regarding other parameters such as step length, stance phase, and step duration, smaller differences were detected in this study. Conclusions: In this exploratory study, we found that surgical revascularization of pelvic and inguinal arteries in IC patients improved certain gait parameters. Further studies with larger patient numbers are needed to confirm these data and provide more evidence on this subject.

A computed tomography based survey study investigating the agreement of the therapeutic strategy for fragility fractures of the pelvis.

Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44-0.62) and 0.42 (95% CI 0.34-0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior-posterior fixation. Despite the consensus on an anterior-posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon's preference.

Epidemiological and Therapeutic Developments in Pelvic Ring Fractures Type C from 2004 to 2014 - a Retrospective Data Analysis of 2,042 Patients in the German Pelvic Register (DGU). / Epidemiologische und therapeutische Entwicklungen bei Beckenringfrakturen Typ C der Jahre 2004 bis 2014 ­ eine retrospektive Datenauswertung über 2042 Patienten des Deutschen Beckenregisters (DGU).

BACKGROUND: Pelvic ring fractures type C present a special challenge due to their high instability, the possible accompanying injuries and the high mortality rate of up to 18.9%. The aim of this retrospective analysis was to use the data from the DGU pelvic register to identify changes in the epidemiology and therapy for type C pelvic ring fractures between 2004 and 2014. MATERIALS AND METHODS: 2,042 patients with type C pelvic ring injury were retrospectively included. Three time periods with roughly equal patient groups were specified and differences in epidemiology and the type of therapy were evaluated. For the surgical cases, the time of the operation, the duration of the operation, blood loss, the location of the fracture and the type of osteosynthesis were evaluated and the reduction result was recorded. RESULTS: For the period under review, there is an age shift in the incidence of a type C pelvic ring fracture towards older age. The isolated pelvic injury has increased, while the proportion of pelvic injuries in the context of polytrauma has steadily decreased. Complications and mortality decreased as a percentage. The tendency towards minimally invasive procedures could be shown in the surgical care. Navigated procedures in the area of the pelvic ring have so far not proven successful. CONCLUSIONS: We were able to show that the majority of the patients are increasingly old, that there is no relevant trauma in the history and that there is an increase in the isolated pelvic fracture type C and a decrease in the number of polytraumatised or multiply injured patients. In conjunction with mortality from pelvic ring injuries, the successes of standardised, pelvic-specific emergency management, an adapted time of operation outside the vulnerable phase and stable osteosynthesis care, which enable early functional follow-up treatment, are also evident.

Insufficiency Fractures vs. Low-Energy Pelvic Ring Fractures - Epidemiological, Diagnostic and Therapeutic Characteristics of Fragility Fractures of the Pelvic Ring. / Insuffizienzfrakturen vs. niederenergetische Beckenringfrakturen ­ epidemiologische, diagnostische und therapeutische Charakteristika der Beckenfragilitätsfrakturen.

BACKGROUND: Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. PATIENTS AND METHODS: In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. RESULTS: There was a relative increase in the insufficiency fracture within the FFP (2008 - 2009: 5.0% vs. 2015 - 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: - 3.66 vs. - 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). CONCLUSION: We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP.

[Triangular minimally invasive spinopelvic stabilization for type C pelvic fractures according to AO/OTA and type IV according to FFP]. / Trianguläre minimal-invasive spinopelvine Stabilisierung bei Beckenfrakturen Typ C nach der Klassifikation der Arbeitsgemeinschaft für Osteosynthesefragen (AO/OTA) und Typ IV nach den Fragilitätsfrakturen (FFP).

INTRODUCTION: Spinopelvic instability is common in type IV fragility fractures of the pelvic ring (FFP) and type C traumatic pelvic fractures. This results in the indications for operative stabilization using a spinopelvic support. Due to the variety of surgical techniques for spinopelvic support it is unclear what importance a minimally invasive spinopelvic screw-rod osteosynthesis can have. MATERIAL AND METHODS: In the retrospective clinical study over a period of 2 years, 23 patients (median age 67 years, 5 male and 18 female) with unstable pelvic fractures (FFP type IV: n = 12, AO/OTA type C: n = 11) treated by triangular minimally invasive spinopelvic stabilization (TMSS) were included in the study. The patient data were examined with respect to the parameters gender, age, fracture morphology, intraoperative blood loss, operating time, postoperative infection, postoperative reduction result in the computed tomography (CT) imaging and screw loosening. RESULTS: The average age of the 11 type C fractures was 43 years and that of the 12 FFP type IV fractures was 80 years. The follow-up period was on average 12.2 months. The average operation time was 67 min, the blood loss was 70 ml, there were 2 postoperative infections and 4 cases of screw loosening. The reduction according to Matta was < 4 mm for all FFP and between 4-20 mm for traumatic pelvic fractures. Symptomatic pseudarthroses occurred in 3 cases. CONCLUSION: The triangular minimally invasive spinopelvic stabilization (TMSS) showed a stable and sufficient treatment of the type IV fragility fractures and in the slightly displaced type C traumatic pelvic fractures. Coarse fracture dislocations limit the procedure.

