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Background: The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G‑DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included., Methods: All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings., Results: A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €)., Conclusion: Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted., (© 2021. The Author(s).)

Background: Sacral U‑shaped fractures are rare but severe injuries. Due to the resulting spinopelvic dissociation they are highly unstable. Reduction and stabilization are usually required and decompression may be necessary due to frequent concomitant neurological injuries. In the literature there is no consensus with respect to the selection of the surgical approach., Case Presentations: After a road traffic accident an 18-year-old woman suffered a U-fracture of the sacrum type II according to Roy-Camille and was treated with bilateral double sacroiliac screw osteosynthesis and sacral laminectomy. A 76-year-old man with a U‑fracture type I according to Roy-Camille after falling down the stairs was treated by lumbopelvic fixation. A 24-year-old man with U‑fracture type II according to Roy Camille after a road accident was treated with triangular vertebropelvic stabilization and sacral laminectomy. For all patients the outcome was good., Conclusion: Surgical treatment is necessary, with minimally invasive techniques offering advantages over open surgery. A distinction must be made between lumbopelvic fixation and posterior pelvic ring fixation. Multiple aspects must be taken into consideration of the indications when selecting the surgical technique.

Purpose: To define a new parameter in CT that could make imaging of the contralateral ankle dispensable evaluating the position of the fibula after syndesmotic injury., Methods: Thirty bilateral CTs of 30 patients were included. Five parameters were defined in axial CT for the injured (_inju) and uninjured (_unin) ankle. Reproducibility was examined for inter-observer and intra-observer reliability. Comparisons for all parameters were performed between the CT scans of both ankles., Results: All measurements had a high agreement for the inter-observer and intra-observer correlation coefficients. A large interindividual variance could be found between all parameters. If the difference of the anterior tibiofibular distance antTFD_unin and antTFD_inju was less than 2 mm, there was a strong significant pairwise correlation between all parameters between both sides., Conclusion: Bilateral CT is still to be recommended, as it is the only way to exactly assess anterior posterior reduction of the fibula.

Background: Spondylodiscitis is a rare disease with an increasing incidence., Methods: In this retrospective study 112 patients with spondylodiscitis surgically treated from 1 January 2005 to 31 December 2012 in a level I spine center were investigated with respect to potential prognostic criteria. The time period covered by the investigation was the duration of hospitalization. The parameters analyzed were mortality, age, localization of the spondylodiscitis, detection of abscesses and pathogens, neurological status and body mass index (BMI)., Results: The average age of the patients was 68.3 years (±12.9 years). The mortality rate during hospitalization was 10.7% (N = 12). Older patients had a significantly higher in-hospital mortality rate (p = 0.008). Abscess formation was found in 49.1% of the patients and was associated with a significantly longer hospital stay (p = 0.001) and in the intensive care unit (ICU, p = 0.001) as well as a higher risk of revision surgery (p = 0.018). In addition, obese patients had a significantly higher occurrence of abscesses (p = 0.034). Pathogen detection was successful in 60.7 % of the cases with Staphylococcus aureus as the most frequent pathogen. Detection of pathogens was associated with a longer hospital stay (p = 0.006) and a greater need of intensive care monitoring (p = 0.017). Patients with a nephropathy had a significantly increased mortality, longer duration of hospitalization and a more frequent occurrence of multilevel afflictions., Conclusion: Old age, abscess formation, positive detection of pathogens and renal failure can be used as prognostic criteria. Risk factors for formation of abscesses include a lumbar localization of spondylodiscitis, nephropathy as well as detection of a pathogen and obesity.

This article presents the case of a rapidly progressing pyoderma gangrenosum (PG) following a minor trauma and surgical intervention. A 46-year-old patient was admitted to hospital after a minor trauma of the right lower leg with a suspected diagnosis of erysipelas bullosum. A magnetic resonance imaging (MRI) scan showed the suspicion of necrotizing fasciitis (NF) with indications for immediate incision and fascia resection. According to the results of the histopathological analysis and microbiological assessment without signs for a bacterial infection, high-dose steroid treatment and immunosuppressive treatment with cyclosporin A were initiated under the assumption of PG. Additionally, the patient was treated with hyperbaric oxygenation (HBO). The 2‑year follow-up showed a gradual restitution of the soft tissues.

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.

Introduction: The purpose of this study was to evaluate risk factors of accompanied C1 fractures in elderly patients with type II odontoid fractures (OF) and to analyze the complication rate and the outcomes of patients after combined anterior odontoid and transarticular C1/2 screw fixation (AOTAF)., Materials and Methods: The study represents a retrospective case series at a single level-1 trauma center. All elderly patients (≥ 70 years) with acute combination injuries (CI) including type II OF with an accompanied C1 fracture, who were treated by an anterior approach, were included. All postoperative complications were analyzed based on the patient notes. Clinical and radiological controls were performed after 1 year. Main parameters of interest were 1-year mortality rate, pain level, and satisfaction rate after 1 year., Results: A total of 23 patients were included. The average age was 84.6 years (range 73-94 years). All patients had atlanto-odontoid osteoarthritis (AOO) and all but two patients were injured by low-energy falls. Dysphagia was the most common postoperative complication (26.1%). Surgical revision was necessary in one of these patients due to hematoma. Dysphagia improved in all patients considerably. Loss of follow-up was 21.7%. The 1-year mortality was 21.7% (n = 5). The mean pain level and satisfaction rate was 2.5 (± 0.9) and 7.3 (± 0.7), respectively. After 1 year, no signs of non-union were visible., Conclusions: AOO was observed in all patients with CI. The main cause of trauma was a low-energy fall. The pain levels were low to moderate and satisfaction levels were promising 1 year after surgery. Nonetheless, AOTAF is associated with a high rate of postoperative dysphagia, which resolves in the majority of patients due to conservative management.

