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Introduction: When needed operative treatment of sacral fractures is mostly performed with percutaneous iliosacral screw fixation. The advantage of navigation in insertion of pedicle screws already could be shown by former investigations. The aim of this investigation was now to analyze which influence iliosacral screw placement guided by navigation has on duration of surgery, radiation exposure and accuracy of screw placement compared to the technique guided by fluoroscopy. Methods: 68 Consecutive patients with sacral fractures who have been treated by iliosacral screws were inclouded. Overall, 85 screws have been implanted in these patients. Beside of demographic data the duration of surgery, duration of radiation, dose of radiation and accuracy of screw placement were analyzed. Results: When iliosacral screw placement was guided by navigation instead of fluoroscopy the dose of radiation per inserted screw (155.0 cGy*cm2 vs. 469.4 cGy*cm2p < 0.0001) as well as the duration of radiation use (84.8 s vs. 147.5 s p < 0.0001) were significantly lower. The use of navigation lead to a significant reduction of duration of surgery (39.0 min vs. 60.1 min p < 0.01). The placement of the screws showed a significantly higher accuracy when performed by navigation (0 misplaced screws vs 6 misplaced screws—p < 0.0001). Conclusion: Based on these results minimal invasive iliosacral screw placement guided by navigation seems to be a safe procedure, which leads to a reduced exposure to radiation for the patient and the surgeon, a reduced duration of surgery as well as a higher accuracy of screw placement. [ABSTRACT FROM AUTHOR]

Purpose: A bilateral fixed-angle plate was biomechanically compared to the two currently preferred methods of osteosynthesis for transverse patella fractures. It was hypothesized that the new angle-stable implant would provide a secure and sustainable fracture fixation, superior to the established standard techniques. Methods: Twenty-one identical patellae made of polyurethane foam (Sawbones), osteotomized to create a transverse two-part fracture, were fixed with modified anterior tension wiring, cannulated lag screws with anterior tension wiring or bilateral polyaxial 2.7-mm fixed-angle plates. The testing protocol consisted of 10,000 repetitive cycles using a non-destructive physiological load between 100 and 300 N at a simulated knee flexion of 60°. Results: All 21 Sawbone-patellae sustained repetitive loading up to 10,000 cycles without failing. The anterior tension wire group displayed significant displacement of the fracture gap (0.7 ± 0.2 mm) during cyclic loading, while both lag screws with tension wiring and bilateral fixed-angle plates showed no fracture gap widening at all ( p < 0.01). Conclusion: The bilateral fixed-angle plate and cannulated lag screws with anterior tension wiring preserved a constantly reduced fracture gap over 10,000 tensile cycles in contrast to modified anterior tension wiring, which exhibited significant widening of the gap after initial loading. Results of in vitro testing indicate that bilateral fixed-angle plates provide sustainable fixation stability offering a promising new option in the treatment for transverse patella fractures. [ABSTRACT FROM AUTHOR]

Purpose: The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty. Methods: Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated. Results: Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age. Conclusion: Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected. [ABSTRACT FROM AUTHOR]

Introduction: A tibial nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular proximal tibial fractures. The goal of this study is to analyze if the angle stable tibial nail (ASN) is biomechanically more stable than an established conventional standard nail (CN). Methods: Two types of nails were compared on a series of ten matched pairs of human tibiae. After setting a proximal tibial defect fracture, the intramedullary stabilized tibiae were axially loaded starting from 100 N increasing in steps of 100 N after every 200 cycles until failure was reached. Failure was defined as deformation of the fracture gap, fracturing of the bone or the implant. Results: The two types of nails showed no significant difference in terms of maximum tolerated load, maximum cycles repeated or axial deformation of the bone-implant construct. The mean load at failure was 1,365 N for the CN and 1,195 N for the ASN. The mean axial deformation for conventional (19 mm) and angle stable nail (21 mm) did not differ significantly. Slightly less nail or screw loosening was noticed with the fixed-angle nail. Conclusion: No significant difference in stability between the two compared implants could be demonstrated. A trend could be shown indicating that the rate of nail loosening in the proximal osteotomized part of the bone was lower for the angle stable nail. This trend, however, could not be substantiated statistically. [ABSTRACT FROM AUTHOR]