Surgical Reconstruction Options in Chronic Distal Biceps Tendon Ruptures - Case Report and Literature Review. / Operative Rekonstruktionsmöglichkeiten chronisch distaler Bizepssehnenrupturen ­ Fallbeispiel und Literaturrecherche.

INTRODUCTION: Chronic distal biceps tendon ruptures are rare and conservative or operative treatment options are suitable. There is a consensus in the literature in case of acute traumatic ruptures the operative refixation should be preferred. Disagreement exists in the best way of care of old ruptures (> 4 weeks) of distal biceps tendon. Several kinds of refixation possibilities up to tendon grafts are described. Aim of this publication is showing an overview of the literature of the approved methods in reconstruction of the distal biceps tendon using autogenous and allogenic grafts, comparing the outcomes and transferring them on an own case. MATERIAL AND METHODS: A literature research was carried out using the online medical database "PubMed" with the following keywords "chronic rupture distal biceps tendon, surgical techniques". 59 citations were found concerning the topic, 37 publications were relevant for this work. RESULTS: There is consensus that even in chronic ruptures the operative management of the distal biceps tendon generates the best results. Consistently the experiences and results of only little patient collectives are reported. Numerous techniques of surgery are described without predominance of one method. Reinsertions of the tendon butts are reported in different techniques: with achilles, palmaris longus, fascia lata, triceps, quadriceps and semitendinosus tendon grafts. All together they showed postoperative satisfactory results. CONCLUSION: With surgical treatment of chronic ruptured distal biceps tendons comparable outcomes can be achieved by primary refixation and graft augmentations. In case of graft augmentations several tissue options are available which showed in all cases satisfactory functional results in the end.

Fragility Fractures of the Pelvic Ring - Does the Evidence of Oedema Lead us to More Surgeries? / Fragilitätsfrakturen des Beckenrings ­ führt der Ödemnachweis zu mehr Operationen?

INTRODUCTION: The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options - sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) - has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population. MATERIALS AND METHODS: We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us. RESULTS: The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 - 2009: 5.3% vs. 2015 - 2017: 60.3%). CONCLUSION: We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.

Modified therapy concepts for fragility fractures of the pelvis after additional MRI.

BACKGROUND: Fractures of the pelvic ring in elderly patients have increased in frequency over time. These injuries are associated with a high morbidity and have a socio-economic impact. The diagnostic procedures and their influence of therapy decisions are still controversial. METHODS: In a retrospective study, we investigate the value of additional MRI examination on therapy decision of fragility fractures of the pelvis. The evaluation of all patients with pelvic fractures without adequate trauma and with performed CT and MRI was conducted at three large German hospitals. The imaging procedure took place within a maximum interval of 4 weeks. After evaluation of the imaging, the resulting therapeutic consequences either based on CT alone or on CT and MRI were reviewed by experienced pelvic surgeons. RESULTS: Of 754 patients with pelvic injuries, 67 (age 80 +/- 9.7 years, f: m 54:13) could be included. The detection of vertical fractures in CT (n = 40 unilateral, n = 11 bilateral) could be increased by the additional MRI (n = 44 unilateral, n = 23 bilateral). A horizontal fracture component was identified in CT in 9.0% (n = 6) vs. MRI in 25.4% (n = 17) of the cases. An anterior pelvic ring injury was detected in 71.6% (n = 44; 4x bilateral) in CT, in 80.6% in MRI (n = 50, 4 bilateral). Additive MRI imaging increased the decision rate for surgical therapy from 20.9% (n = 14) to 31.3% (n = 21). CONCLUSIONS: The results of this study further support the value of bone marrow edema detection by MRI diagnostics (or dual source CT which showed promising initial results) for the detection of pelvic ring fractures. For the first time, the study identifies an additional therapeutic consequence by an increased rate of surgical procedures.