Introduction: Surgical treatment of unstable burst fractures of the thoracolumbar spine in the elderly population is highly variable with combined posterior and anterior stabilization (CPAS) and posterior augmented stabilization with cementation of the vertebral body (hybrid) being two commonly used techniques. The aim of this study was to compare the clinical and radiographic outcomes of CPAS versus hybrid stabilization for the treatment of unstable burst fractures of the thoracolumbar spine in patients aged between 60 and 70 years., Materials and Methods: A retrospective analysis was performed of all thoracolumbar burst fractures treated surgically in a single level I trauma center between June 2013 and February 2015. Two commonly used strategies of surgical stabilization were compared; the first consisted of initial posterior reduction and bisegmental stabilization, followed by additional anterior spondylodesis (CPAS); the second method comprised a hybrid technique with a posterior cement augmented bisegmental minimally invasive stabilization and kyphoplasty of the fractured vertebral body. Patients were evaluated clinically after a minimum follow-up of 18 months. The primary endpoint was the Oswestry Disability Index (ODI) at the latest follow-up. Secondary parameters of interest were length of in-hospital stay (LIHS), duration of surgery (DS), surgical revisions (SR), pain level (P-VAS), satisfaction level and the SF-36 score (PSC, MSC), the bisegmental postoperative Cobb angle, the reduction loss (RL), and all alignment parameters (pelvic tilt, pelvic incidence, sacral slope, lumbar lordosis, C7 plumb line)., Results: A total of 29 patients were included (17 females, 12 males, mean age 65.6 years ± 3.4 years). The following vertebral bodies were fractured: thoracic level (T) 12: n = 6; lumbar (L) 1: n = 14; L 2: n = 6; L 3: n = 3. CPAS was performed in 10 patients (34%), whereas the hybrid was carried out in 19 patients (66%). There were no statistical significant differences between both study groups regarding age, gender, trauma energy, fracture level, and fracture morphology. The latest follow-up was performed after a mean of 27 months (range 18-53 months). The LIHS between the treatment methods was statistically significant (p < 0.01); CPAS-mean 24 days versus hybrid-mean 12 days. DS was also significantly longer in patients treated with CPAS, 254 versus 95 min for the hybrid group (p < 0.01). No SR were necessary in either group. No significant differences were found regarding the clinical and radiological outcomes between the groups. The mean ODI score was 13.6 in the CPAS patients compared to 10.8 in the hybrid patients without significant differences between the groups. The majority of patients had no (80%) or minor (13%) limitations according to the ODI score. The P-VAS was 2.8 in CPAS and 2.9 in the hybrid group. RL was 7.1° in CPAS and 4.2° in the hybrid group., Conclusions: CPAS and hybrid stabilization provide safe and promising short- and middle-term results in patients between 60 and 70 years of age. The majority of patients demonstrated no disability or minimal limitations with either technique. CPAS resulted in prolonged inpatient hospital stays, longer duration of surgery compared to hybrid stabilization without significant differences in clinical and radiological outcome.

Purpose: The purpose of this study was to identify the rate of primary screw perforations after osteosynthesis of proximal humerus fractures with intra-operative 3D fluoroscopy and to analyse the rate of secondary screw perforations as well as complications, outcome, and revision surgeries after a minimum of 12 months., Materials and Methods: Thirty-three patients (20 female, 13 male, median age 67 years, range 35-85 years) with displaced proximal humerus fractures were included. After reduction and fixation, an intra-operative 3D fluoroscopy was performed to evaluate primary screw perforations (PS) and screws with "near perforation" (nPS). These screws were changed intra-operatively. Patients were followed-up for a minimum of 12 months. Clinical and radiological parameters, such as secondary screw perforation, secondary loss of reduction, or functional outcome, were investigated., Results: In six patients (18.2%), humeral head screws were changed due to primary PS (n = 2) or nPS (n = 4) after the intra-operative 3D fluoroscopy. Follow-up revealed an adapted constant score (%CMS) of 76.2% after a mean follow-up of 17.7 months. Two secondary screw perforations were observed (6%). Loss of reduction was observed in eight patients (24.2%)., Conclusion: The intra-operative 3D reveals a high rate of primary screw perforations or near perforations. Immediate change of these screws may lead to a lower rate of secondary screw perforations and, therefore, reduce post-operative complications.

Objectives: The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management., Methods: From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA., Results: The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1)., Conclusion: The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