Surgical treatment of femoral neck fractures is associated with a significant impact on quality of life. The aim of this study was to determine the long-term influence of displaced femoral neck fractures treated by bipolar hemiarthroplasty on the activities of daily living, quality of life and social dependency. We studied 487 geriatric patients treated in the years 1989 to 2003. At the beginning of follow-up in 2004, 166 patients were alive and evaluation was carried out on 145 patients (87.3%) at 91.3 (14 - 244) months postoperatively by a standardized questionnaire. All enrolled patients had been treated with cemented bipolar hemiarthroplasty for a displaced femoral neck fracture. Patients were evaluated concerning their average pre- and postoperative ability to walk, the need for assisting devices, type of residency and the SF-12® Score. Femoral neck fracture and hemiarthroplasty had a significant influence on all recorded aspects of quality of life. Even though almost two thirds of the patients needed assisting devices to walk after surgery, about two thirds returned to their original type of accommodation and the majority reached their original degree of mobility. Compared to a normal population no significant impact was observed on the quality of life measured by the SF-12® score. We consider bipolar hemiarthroplasty an effective treatment option for displaced femoral neck fractures in geriatric patients. Most patients returned to their original type of accommodation and level of mobility, even though the majority required a number of assisting devices to do so. [ABSTRACT FROM AUTHOR]

We report a case of a 77-year-old female patient who died 4 days after a closed colles-fracture of the right wrist because of secondary emerged necrotising fasciitis. At the time of visiting our emergency department, the patient reports about untypical pain and progressive swelling of the entire right arm 3 days following a fall onto the outstretched hand where she sustained a closed distal radius fracture. Within 6 h, the patient developed hypotension and fever leading to cardiac and respiratory failure. The emergent-induced diagnostic presented a severe septic situation in the laboratory examination of the blood samples, an apparent before unknown diabetes mellitus and an unknown bronchial carcinoma with part of post-stenosis pneumonia of the right lung. After initial CPR and stabilisation, the patient underwent an urgent and aggressive surgical debridement with fasciotomies of the muscle compartments of the entire right upper extremity. The microbiological investigation of the intraoperative taken specimens presented plentiful group-A-β-haemolytic streptococcus. Despite a broad spectrum intravenous antibiotic therapy, intensive care support and a second look operation 12 h later with exarticulation of the right arm in the shoulder joint, the patient died of septic shock and multiorgan failure 34 h after admission. [ABSTRACT FROM AUTHOR]

Locked antegrade or retrograde nailing of humeral shaft and proximal humerus fractures is a well etablished treatment option. Anatomic-morphological studies revealed a potential high risk of axillary nerve injury within proximal interlocking screw insertion. However, clinical experiences do not seem to confirm this, as there is a lack of interlocking screw insertion associated axillary lesions in literature. We report about a 69-year-old man with a humeral shaft fracture (AO-type 12-A3) stabilized by a retrograde implanted interlocking nail. Proximal interlocking screw insertion was performed in a posterior-to-anterior direction. The fracture healed uneventfully. In a follow-up examination 2 years later, an atrophy and paralysis of the deltoid muscle were visible. Electrophysiological evaluation confirmed an isolated axillary nerve injury. Nevertheless, the patient showed good functional recovery with almost free range of motion. Even for clinical practise proximal interlocking screw insertion is associated with a substantial risk of axillary nerve injury. Particularly for posterior-to-anterior screw insertion anatomic conditions should be considered. In spite of axillary nerve lesion, recovery of almost full shoulder function is possible by compensating the loss of deltoid function by rotator cuff muscles. [ABSTRACT FROM AUTHOR]