Magnetic Resonance Imaging in Pelvic Fractures - Part 1: Which Criteria Lead Us to Supplementary MRI Diagnostics? / Die Kernspintomografie bei Beckenfrakturen ­ Teil 1: Welche Kriterien veranlassen uns zur ergänzenden MRT-Diagnostik?

INTRODUCTION: Isolated pelvic fractures are relatively rare with an incidence of 3 - 6% of all fractures, but their incidence in polytraumatized individuals increases to 25%. The S3 guideline Polytrauma gives a clear recommendation for diagnostics by means of pelvic radiography (X-ray) and computed tomography (CT). A recommendation for the diagnosis by means of magnetic resonance tomography (MRI) especially in patients with low energetic/missing trauma does not currently exist. It is unclear on the basis of which criteria the MRI can be indicated in pelvic fractures. The aim of our study was therefore to retrospectively record indications for the indication of MRI in pelvic fractures - with adequate as well as inadequate trauma. MATERIAL AND METHODS: In a retrospective clinical study, a total of 140 patients (median 68 years, range 15 - 97, 75 female, and 66 male) with a pelvic fracture were included in the study over a period of three years. Overall, the trauma mechanism revealed 73 adequate and 67 inadequate fractures. 31/140 patients had undergone MRI of the pelvis in addition to a CT/X-ray scan. The two subgroups "with MRI" and "without MRI" were analyzed with regard to the parameters "sex", "age", "adequacy of the trauma", "fracture localization", "duration of admission to imaging", "type of therapy" and "duration to surgery" compared. RESULTS: It was shown that the MRI diagnosis was performed especially in female, elderly patients (81 years, range 19 - 94 years). Patients with inappropriate trauma have received MRI more frequently (74%) than patients with adequate trauma (26%). With regard to fracture localization no differences could be shown. The MRI was performed on a median 4 days after the CT examination. Regarding the decision "conservative" vs. "operationally" our two groups without and with MRT tended to differ not. Patients with MRI were operated on median 2 days later than patients who did not receive MRI. CONCLUSIONS: Pelvic fracture MRI should be performed primarily in elderly female patients without adequate trauma. In patients with adequate trauma, MRI is of low value, especially as MRI diagnostics are performed with delay, resulting in later surgery.

Magnetic Resonance Imaging in Pelvic Fractures - Part 2: Gaining Information and Clinical Therapeutic Relevance. / Die Kernspintomografie bei Beckenfrakturen ­ Teil 2: Informationszugewinn und klinische Therapierelevanz.

BACKGROUND: Magnetic resonance and computed tomography (MRI, CT) has been known to compare the sensitivity for the detection of pelvic fractures with others. It is unclear whether MRI imaging beyond CT leads to therapy change. The aim of our study is to determine the information gained from MRI in the diagnosis of pelvic fractures and to reduce the effects on the form of therapy. PATIENTS AND METHODS: In a retrospective, clinical study, 31 patients with pelvic fracture and CT and MRI imaging (median 81 ± 20 years, 22 female and 9 male) were examined. There was a classification according to AO classification for adequate or FFP classification for inadequate fractures. In addition, vascular, muscular, haematomatous and organic concomitant injuries as well as bone marrow edema and additional secondary findings requiring evaluation were evaluated. The type of therapy (conservative vs. surgical) and a possible type of therapy change were documented for each patient. Exact test according to Fisher was tested orienting. RESULTS: Overall, MRI showed a greater fracture rate of pelvic fractures in 29% (n = 9) patients than CT. Four type I fractures according to FFP classification were identified as type II fractures and 4 type II fractures as type IV fractures. One type B1 fracture according to AO classification was found to be C2 fracture on MRI. Fisher's Exact Test found that the parameters "adequacy of trauma" and "fracture type change" by MRI were p = 0.38. MRI showed a total of 82 concomitant injuries, CT 31. Overall, MRI gained information in 75% (n = 24) of all patients examined. A change from conservative to operative after MRI took place in 2 patients. No patient was surgically changed from planned surgery to conservative. The extent to which MRI caused changes within one form of therapy (conservative, operative) could not be determined retrospectively. In 18% of patients with an inadequate fracture, however, according to the literature, the treatment regimen would have changed pro forma. CONCLUSION: In summary, it can be stated that the MRI in our study provided an information gain in the case of adequate and inadequate pelvic fractures as well as their accompanying injuries and that a possible therapeutic relevance of this information gain could be obtained specially at the inadequate fractures showed.