Background: Bisegmental dorsal stabilization is a common treatment option for instable compression fractures of the thoracolumbar spine; however, it remains unknown to what extent bridging compromises intervertebral discs., Objectives: The purpose of this study was to determine the disc height and functional features in comparison to healthy intervertebral discs after removal of the dorsal fixator and particularly under consideration of the time span between dorsal stabilization and implant removal (IR)., Material and Methods: The IR was performed in 19 patients after an average of 13 months (range 8-24 months) after dorsal stabilization of instable vertebral compression fractures of the thoracolumbar junction and lumbar spine. An additional ventral monosegmental spondylodesis was performed in 10 patients with incomplete burst fractures. Thus, a total of 28 intervertebral discs were temporarily bridged (bridged discs), with an adjacent endplate fracture in 10 (injured discs) and no adjacent bony lesion in 18 discs (healthy discs). The intervertebral discs superior and inferior to the instrumentation were selected as controls (control discs). Standardized conventional lateral radiographs were taken prior to and after IR as well as after 6 months. Additionally, standardized lateral radiographs in flexion and extension were taken. The intervertebral disc height (disc height) was determined by two independent board approved orthopedic observers by measuring the anterior, central and dorsal intervertebral disc spaces on all lateral radiographs as well as the intervertebral disc angles (disc angle) defined by the intervertebral upper and lower endplates in the flexion and extension views. Intradisc function (disc function) was defined as the difference between the disc angle in extension and flexion. The measurements were repeated after 12 months. Univariate analysis was performed using ANOVA and significance was set at p < 0.05. Interobserver and intraobserver comparisons of the disc heights and the disc angles were determined with intraclass correlation coefficients., Results: No significant differences were seen in disc function and disc height between the controls and the bridged discs at all times of measurement; however, injured discs showed a significantly reduced disc height and disc angle in extension compared to healthy discs (p = 0.028 and p = 0.027, respectively). Additionally, patients with IR during the first 12 months had significantly reduced disc heights compared to those patients with delayed IR within the second postoperative year (p = 0.018). Interobserver and intraobserver agreement for disc function was 0.80 (95 % confidence interval CI: 0.68-0.88) and 0.85 (95 % CI 0.76-0.90), respectively. The interobserver and intraobserver correlations for disc height were 0.85 (95 % CI: 0.76-0.90) and 0.93 (95 % CI 0.88-0.95), respectively., Conclusion: Bridging of an intervertebral disc with IR within 24 months does not cause immediate loss of disc function or reduction of disc height; however, temporary bridging in combination with an adjacent endplate fracture causes significant reduction of disc height and loss of extension. Additionally, no beneficial effects could be seen by reducing the time span between stabilization and IR to below 12 months.

Introduction: There is a general consensus that unstable vertebral body fractures of the thoracolumbar junction with a B type fracture or a high load shear index need to be surgically stabilized, primarily by a dorsal approach. The authors believe that there are indications for an additional ventral spondylodesis in cases of reduction loss or a relevant intervertebral disc lesion in magnetic resonance imaging (MRI) 6 weeks after dorsal stabilization. However, in cases of unstable vertebral fractures it remains unclear if a delayed anterior spondylodesis will lead to unacceptable loss of initial reduction., Material and Methods: A total of 59 patients were included in this study during 2013 and 2014. All patients suffered from a traumatic vertebral fracture of the thoracolumbar junction and were initially treated with a dorsal short segment stabilization. All vertebral body fractures had a load shear index of at least 5 or were B type fractures. An x-ray control was carried out after 2 and 6 weeks and MRI was additionally performed after 6 weeks. An additional ventral spondylodesis was recommended in patients showing a reduction loss of at least 5° and in patients with relevant intervertebral disc lesions. The extent of the reduction loss was analyzed. Other parameters of interest were the fracture level, fracture classification, patient age and surgical technique (e.g. implant, index screw, laminectomy and cement augmentation)., Results: The patient collective consisted of 23 women and 36 men (average age 51 years ± 17 years). The mean reduction loss was 5.1° (± 5.2°) after a mean follow-up of 60 days (± 56 days). The reduction loss was significantly higher when polyaxial implants were used compared to monoaxial dorsal fixators (10.8° versus 4.0°, p < 0.001). There was a significantly higher reduction loss in those patients who received a laminectomy (11.3° versus 4.3°, p = 0.01) but there were no significant differences if an index screw was used (4.5° versus 5.3°). Additionally, there was a significantly lower reduction in the subgroup of patients 60 years or older who were stabilized using cement-augmented screws (3.9° versus 11.3°, p = 0.02). The mean reduction loss was 2.8° (± 2.5°) in patients treated with a monoaxial implant, cement-augmented if 60 years or older and without laminectomy (n = 39). There was no significant correlation between reduction loss and the other parameters of interest, such as fracture morphology with classification according to the working group on questions of osteosynthesis (AO) and McCormack or fracture level., Conclusion: Delayed indications for an additional ventral spondylodesis in patients with unstable thoracolumbar vertebral fractures and initial dorsal stabilization will cause no relevant reduction loss if monoaxial implants are used and laminectomy can be avoided. Additionally, cement augmentation of the pedicle screws seems to be beneficial in patients 60 years of age or older.

Background: Because of the rise in primary implantations in elective knee and hip arthroplasty, the number of complications, particularly due to prosthetic infections has increased. Partly due to multimorbidities, an increase in geriatric patients and often unnecessary use of antibiotics, a change in the spectrum of bacteria with an increase in multi-drug resistant pathogens is to be expected. For physicians this creates not only new medical and economic but also sociopolitical challenges., Question: Has the spectrum of bacteria in prosthetic joint infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA) changed during the 12-year period 2001-2012 in our hospital and what role do multi-drug resistant bacteria play?, Investigation Collective: A total of 320 patients with prosthetic joint infections (PJI) following TKA or THA could be identified and were included in this study. The sample consisted of 172 patients with an infection after THA (56 % females n = 96 and 44 % males n = 76) with a mean age of 70.9 years (range 39-92 years) and 148 patients with an infection after TKA (55 % females n = 82 and 45 % males n = 66) with a mean age of 70.7 years (range 15-87 years). The bacteria detected and the development over the course of time were evaluated., Results: An increase was found in the occurrence of coagulase negative staphylococci (CNS), in particular Staphylococcus epidermidis (2001-2003 n = 10 and 2010-2012 n = 27). The proportion of oxacillin and methicillin-resistant Staphylococcus epidermidis (MRSE) was also found to increase (0 % in 2001-2003 and 74 % in 2010-2012). A substantial increase in methicillin-resistant Staphylococcus aureus (MRSA) infections could not be found and there was a tendency towards reduction in the total number of Staphylococcus aureus infections. A total of five extended spectrum beta-lactamase (ESBL)-producing bacteria were isolated., Conclusion: The spectrum of bacteria has only slightly changed over the years from 2001 to 2012, whereby an increase was only found in the number of CNS infections. Multi-drug resistant bacteria, in particular MRSE have increased. The changes in MRSE found in this study do not appear to warrant a general rethinking of antibiotic prophylaxis.

