[Realization and implementation of a trauma network of the German Association of Trauma Surgery (DGU) exemplified by the Trauma Network of eastern Bavaria]. / Umsetzung und Implementierung eines TraumaNetzwerksD der DGU am Beispiel des TraumaNetzwerks Ostbayern.

The quality of care of seriously injured persons in Germany is nationally and internationally recognized to be at a high level. However, there are local discrepancies. In 2006 the German Association of Trauma Surgery published the White Paper for the Management of the Seriously Injured. The goal of the paper is a further increase in the quality of care of seriously injured persons. A crucial point of the publication is the call to establish regional trauma networks in Germany. Work on this project has been carried out in eastern Bavaria since spring 2007. The first meeting of the Trauma Network of eastern Bavaria took place in July 2007. On 3rd September 2008 the university hospital of Regensburg was the first clinic audited in Germany. To date nearly 75% of all hospitals in the trauma network of eastern Bavaria have been audited. The establishment of a regional trauma network is a multifactorial event. Essential factors in the development of the trauma network were found to be the communication between the head physicians and the nomination of an appointee of the regional trauma network. For the head physicians the 9 meetings of the trauma network since July 2007 functioned as the communication platform. These exchanges of the head physicians are necessary to animate a trauma network. The appointee of the regional trauma network--most suitably a member of staff of the speaker of the trauma network--is essential to guarantee communication between meetings and to manage prompt responses to questions from the network. This article describes the experiences gained during the implementation of the trauma network in eastern Bavaria.

Single lateral locked screw plating of bicondylar tibial plateau fractures.

We prospectively followed a case series of 68 patients with 69 AO/ASIF 41-C-type fractures treated with the Less Invasive Stabilization System for the proximal lateral tibia. We assessed malreduction, secondary loss of reduction, and infection rates in patients with a locked screw plate for unilateral fixation of bicondylar fractures. Sixty-two (91%) patients returned for final followup (range, 11-13 months). Malreduction and malalignment were defined as an intraarticular step-off of 2 mm or greater, or as a malalignment in the frontal or sagittal plane greater than 5 degrees . Fourteen fractures were open. Primary bone grafting was done in 13 patients. Significant malreduction was seen in 16 patients. There were four superficial infections and one deep infection. One fracture did not heal, and nine patients had substantial loss of reduction. Unilateral locked screw plating is a good alternative for treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

Less invasive stabilization of complex tibial plateau fractures: a biomechanical evaluation of a unilateral locked screw plate and double plating.

OBJECTIVE: To compare the vertical subsidence in a bicondylar tibial plateau fracture model stabilized either by a unilateral locked screw plate (LSP) or by double plating. DESIGN: Biomechanical cadaver study. INTERVENTION: A 41-C1 fracture model was created in eight pairs of fresh-frozen human cadaver tibiae. Stabilization was performed either by open reduction and internal fixation (ORIF) using a lateral L-buttress plate and a medial four-hole, one-third tubular antiglide-plate or by a lateral LSP. Four load levels (400N, 800N, 1200N, 1600N), each with five cycles, were consecutively applied to the medial plateau. MAIN OUTCOME MEASUREMENTS: The vertical plastic deformation at the end of each cycle was the main parameter of interest. Statistical analysis was performed with the two-way ANOVA test for repeated measurements. Each individual loading level was analyzed separately using Student t test. RESULTS: In one pair, both fixation techniques failed at the first loading cycle of 1200N. One ORIF fixation failed at the first loading cycle of 1600N. The average plastic vertical subsidence was 0.40 mm (LSP) and 0.25 mm (ORIF) at 400N (P = 0.291), 0.83 mm (LSP) and 0.81 mm (ORIF) at 800N (P = 8.82), 1.06 mm (LSP) and 0.96 mm (ORIF) at 1200N (P = 0.98), and 1.54 mm (LSP) and 1.14 mm (ORIF) at 1600N (P = 0.53). Vertical subsidence depended on the applied load (P = 0.002), but not on the method of fixation (P = 0.236). CONCLUSION: Both fixation techniques have a high resistance to vertical subsidence even with loads exceeding the average body weight. No statistically significant difference was seen between the two methods of fixation.

[Fracture of the medial femoral condyle as a complication of retrograde femoral nail removal]. / Fraktur des medialen Femurkondylus als Komplikation bei der Entfernung eines retrograden Femurnagels.

A 26-year-old female patient with a femoral shaft fracture underwent retrograde femoral nailing. Nail removal was performed 2 years later, after fracture healing. An intraoperative fracture of the medial condyle of the femur occurred. This complication has not been previously described in the literature. Screw osteosynthesis of the fracture was performed and articular congruence reestablished. After 6 weeks of fractional weight bearing, the patient proceeded up to full weight bearing without complication. The case demonstrates that the removal of retrograde femoral nails is not without complications. The decision to undertake implant removal should be made carefully.