Can a Balance Wristband Influence Postural Control?

Eichhorn, S, Foerster, S, Friemert, B, Willy, C, Riesner, H-J, and Palm, H-G. Can a balance wristband influence postural control? J Strength Cond Res 34(12): 3416-3422, 2020-Top sports performances cannot be achieved without a high level of postural control. Balance wristbands purport to improve the mental and physical balance of the wearer. It is still unclear, however, whether these wristbands can indeed enhance postural control. Our aim was to ascertain through computerized dynamic posturography whether balance wristbands can improve postural stability. In this randomized controlled single-blind clinical study, posturography was used to assess postural control in 179 healthy subjects with or without a balance wristband. Tests were also performed with the subjects blinded to whether they were wearing an intact or a defective wristband. Analysis of variance (ANOVA) was used to detect significant differences (p ≤ 0.05). Stability indexes did not reveal significant differences in postural control between wearing and not wearing a wristband. Our study did not provide evidence of an improvement in postural stability. Because the single-blind trials too revealed no significant differences, a placebo effect could be ruled out.

Dual-energy CT as an innovative method for diagnosing fragility fractures of the pelvic ring: a retrospective comparison with MRI as the gold standard.

INTRODUCTION: As the average age of society increases, so does the number of cases of fragility fractures of the pelvis (FFP). Magnetic resonance imaging (MRI) can visualise associated oedema and is thus the gold standard for diagnosing such fractures. MRI, however, is costly, not always available, and involves certain exclusion criteria. Dual-energy computed tomography (DECT) appears to be a promising alternative. It is unclear, however, whether it could be used for diagnosing FFP with similar sensitivity/specificity. The aim of our study was thus to compare conventional CT and DECT with MRI in cases of suspected FFP. MATERIALS AND METHODS: A total of 46 patients with suspected FFP underwent MRI, CT and DECT scans. There were three comparison groups for each of these patients: conventional CT image analysis without dual-energy modification (Arm 1), DECT analysis (Arm 2) and MRI as the gold standard (Arm 3). Diagnosis and FFP classification were performed by a radiologist in random order and without clinical information. The sensitivity and specificity of conventional CT and DECT were calculated in comparison with MRI as the reference standard. RESULTS: With 100% sensitivity and specificity, DECT is on par with MRI when it comes to diagnosing fragility fractures of the pelvis and is superior to conventional CT (90.3% sensitivity, 100% specificity). In terms of classification as well, there were no differences between DECT and MRI. On conventional CT, on the other hand, 16 patients were classified differently than they were on MRI. CONCLUSIONS: Our study shows DECT to be reliable and superior to conventional CT in terms of oedema detection and specific fracture classification in FFP. DECT thus combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures).

[Internal meniscus resections do not affect anterior knee joint stability]. / Innenmeniskusresektionen beeinflussen nicht die anteriore Kniegelenksstabilität.

BACKGROUND: Meniscus injuries lead to increased knee joint instability. Currently, however, it is unclear whether a relevant medial meniscus part resection leads to an increased ventral tibia translation with intact anterior cruciate ligament. The aim of our study was therefore to clinically examine the stabilizer function of at least 30% resected medial meniscus for anterior tibial translation. MATERIALS AND METHODS: In this prospective study, 18 patients with unilateral medial meniscus lesion were treated before and after arthroscopic medial meniscus resection. They were treated on the healthy and on the sick leg through the use of two different apparatus methods (dynamic translation measurement using hamstring reflex apparatus and KT-1000 arthrometers) as well as a functional test (computer-supported dynamic posturography (CDP)) and a clinical hop test. Further, the mean values for significance using non-parametric Wilcoxon test. RESULTS: After completing all the studies, we were not able to detect any significant differences in our study that would indicate increased ventral instability in the knee joint after arthroscopic medial meniscus resection. CONCLUSIONS: Inner meniscal partial resection does not lead to increased ventral knee instability in intact VKB. Whether in patients with instability (feeling) after partial meniscus resection, a rotation instability is the cause or whether further injuries or disturbances in the capsular ligament apparatus are present, must be examined in further studies. Anterior knee joint instability cannot be adequately explained according to our study.

Initial Harm Reduction by N-Acetylcysteine Alleviates Cartilage Degeneration after Blunt Single-Impact Cartilage Trauma in Vivo.