Background: Osteitis pubis or symphysitis pubis is a rare occurring non-infectious inflammation of the symphysis, the adjacent pubic bones and surrounding tissue. The therapy might be conservative or surgical by a resection of the symphysis and involved parts of the pubic bone. Nevertheless, this resection might lead to an anterior instability impairing the posterior arch and the sacroiliac joints in the aftermath., Case Presentation: Here, we report about a 50-year-old women suffering from osteitis pubis treated by wedge resection of the symphysis and parts of the pubic bone. To maintain stability and for local antibiotic treatment a cement spacer was implemented. By clinical inconspicuous findings and the patient's desire, no further surgery was performed. However, 2 years after surgery the spacer dislocated and the patient complained about pain in the posterior arch due to an impaired mobility. Reconstruction surgery was planned including the bridging of the accrued space with a vascularized double-barrelled fibula graft, plate osteosynthesis and rectus abdominis flap coverage. The performed surgery led to pain relief and increased mobility., Conclusion: The present case highlights the possible complication of surgical treated osteitis pubis leading to anterior arch instability affecting the posterior arch and thus impairing pelvic ring stability and patient mobility. Furthermore, we describe an opportunity to treat this complication or other etiologies contributing to anterior pelvic ring stability with large bone defects using a vascularized double-barrelled fibula graft to restore pelvic stability.

Background: Reconstruction of the coracoclavicular ligament functions to restore anatomic alignment of the clavicle and may improve biomechanical function and clinical outcomes. Improper placement of the coracoclavicular tunnel may inherently weaken the coracoid. The purpose of this study was to evaluate the feasibility and accuracy of navigated image-free placement of K-wires for coracoclavicular tunnel position in comparison to conventional drill guide-based placement., Materials and Methods: Eight human shoulder specimens were assigned for conventional technique with a coracoclavicular guide device (group CP) and the paired contralateral side for the navigated procedure (group NP) with an optoelectronic system with a fluoro-free software module. First-pass accuracy (%) and the K-wire trajectory (lateral-center orientation (LC), center-center (CC) orientation and medial-center orientation (MC) were measured., Results: In all navigated K-wires a 100 % first-pass accuracy was observed. In three of the eight (37.5 %) specimens of the drill guide-based group, drilling had to be repeated. One of them had to be repeated twice, resulting in eight versus twelve drillings for the navigated versus conventional group, respectively (p = 0.021). K-wire trajectory showed an MC orientation in most of the specimen (n = 9, group NP 4, group CP 5)., Conclusions: Image-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation has higher first-pass accuracy in comparison to conventional drill guide-based placement and, therefore, may enable a precise anatomic position of the drill holes and reduce the risk of an iatrogenic coracoid fracture.

Background: To improve patient safety and quality in joint arthroplasty a certification of arthroplasty centers (EndoCert©) and a German arthroplasty register (EPRD) have been implemented. This should guarantee a long-term improvement in documentation of arthroplasty in the future. Although the stages of operations in elective and trauma-associated joint arthroplasty are comparable, the surgical preconditions are often quite different. As required by the German Society of Trauma Surgery (DGU) this study analyzed the current situation with respect to the proportion of fracture-associated joint arthroplasties among the total volume carried out in Germany., Material and Methods: A uniform internet-based questionnaire was sent to all listed trauma centers in Germany by the central office of the DGU. In addition any information regarding hip joint arthroplasty in 2011 was collected from the Federal Statistical Office of Germany., Results: The questionnaire was returned by 324 (47 %) out of 690 of the trauma centers contacted. A total of 34,135 total hip arthroplasties (THA) and 26,753 total knee arthroplasties (TKA) were carried out in 2011 by these clinics. The absolute numbers for total endoprosthesis replacement cited by the trauma centers were 5718 THAs and 3829 TKAs. According to the data from the Federal Statistical Office of Germany 131,966 hip fractures were registered in 2011, including 69,582 femoral neck fractures (patient age >19 years) and 62,384 pertrochanteric fractures. From a total number of THAs of approximately 200,000 in Germany 47,695 (approximately 25 %) of these were associated with trauma., Discussion: The data analyzed in this study and the results obtained from known literature sources demonstrate that THA is the most frequently performed procedure in trauma management of femoral neck fractures. Because of the ubiquitous and high incidence and the need for emergency treatment due to correlated risks and complications of delayed treatment, a high and standardized around the clock (24 h and 7 days a week) treatment option is mandatory. Long waiting times to treatment or transfer are inacceptable due to the increased mortality and complications.

Background: Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department., Objectives: This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery., Materials and Methods: Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery., Results: A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case., Conclusion: The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

Purpose: The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures., Materials and Methods: In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications., Results: In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients., Conclusion: Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.

Osteomyelitis in the adult is a rare disease. In this review we present the diagnostic and therapeutic principles for treatment of chronic osteomyelitis of long bones in adults. The most important step in treating osteomyelitis is the detection of the offending bacteria. The diagnostics should be performed with tissue and fluids from the depth of the wound. Superficial samples and swaps from fistulas should not be used to determine the offending bacteria. The defining criteria of chronic osteomyelitis are necrotic and non vascularized bony tissue. The appropriate therapy includes radical excision of the diseased bone and infected scar tissue, closure of the wound with well vascularized tissue including (muscle) flaps, stabilization of instable situations by external fixation and administration of adequate antibiotics. Remaining necrotic bone tissue is one of the most relevant sources for recurrent infection.