Fractures of the glenoid treated by operation. A 5- to 23-year follow-up of 22 cases.

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection. At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus.

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases.

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

[Bone segment transport of the femur. Biomechanical value of an unreamed titanium intramedullary nail with reference to stiffness of external distraction systems]. / Der Knochensegmenttransport am Femur. Der biomechanische Stellenwert eines unaufgebohrten Titanmarknagels bezüglich des Steifigkeitsverhaltens externer Distraktionssysteme.

The influence of an unreamed femur nail on axial and torque stiffness of nine different external fixator devices was investigated in a biomechanical study. With a newly developed femur bone model simulating segmental transport, 582 biomechanical tests were performed. The additional use of an unreamed femur nail (UFN) increased axial stiffness of the external fixator devices up to 8108% (average 1673.8-2631.8%) and increased torque stiffness up to 86% (average 47%). The best results could be achieved when combining a small-diameter UFN (9 x 360 mm, Synthes Co.) and external fixator devices with high torque and comparatively little axial stiffness. The use of stainless steel half-pins instead of titanium half-pins improved torque stiffness significantly. Concerning the biomechanical demands made on external fixator devices used for femoral segmental transport, the Hexfix fixator with steel bar and steel half-pins combined with an UFN achieved the best results.

Distal femoral fractures and LISS stabilization.

In recent years, the technique of surgical stabilization in the distal femur has changed. This change decreased the number of non unions and the need for bone grafting. Minimally invasive surgical techniques with a submuscular plate placement have replaced the emphasis on anatomical reduction in the shaft area. Reconstruction of complex articular injuries has been simplified by more direct visualization of the articular surface with the lateral peripatellar approach. Problems remaining are surgical technique and implant considerations. The Less Invasive Stabilization System (LISS) simplifies the surgical technique for percutaneous plate osteosynthesis. An insertion guide is used to insert monocortical, self-tapping screws through a stab incision. A thread in the plate provides the angular stability for the anchoring of these screws. In extra-articular fractures and simple intra-articular fractures, the distal femoral nail permits intramedullary stabilization. A spiral blade improves fixation of the distal femoral condylar block. Despite the enhanced surgical technique and implant possibilities, a great number of patients show a functional deficiency. These are particularly patients with complex intra-articular fractures. The 'fatigue failure' of the osteoporotic implant-bone construct is a problem in elderly patients. The LISS represents a good option to avoid the addition of bone cement to an osteosynthesis.

[Distal fractures of the femur]. / Distale Femurfrakturen.

Supracondylar femoral fractures still present a challenge to the treating surgeon. The incidence of delayed and non-unions is reduced due to the minimally invasive plating techniques, but establishing a correct axis and good function is still a problem. During the last few years new implants have been developed to allow less difficult operative techniques in minimally invasive surgery. The Less Invasive Stabilization System (LISS) is a percutaneous plating system with monocortical self-drilling screws. The screws are inserted with an aiming guide and form a stable angle with the plate. The distal femoral nail allows placement of a spiral blade in the nail, thereby enhancing the interlocking stability.

Biomechanics of femoral interlocking nails.

Today there is a variety of different interlocking intramedullary nail designs available for the femur. We compared different nail types in the bone implant complex (BIC) of four unreamed solid nails and a slotted reamed nail with simulated comminuted mid shaft fractures to see if there are major differences in stiffness for axial load, bending and torsion. The fractures were simulated by a 2 cm defect osteotomy in paired human cadaver femora. Each bone was tested intact in a universal testing machine, osteotomy and osteosynthesis were performed, and the BIC was tested. Relative stiffness was calculated. In torque testing the unslotted solid nail showed significantly more stiffness (0.6-1.8 Nm/degrees) compared to the slotted nail (0.2 Nm/degrees). Compared to intact bone (6.9 Nm/degrees), both groups of nails were significantly less stiff (relative stiffness 2-20%). In axial load and bending testing the large diameter unreamed nail showed significantly higher stiffness (32-68%). This study shows that stiffness of bone implant complex in interlocking femoral nails is more dependent on nail profile than on the pressfit of nails in the medullary canal.

The topography of the perforating vessels of the deep femoral artery.