Joint injuries are highly associated with the development of post-traumatic osteoarthritis. Previous studies revealed cell- and matrix-protective effects of N-acetylcysteine (NAC) after ex vivo cartilage trauma, while chondroanabolic stimulation with bone morphogenetic protein 7 (BMP7) enhanced type II collagen (COL2) expression. Here, as a next step, we investigated the combined and individual efficacy of intra-articular antioxidative and chondroanabolic treatment in a rabbit in vivo cartilage trauma model. Animals were randomly divided into group A (right joint: trauma (T); left joint: T+BMP7) and group B (right joint: T+NAC; left joint: T+BMP7+NAC). Condyles were impacted with the use of a spring-loaded impact device to ensure defined, single trauma administration. After 12 weeks, histopathological analysis was performed and the presence of matrix metalloproteinase 13 (MMP-13) and COL2 was assessed. Trauma-induced hypocellularity, MMP-13 expression, and cell cluster formation were reduced in NAC-treated animals. In contrast, BMP7 further increased cluster formation. Moreover, synovial concentrations of COL2 carboxy propeptide (CPII) and proteoglycan staining intensities were enhanced in NAC- and NAC+BMP7-treated joints. For the first time, the efficacy of NAC regarding early harm reduction after blunt cartilage trauma was demonstrated in vivo. However, parallel administration of BMP7 was not significantly superior compared to NAC alone.

Fragility Fractures of the Pelvis Classification: A Multicenter Assessment of the Intra-Rater and Inter-Rater Reliabilities and Percentage of Agreement.

BACKGROUND: The fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking. METHODS: Six experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references. RESULTS: The intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III. CONCLUSIONS: The FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities. CLINICAL RELEVANCE: With moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.

Age and "general health"-beside fracture classification-affect the therapeutic decision for geriatric pelvic ring fractures: a German pelvic injury register study.

PURPOSE: Pelvic ring fractures in the elderly gain increasing importance. Nonetheless, data on factors influencing treatment decision in relation to fracture classification, age, and the resulting treatment are still rare. METHODS: Prospectively collected data of the German Pelvic Injury Registry from patients aged over 65 years with a pelvic ring fracture were evaluated retrospectively. Acetabular fractures, as well as type A1 and A3 fractures, were excluded. The variables age, injury pattern, type of treatment, the reason for conservative treatment, and Orthopaedic Trauma Association (OTA)/Tile classification were analyzed. Furthermore, the fracture distribution was examined after dividing patients into six age groups. RESULTS: A total of 1814 patients with a mean age of 80.7 ± 7.6 years, predominantly female (79.0%), were available for evaluation. The majority of patients suffered from isolated pelvic ring fractures (70.1%) and 8.2% were severely injured (ISS > 16). The most common fracture types were type A2 (35.4%), type B2 (38.0%), and type C1 (7.3%). Especially pelvic ring fractures of type A2 (96.9%) and type B2 (83.0%) were treated conservatively (overall 76.9%). Fracture instability according to the OTA/Tile classification increased the probability for an operative treatment (generalized odds ratio [OR] 6.90 [5.62; 8.52]). In contrary, increasing age independent of the fracture pattern decreased this probability (OR 0.47 [0.41-0.53]). With increasing fracture instability, general health conditions were up to 50% of the reasons for conservative treatment. CONCLUSION: The results of the present study underline the importance of the factors age and general health besides fracture classification for therapeutic decision-making in the treatment of pelvic ring fractures in the elderly.

Avulsion Fractures of the Ischial Tuberosity and Resulting Ischiofemoral Impingement - a Case Report with Literature Review. / Avulsionsfrakturen am Tuber ischiadicum und resultierendes ischiofemorales Impingement ­ ein Fallbericht mit Literaturreview.

INTRODUCTION: Apophyseal avulsion fractures of the ischial tuberosity are rare injuries and therefore often not diagnosed in a timely manner. Healing may then result in massive hypertrophic ischial tuberosity. This can cause ischiofemoral impingement symptoms. Due to the low incidence and scarce literature, the optimal treatment and surgery is unclear. MATERIALS AND METHODS: A literature search was carried out using the online medical database "PubMed". The findings of the literature were then applied to a clinical case of delayed diagnosis of the apophyseal avulsion fracture of the ischial tuberosity. RESULTS: There is no gold standard in the literature for the treatment of avulsion fractures on the ischial tuberosity. Nearly 90% are treated conservatively and a fragment dislocation of more than 2 cm is often the indication for surgical care. However, the surgical procedures described are very diverse. An ischiofemoral impingement symptom may result from excessive ossification of the ischial tuberosity, bringing the ischiofemoral distance to the critical limit of 2 cm. CONCLUSIONS: The timely correct diagnosis and initiation of a therapy is crucial for the later outcome of the patient. Ischiofemoral impingement symptoms may be the indication of bony displacement of the ischial tuberosity as a result of injury. Therapy is then surgical with partial resection of the ischial tuberosity and plate osteosynthesis.