Background: The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function., Methods: A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay., Results: The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01)., Conclusions: In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

Introduction: The aim of the study was to identify risk factors of failed two-stage procedures in cases of chronic posttraumatic periprosthetic hip infections., Patients and Methods: Between 2006 and 2008, 26 patients with chronic posttraumatic periprosthetic infections after hip arthroplasty were included. In all cases operative bacterial eradication was initiated. The therapy was carried out according to a standardized treatment protocol including the eradication of the bacterial infection and the prosthetic replacement after three negative intra-operative specimens as a two-stage procedure. Follow-up was performed at least 2 years after revision procedure., Results: Twelve patients showed no signs of infectious recurrence 2 years after prosthetic hip revision therapy (46 %) and were assigned to group I. Group II is constituted by the other 14 patients (54 %). Four of them (16 %) suffered from an infectious recurrence after prosthetic hip replacement, ten patients (38 %) were characterised by a failed bacterial eradication. The spectrum of pathogens showed a significantly higher resistance pattern (p = 0.001) in group II, with a majority of methicillin-resistant Staphylococcus epidermidis (MRSE) and highly resistant Pseudomonas. In addition, patients of group II offered significantly higher American Society of Anesthesiology (ASA) scores (p = 0.015), the body mass index (BMI) was significantly elevated (p = 0.031) and received a significantly higher number of operative procedures (p = 0.016)., Conclusions: A reduced general state of health, a high BMI and highly resistant pathogens are the main risk factors for a failed two-stage procedure after chronic posttraumatic periprosthetic hip infections. Therefore, different treatment strategies are required for a defined subgroup of patients.

In cases of severe osteoporosis vertebral body fractures of the thoracolumbar spine can occur without any relevant trauma. Initially, a standardized diagnostic algorithm is recommended to detect acute vertebral body fractures and to be able to interpret the individual fracture stability. Aim of the therapy is to assure a relatively pain-free mobilization while maintaining vertebral spine alignment. A conservative therapy concept is initiated in patients with stable fractures. In cases of persistent pain, reduced mobility or increased kyphotic misalignment minimally invasive cement augmented therapy strategies are chosen. In cases of unstable fracture morphology a more complex therapy concept has to be chosen such as hybrid stabilization. A great deal of experience is needed for revision surgery. In such cases reconstructive, multi-segmental techniques might be necessary and the instrumentation should surpass the apex of kyphosis.

The incidence of osteoporotic pelvic fractures is rapidly increasing. Following low energy trauma fractures are frequently classified as pelvic girdle fractures. Based on the pelvic expert group database of the German Trauma Society the estimated rate of osteoporotic pelvic ring fractures is about 51%. In cases of fractured pubic rami standard X-ray in anterior-posterior, inlet and outlet views should be carried out by computed tomography (CT) scanning to identify fractures of the sacrum. Only if pain persists and no fracture is evident with CT is magnetic resonance imaging (MRI) indicated. Therapy should be carried out under biomechanical instability aspects. Pubic rami fractures are stable and treated conservatively with sufficient pain medication, thromboembolic prophylaxis and physiotherapy. In cases of persisting pain or biomechanical instability operative treatment is indicated and stabilization methods should be chosen under biomechanical aspects. Therefore external fixator for pubic rami fractures and iliosacral screws, optionally with cement augmentation for posterior pelvic girdle fractures are the preferred techniques. Sacral fractures with severe osteolysis should be stabilized by lumbopelvic fixation techniques.

Objectives: Poor bone quality increases the susceptibility to fractures of the proximal humerus. It is unclear whether local trabecular and cortical measures influence the severity of fracture patterns. The goal of this study was to assess parameters of trabecular and cortical bone properties and to compare these parameters with the severity of fractures and biomechanical testing., Methods: Twenty patients with displaced proximal humeral fractures planned for osteosynthesis were included. Fractures were classified as either 2-part fractures or complex fractures. Bone after core drilling was harvested during surgery from the humeral head in each patient. Twenty bone cores obtained from nonpaired cadaver humeral heads served as nonfractured controls. Micro-CT (μCT) was performed and bone volume/total volume (BV/TV), connectivity density (CD), trabecular number (Tb.N), trabecular thickness (Tb.Th), trabecular spacing (Tb.Sp), and bone mineral density (BMD) were assessed. The cortical index (CI) was determined from AP plain films. Biomechanical testing was done after μCT scanning by axially loading until failure, and ultimate strength and E modulus were recorded., Results: BV/TV, BMD and CD showed moderate to strong correlations with biomechanical testing (r = 0.45-0.76, all p < 0.05). No significant differences were detected between the 2-part and complex fracture groups and controls regarding μCT and biomechanical parameters. CI was not significantly different between the 2-part and complex fracture groups., Conclusions: In our study population local trabecular bone structure and cortical index could not predict the severity of proximal humeral fractures in the elderly. Complex fractures do not necessarily imply lower bone quality compared to simple fractures.

We present the case of a 37-year-old, multiply injured man who sustained a bilateral perilunar fracture dislocation after a 6 m fall. The fracture dislocations were diagnosed by standard radiographs. The right side was initially treated by closed reduction and external fixation, the left side by closed reduction and splint immobilization. The patient received definite treatment 5 days after the initial injury by open reduction and internal fixation using suture anchors and temporary K-wire fixation which were removed after 6 weeks. The patient achieved almost a full range of motion in both hands and went back to his work as a roofer 5 months after surgery.

Background: Recording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected., Patients and Methods: From 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled., Results: The most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer., Conclusion: It has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.