This study evaluated the anatomic relationship between the femur and the vessels that arise from the deep femoral artery, that is, the perforating arteries and the nutrient artery. Blue silicone dye was injected through the common femoral artery in 20 fresh human cadavers. An anteromedial and a posterolateral dissection were performed to identify the femoral perforating arteries and the nutrient artery of the femur. The length of the femur and the distances between the tip of the greater trochanter and the perforating arteries and nutrient artery were measured. This study showed that a reliable, clinically applicable topographic relationship exists between the femur and the perforating arteries and the nutrient artery.

Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique?

OBJECTIVES/HYPOTHESIS: Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model. STUDY DESIGN/METHODS: Ten fresh human cadavers underwent lateral conventional plate osteosynthesis (CPO) through a standard lateral approach on one side and minimally invasive plate osteosynthesis (MIPO) through two three-centimeter incisions on the contralateral side. After injection of silicone dye, a dissection was performed bilaterally to identify the femoral perforating and nutrient arteries. RESULTS: All MIPO specimens showed intact perforating and nutrient arteries, whereas the CPO specimens had a variable incidence of vessel disruption. The MIPO group demonstrated better periosteal perfusion in each of the cadavers and improved medullary perfusion in 70 percent of the MIPO specimens compared with the CPO specimens. CONCLUSION: A percutaneous minimally invasive plating technique disrupts the femoral blood supply less than the traditional open method. Such minimally invasive methods may be more advantageous biologically than the traditional method.

[Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate]. / Hüftkopfnekrose nach Kondylenplattenosteosynthese einer proximalen Oberschenkelschaftfraktur.

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of sub-trochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.

The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails.

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter. We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29). All fractures had united. Healing was evident radiologically at a mean of 5.4+/-2.1 months (3 to 12) with a mean varus-valgus alignment of -1.0 degree (-5 to 3) and mean antecurvatum-recurvatum alignment of 1.6 degrees (-6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5 degrees in the frontal plane and 0.4 degrees in the sagittal plane. There were no complications related to the Poller screw. The clinical outcome, according to the Karström-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%).

The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails.

OBJECTIVES/HYPOTHESIS: To evaluate the mechanical effects of medial and lateral blocking screws in supplementing intramedullary nail fixation of high proximal and low distal tibial fractures treated with small-diameter intramedullary nails. STUDY DESIGN: Intact fresh human cadaveric tibiae were sectioned to provide ten distal segments measuring seventy millimeters and ten proximal segments measuring ninety millimeters. In the distal segments, stainless steel solid eight-millimeter tibial nails were advanced to eight millimeters from the ankle joint. Two transverse and one anterior-posterior (AP) locking screw were inserted using a custom-made jig. The same jig was used for the placement of a medial and a lateral blocking screw (BS) in the AP direction, nine millimeters above the superior most interlocking screw and eight millimeters distal to the lower end of the segment. In the proximal segments, two interlocking screws (both static and dynamic screws) were placed in a medial-lateral direction with the use of the insertion handle. A jig was used for placement of a medial and a lateral BS in the AP direction, nine millimeters below the lower transverse interlocking screw and sixteen millimeters proximal to the lower end of the segment. The bone-implant construct (BIC) was embedded and fixed in a materials testing machine. The BICs were loaded in the medial-lateral direction at a distance of 185 millimeters from the nail ends with loads from -150 newtons to + 150 newtons. Force-displacement curves were recorded before and after insertion of the BSs. RESULTS: In proximal BICs, the addition of BSs decreased the deformation of the BICs 25 percent, from 8.9 +/- 1.9 degrees [mean +/- standard deviation (SD)] in the control group to 6.8 +/-1.1 degrees in the BS group (mean +/- SD) (p < 0.0001). In distal BICs, the addition of BSs decreased the deformation of the BICs 57 percent, from 9.5 +/- 1.4 degrees (mean +/- SD) in the control group to 4.0 +/- 1.0 degrees in the BS group (mean +/- SD) (p < 0.0001). CONCLUSIONS: The study suggests that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability.

Effects of percutaneous and conventional plating techniques on the blood supply to the femur.

A cadaveric arterial injection study was performed to study the effects of percutaneous and conventional surgical plating techniques on femoral vascularity. Sixteen-hole dynamic condylar screw and condylar buttress plates were applied on the proximal and distal shafts, respectively, of intact femora in ten human cadavers. On one side, the plate was inserted using a lateral conventional plate osteosynthesis (CPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPPO) technique. After plating, blue silicone dye was injected through the common femoral artery. A dissection was then performed to identify the femoral perforating arteries (PAs). The pattern of periosteal filling of the injected dye was analyzed. The MIPPO technique maintained the integrity of the PAs and exhibited superior periosteal perfusion. The results of this study indicate that the MIPPO technique maintains femoral vascularity and perfusion better than the CPO technique.