Diagnostic Accuracy of Fluoroscopy, Radiography, and Computed Tomography in Detecting Cement Leakage in Kyphoplasty.

PURPOSE: Cement leakage is a typical complication of kyphoplasty for vertebral fractures. It is unclear if cement application intraoperatively can be improved by using other techniques of visualization and which kind of postoperative imaging should be recommended to detect cement extravasation accurately. OBJECTIVE: To compare the rates of cement leakage detected by intraoperative fluoroscopy, postoperative radiography, and postoperative computed tomography (CT) in a retrospective study. PATIENTS AND METHODS: The study included 78 patients (60 women and 18 men; 115 vertebral bodies) who were treated with two kinds of kyphoplasty. The patients underwent intraoperative fluoroscopy and postoperative radiography and CT. After surgery, the images were evaluated to compare cement leakage rates and locations in the three visualization techniques. Leakage locations were described as epidural, intradiskal, extravertebral, or intravascular. RESULTS: Compared with CT, intraoperative fluoroscopy regularly detected intradiskal leakage (75%) but had a considerably lower sensitivity for visualizing epidural (21%), extravertebral (31%), and intravascular (51%) cement leakages. A comparison of radiography and CT showed that radiography had a high sensitivity for detecting intradiskal (82%) and intravascular (70%) cement extrusions but a lower sensitivity in identifying epidural (42%) and extravertebral (50%) leaks. Therefore, the CT scan overall was best in detecting location and accuracy. CONCLUSION: CT detected more cement leaks than any of the other investigated techniques, especially epidural, extravertebral, and intravascular cement leakages. To achieve the best accuracy, only CT provides complete information.

[Vertebral Body Height after Balloon Kyphoplasty vs. Radiofrequency Kyphoplasty]. / Retrospektiver Vergleich der Wirbelkörperaufrichtung nach Ballonkyphoplastie vs. Radiofrequenzkyphoplastie.

BACKGROUND: Kyphoplasty is used to alleviate pain and to restore the initial height of osteoporotic vertebral fractures (OVF). One of the most recent procedures is radiofrequency-targeted vertebral augmentation (RFTVA). We investigated whether restoration with this method is similar and as adequate as with the established procedure of balloon kyphoplasty (BKP), as assessed by the anatomical height of the vertebral body. The aim of our study was to compare the intravertebral angles (base-endplate) post- and preoperatively with these two procedures. PATIENTS AND METHODS: The base and endplate angles were measured on 142 vertebral bodies treated by kyphoplasty (67 BKP and 75 RFTVA), on the basis of pre- and postoperative X-rays in the upright position in 87 volunteers (46 BKP and 41 RFTVA). The main object was to detect the degree of correction (Δpost-preop) with BKP compared to RFTVA. Furthermore, the sagittal alignment of the adjacent heathy levels were measured. RESULTS: Significant correction was detected with both BKP (BKPpre: 11.5 ± 6.0°, BKPpost: 6.2 ± 4.6°, p < 0.001) and RFTVA (RFTVApre: 9.9 ± 6.2°, RFTVApost: 6.3 ± 4.4°, p < 0.001). Potential correction was greater with BKP than with RFTVA (Δpost-pre BKP: - 5.3 ± 4.4°, Δpost-pre RFK: - 3.6 ± 4.4°, p = 0.03). Neither procedures gave a significant change in the sagittal angle in the adjacent segment (segment BKPpre: 13.8 ± 8.0°, Segment BKPpost: 12.5 ± 9,2°, p = 0.638; Segment RFTVApre: 18,8 ± 14,3°, Segment RFTVApost: 15.0 ± 13.2°, p = 0.330). CONCLUSION: BKP gave significantly better correction, even though both methods were able to restore significant improvement in the kyphotic angle. In the adjacent levels, correction of the sagittal angle was not significant, although the influence of the intervention on alignment tended to be less.