Benchmarking is a very popular business process and meanwhile is used in research as well. The aim of the present study is to elucidate key numbers of German university trauma departments regarding research and teaching. The data set is based upon the monthly reports given by the administration in each university. As a result the study shows that only well-known parameters such as fund-raising and impact factors can be used to benchmark university-based trauma centers. The German federal system does not allow a nationwide benchmarking.

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the "Deutsche Gesellschaft für Unfallchirurgie" and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

Techniques of percutaneous spinal instrumentation have in the meantime become standard methods in many hospitals. While several indications have been established that are excellently suited to this technique, uncertainty prevails for other indications. This contribution intends to clarify the technical prerequisites for performing percutaneous instrumentation in the region of the thoracic and lumbar spine in addition to describing customary indications and various techniques of percutaneous instrumentation. This is combined with a critical assessment of what intrinsically cannot or cannot yet be achieved with a percutaneous approach to illustrate that the percutaneous procedure can by no means be considered a mere evolution of the previous classic open techniques.

Purpose: Clinical applications of quantitative computed tomography (qCT) in patients with pulmonary opacifications are hindered by the radiation exposure and by the arduous manual image processing. We hypothesized that extrapolation from only ten thoracic CT sections will provide reliable information on the aeration of the entire lung., Methods: CTs of 72 patients with normal and 85 patients with opacified lungs were studied retrospectively. Volumes and masses of the lung and its differently aerated compartments were obtained from all CT sections. Then only the most cranial and caudal sections and a further eight evenly spaced sections between them were selected. The results from these ten sections were extrapolated to the entire lung. The agreement between both methods was assessed with Bland-Altman plots., Results: Median (range) total lung volume and mass were 3,738 (1,311-6,768) ml and 957 (545-3,019) g, the corresponding bias (limits of agreement) were 26 (-42 to 95) ml and 8 (-21 to 38) g, respectively. The median volumes (range) of differently aerated compartments (percentage of total lung volume) were 1 (0-54)% for the nonaerated, 5 (1-44)% for the poorly aerated, 85 (28-98)% for the normally aerated, and 4 (0-48)% for the hyperaerated subvolume. The agreement between the extrapolated results and those from all CT sections was excellent. All bias values were below 1% of the total lung volume or mass, the limits of agreement never exceeded ± 2%., Conclusion: The extrapolation method can reduce radiation exposure and shorten the time required for qCT analysis of lung aeration.

Background: Posterior pelvic ring fractures are often associated with injuries of lumbopelvic soft tissue structures. The aim of this prospective MR study was to examine whether ruptured iliolumbal ligaments could be diagnosed in types B and C pelvic ring fractures. The influence of triangular lumbopelvic stabilization (TLPS) was also investigated with respect to stiffening of the lumbopelvic region., Material and Methods: Using a 1.5 Tesla MRI, 20 patients with types B and C fractures were examined to identify ruptured iliolumbal ligaments. In a retrospective study of 30 patients previously stabilized with a TLPS, pain scores, clinical instability testing and measuring of the segmental dislocation in extension, flexion and lateral flexion based on x-rays were also investigated., Results: Of the patients 3 (1 type B, 2 type C fractures) had incompletely ruptured iliolumbal ligaments. In five patients pain intensity and localization could be significantly correlated with clinical instability of the lumbopelvic region, segmental hypermobility and instability., Conclusion: Pelvic ring fractures types B and C can be associated with ruptured iliolumbal ligaments. Lumbopelvic instability can be correlated with early implant loosening of TLPS.

Introduction: We performed a consecutive study on patients with proximal tibial fractures without joint participation to determine the early clinical and radiological outcome., Patients: From January 2000 to December 2005, 22 fractures of the proximal and proximal diaphyseal tibia without joint participation were operated on using the new tibia nail. A total of 18 patients (82%) completed full follow-up after 6 weeks and 3 and 6 months., Results: Two primary and one secondary malalignment were observed Two of them were initially polytraumatised. Furthermore, two patients developed a delayed union, and one non-union occurred. Risk factors for limited bony consolidation were smoking and an open fracture. Screw or nail breakage did not occur, and no infection was observed.

Lump sum reimbursement and the resulting concentration of medical treatment in maximum care clinics have led to substantial increase in economic pressure on university hospitals. Nearly all hospitals have introduced business ratios to economically judge each department. In order to evaluate the validity and comparability the business ratios of seven university traumatology departments were evaluated. Structural data as well as cost calculation results in different cost groups were evaluated. Major differences could be identified despite the fact that the cost calculations were all based on the same method (InEK method). In particular the costs for distribution to other medical specialties such as radiology or anesthesiology differed widely. Costs for infrastructure also showed a great variation. Differences in efficiency cannot be the only cause for these discrepancies and lacking standardization of cost calculation methodology is also another major cause. All the business ratios analyzed must be looked at critically and unless a thoroughly standardized methodology of cost calculation is implemented, cost ratios will have a limited potential for hospital benchmarking.

Aim: To analyse the radiogrammetric parameter "cortical index" (CI) and its predictive value for proximal humerus fractures. Furthermore, to investigate the reoperations and the cause of reoperations after locking plate osteosynthesis of displaced proximal humerus fractures., Patients and Methods: 113 consecutive patients (73 women and 40 men) with a median age of 66 years (range 18-100 years) were included in this study. The median follow-up time in our database was 4.7 years (range 45-72 months). For a comparative matched-group analysis of the CI, patients with a fall on the shoulder without fracture were selected. Demographic data and all reoperations were recorded after median 58 months postoperatively. The CI was measured at the proximal humeral diaphysis., Results: The CI showed to be significant lower in the fracture group (mean 0.28) when compared to the matched group (mean 0.47, p < 0.01). 39% patients underwent a reoperation within 40 months postoperatively. 24% were reoperated within the first 12 months postoperatively, and 15% were reoperated after 12 months or later. The reoperation was independent of bone quality (p = 0.85)., Conclusions: The risk for reoperation is independent of the CI even though the CI may be a predictor for proximal humerus fracture. Younger patients should be aware that surgical treatment of proximal humerus fractures might be a two-stage surgery. Regular follow-up visits for older patients during the first postoperative year must be assured.

In the literature it has been unanimously reported that here is a heavy burden on operative disciplines due to the occurrence of complications and the commonly resulting accusation of an error in treatment. Most of these accusations affect the discipline of surgery and in the main aspects trauma surgery is disproportionally represented. This substantial burden and high rate of accusations against trauma surgery arises from the high transparency as complications in trauma surgery are visualizable. Dealing with complications is therefore an elementary function of trauma surgeons. The analysis of postoperative complications shows clearly that in most cases they do not only result from the postoperative course. The causes of postoperative complications in many cases are more likely to have already begun in the pre-operative and peri-operative phases. Pre-existing diseases and risk factors as well as operation planning and establishing indication status are in many cases the pre-operative and intra-operative origins of postoperative complications. In the present article the authors attempt to address the issues of new aspects of complications and therefore the quality management of trauma surgery, without making claim to completeness.

The standard technique for restoring footprint after full-thickness tears of the rotator cuff includes double-row or transosseous-equivalent techniques. However, the anatomically typical bird's beak shape and profile of tendon insertion may not be originally restored and biomechanics may be altered. In this report, the authors describe a technique that involves creating two intratendinous stitches at different levels of the torn tendon. The first passes through the bursal-side layer, the second stitch through the joint-side layer. Both stitches may be performed in mattress suture configuration. The anchorage is performed by knotless anchors in order to avoid knots lying within the insertion area. The footprint is restored first medially then laterally by the use of double-row principles. The joint-side suture is anchored within the medially placed anchor. The bursal-side suture is anchored by a laterally placed anchor. The anatomic insertion and restoration of the shape and profile may be enabled by the described double-layer suture technique. Using a double-layer double-row repair may potentially improve functional results of rotator cuff repair constructs.

Traumatic posterior dislocation of the shoulder is frequently associated with an osteochondral defect on the anterior articular surface of the humeral head (so-called reverse Hill-Sachs lesion). Possible treatment options are either filling or elevation of the osseous defect. Previously, an open technique has been described using a bioabsorbable interference screw. On the basis of a 64-year-old patient presenting with a reverse Hill-Sachs lesion after epileptic seizure, we describe an arthroscopic technique in which the defect is reconstructed under arthroscopic and fluoroscopic control and supported by a bioabsorbable interference screw.

The case of a 51-year-old patient is presented, with a humeral shaft fracture in combination with an ipsilateral reverse Hill-Sachs lesion, presumably after posterior shoulder dislocation as a result of an electrical accident followed by a fall from a ladder. After corresponding diagnostics, osteosynthesis of the shaft fracture was performed with a locked antegrade intramedullary nail. Simultaneously the reverse Hill-Sachs lesion was elevated und supplemented with the bone core that accrues during drilling of the nail entrance. In the follow-up period good fragment alignment, persistent joint stability and freedom of pain could be observed. On the basis of this case and the current literature the injury mechanism and potential therapy alternatives are discussed.

Background: In anterior reconstruction of the unstable thoracolumbar spine, discectomy and corpectomy are technically demanding steps requiring maximal surgical precision. This study investigated the feasibility of computer-aided guidance for discectomy and corpectomy. It also analysed the precision, advantages, and disadvantages of the procedure., Patients and Methods: Vertebral body fractures of the non-osteoporotic thoracolumbar spine addressed by discectomy/corpectomy and subsequent implant interposition (cage, tricortical strut graft) for anterior reconstruction were included. All surgical steps were done under endoscopic assistance. In the trial group, discectomy and corpectomy were performed with computer-aided guidance; in the control group, no computer navigation was used. The time required for surgery was noted. To assess surgical precision, decentralization of the implant in the frontal plane was measured in postoperative x-rays and computed tomography. Additionally, parallel alignment of vertebral body end plates with the implant was evaluated., Results: The trial group (TG) consisted of 16 patients, and the control group (CG) of 10 patients. Fractures were localized between T10 and L1 in TG, and between T9 and L1 in CG. Operating time was significantly shorter in CG: 104+/-28 min compared with 229+/-64 min in TG (p<0.0005). In contrast, data on surgical precision showed no statistically significant differences between the 2 groups for either decentralization or parallel endplate alignment of implants. Remarkably, for CG we noted 2 cases of cage subsidence into an adjacent end plate, whereas for TG this was noted in only 1 case. However, this difference was not statistically significant., Conclusion: Computer-aided guidance for anterior reconstruction of the thoracolumbar spine is a technically feasible option that may help in performing discectomy and corpectomy. However, this technique significantly prolongs the operating time. There were no differences in the precision of implant positioning between the groups. However, during discectomy the use of computer navigation may possibly add to the protection of adjacent end plates.

Background: The development towards a combined speciality of orthopaedic and trauma surgery requires not only consolidation and revision of the postgraduate education training programme but also the development of a catalogue of learning objectives as a uniform basis for undergraduate medical training in the new speciality at German medical schools and teaching hospitals., Materials and Methods: Based on the Frankfurt catalogue of learning objectives for trauma surgery and the Ulm catalogue of learning objectives for orthopaedics, a task force of experts developed a combined catalogue of learning objectives for the new speciality. Experts from both specialities classified the learning objectives into two levels of knowledge and four grades of skills competence, in addition to objectives for attitudes and social competence., Results: The section on general operative specialities contains 120 items classified into 39 learning objectives for knowledge and 83 for skills. Two learning objectives comprise both knowledge and skills. The section on orthopaedic and trauma surgery comprises 141 learning objectives, including six items for skills and 138 for knowledge, as well as three learning objectives for both knowledge and skills. In addition, 22 learning objectives deal with aspects of attitude and social competence., Conclusion: Although this alliance of orthopaedics and trauma surgery is recent, the commission has developed not only a collection of topics but a joint catalogue of learning objectives for undergraduate training that can be used nationwide. This catalogue paves the way for modern education that looks to the future. The integrated recommendations for content prioritisation, links to other subjects and specialities, and the integration of didactic methods facilitate local implementation of the learning objectives without loss of academic freedom.

Isolated fractures of the greater tuberosity represent 14-21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.

This report describes the case of a 26-year-old woman with a recurrent extraarticular diffuse-type tenosynovial giant cell tumor (D-TGCT) of the medial region of the knee affecting the pes anserinus and hamstring tendons. Presurgical MRI did not exclude infiltrative properties of the tumor. In the histological evaluation, the tumor showed an aggressive dispersion by infiltrating the collagenous tissue of the hamstring tendons. The treatment included a resection of the pes anserinus complex with distal semitendinosus and gracilis tendons. Regarding extraarticular D-TGCT a review of the literature showed a predominant affection of the medial region of the knee and thigh.

Background: Low postoperative pain level, decreased length of hospital stay and accelerated rehabilitation are the major benefits of unicondylar knee arthroplasty. Especially in comparably young, not yet retired and still active patients with an isolated medial gonarthrosis, these prostheses offer many advantages. However, one important requirement to be treated with such implants is a well functioning stability system of the muscles and ligaments. Thus in patients with degenerated or destroyed anterior cruciate ligaments it is contraindicated to use this method. In order to still take advantage of this therapy for treatment of isolated arthrosis, reestablishment of the proprioceptive structures through simultaneous or staged ACL reconstruction is mandatory., Patients and Methods: Pursuing this goal we performed unicondylar knee arthroplasty with simultaneous ACL reconstruction on eligible patients. Between 2003 and 2006 we treated 32 knees with this combined surgery and followed them for a mean of 31 months (range: 10-38)., Results: The mean Knee Society Score significantly improved from 83.2 (44-103) to 167.6 (145-177) at a mean follow-up of 31 months (10-38)., Conclusions: Preliminary results of this short-term follow-up are promising. Especially the predominant number of patients who were able to return to work soon after rehabilitation and the significantly improved score postoperatively reflect the benefits of this prosthesis system in select patients. However, long-term follow-up and larger case numbers are necessary to confirm these encouraging results in the future.

A 30-year-old man presented several times with pain in the calf after twisting his foot and injuring it during bowling. It was some time before the diagnosis of acute exertion-induced compartment syndrome was made, and an immediate fasciotomy could no longer prevent necrosis of the peroneal muscles. Because of the patient's drop-foot, we performed a tibialis posterior tendon transfer, fixing it to the cuneiform bone. The sort of compartment syndrome observed after engagement in various sports is a recognised, albeit uncommon, variant of acute compartment syndrome. A high level of suspicion and observation is required to make the diagnosis when any leg pain has no definite diagnosis. Fasciotomy should be performed early.

Introduction: Anterior cruciate ligament reconstruction is an increasingly established method even in patients over 40 years old. Recent studies with regard to this procedure used BTB transplants. We did a retrospective follow-up examination on over-40-year-old patients with anterior cruciate ligament reconstruction using hamstring transplants and compared them to a younger control group. Our hypothesis is that functional outcome after ACL-reconstruction is comparable in patients under and over 40 years of age., Materials and Methods: Retrospective follow-up examinations in 28 patients, 11 women and 17 men. The average age at the time of operation was 43.5 years (range 40-61). The average follow-up period was 30.4 months. Half of the patients had a femoral fixation in TransFix technique (Arthrex, Naples, USA), while the other 14 patients had a femoral bioscrew fixation (Arthrex, Naples, USA). Objectivity was ensured by measurements of anterior tibial translation with the rolimeter (Aircast). The functional outcome was determined by clinical scores (Tegner activity scale, Lysholm knee score, OAK score and IKDC score). The degree of arthrosis was defined on the basis of tunnelview radiographs and compared to the non-operated site. Functional results and degree of laxity was compared to a sex matched control group (mean age 28.0)., Results: The median values for the Lysholm knee score were 91.5 points (range 69-100), for the OAK score 93.5 points (range 67-100) and for the IKDC score 83.35 points (range 62.1-100). For the Tegner activity scale values of 4.5 points (range 3-8) were obtained. In the IKDC knee examination form we found normal and nearly normal values in 86% and in the OAK examination score good and very good results in 82%. Ninety-three percent had an AP side-to-side difference of <5 mm in the operated knee. Subjectively, 75% reported that they had no feeling of instability, even when practising sport. No significant correlation between functional outcome and patients' age was present. Furthermore there were no significant differences between the investigated and the younger control group. The most advanced signs of arthrosis were found in the medial compartment of the operated side (degree A: 36%; degree B: 46%; degree C: 14%; degree D: 4%)., Conclusion: The predominantly good results and a high level of patient satisfaction show that anterior cruciate ligament reconstruction is justified even in over-40-year-old patients with persistend subjective symptomatic anterior knee instability. The indication for reconstruction should be based on individual factors such as level of activity or subjective feeling of instability rather than on a dogmatic age limit. Advanced arthrotic changes compared to the healthy side, might be due to a too long period of preoperative decision making.