Distal radius fracture management in elderly patients remains without consensus regarding the appropriate treatment or anticipated outcome. Forty-one studies that included at least 10 patients with a minimum mean age of 65 years and that were indexed in Medline or Embase were reviewed. Treatment methods included pins and plaster, external fixation, K-wires, bone cement, and open reduction and internal fixation with plates. The methodological quality of each study was evaluated through use of a grading scale. Despite study heterogeneity, higher rates of infection were noted with external fixation and K-wire stabilization. Stratifying patients into low-demand and high-demand groups may improve the management of distal radius fractures in elderly patients. In sedentary patients with low demands, functional outcomes are good despite the presence of deformity. Patients with higher demands may benefit from fracture stabilization with locking volar plates. Volar plating with fixed-angle screws may be particularly suitable for elderly patients who may take longer to heal a fracture, be more susceptible to pin-track infection, and demonstrate earlier tendon irritation leading to rupture. [Copyright &y& Elsevier]

In recent years, there has been a trend from operative to conservative management of complete acromioclavicular separations. Despite this, surgical treatment is still recommended to manual workers and athletes, who account for a large part of the patients. The objective of this study was to evaluate the functional outcome of type III separations according to Tossy managed by temporary arthrodesis of the acromioclavicular joint combined with coracoclavicular augmentation. Special attention was paid to sport exercising patients. In this study, 32 patients (mean age 39 years) with a complete acromioclavicular separation were investigated. All of them underwent a surgical treatment managed by temporary acromioclavicular arthrodesis with two parallel k-wires and augmentation of the coracoclavicular ligaments with a biodegradable cord (PDS). Functional outcome was assessed after an average follow-up of 36 months by using the Constant-Murley-, Neer- and DASH-score. Additionally, incidence of complications and subjective results were observed. Evaluation of the data, obtained from the scores, revealed an excellent result for the Constant-Murley- and DASH-score for 84% of the patients. Regarding the Neer-score, 78% had an excellent outcome. Eighty-four percent of the patients assessed revealed an excellent to fair subjective result. Cosmetic reasons were most frequently the cause for discontentedness. Minor complications occurred in three patients without severe sequelae. All patients returned back to former working and sport activity level. Surgical treatment of complete acromioclavicular separations by temporary arthrodesis with two k-wires and coracoclavicualar PDS-augmentation results in good to excellent function. It is associated with a low complication rate and a high patient contentedness. Particularly for athletes in non-contact sports this surgical technique can still be recommended. [ABSTRACT FROM AUTHOR]

Background and aims: Osteosynthesis with the proximal femoral nail (PFN) features the advantages of high rotational stability of the head-neck fragment, an unreamed implantation technique and the possibility of static or dynamic distal locking. However, the use of the nail is technically ambitious and is accompanied by some risks of error, which can lead to failure of the osteosynthesis. In this paper we present the results of a critical analysis of mistakes that were made in our hospital during the introduction period of this implant. Patients and methods: We carried out a prospective analysis of the data of 121 consecutive patients who were suffering from trochanteric or subtrochanteric fracture between December 1997 and December 2000 and who had been treated with a PFN. Results: We identified intraoperative technical difficulties in 23 patients (19.1%). Seven cases showed postoperative local complications that required operative revision on six patients (4.9%). The main reasons for the failure of the operations involved were poor reduction and wrong choice of screws. Following our critical analysis, we were able to avoid those problems. Conclusions: When 31A fractures are to be stabilised with a PFN, the precise technical performance of the implantation represents the basic surgical requirement. Already present minor deviations will subsequently cause loosening of the implants and failure of the operation. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the clinical impact of MRI in the early diagnosis of wrist trauma. High-resolution MR imaging was performed on a 1.5-T unit (Symphony Quantum, Siemens, Erlangen, Germany) using coronal and axial T1- and T2-weighted fat-saturated turbo-spin-echo sequence via a dedicated wrist coil within a mean of 6.6 days after initial radiographs in 54 patients (56 wrists) with clinical suspicion of wrist fractures and normal plain or indistinct radiographs. Initial radiographs were evaluated independently by two senior radiologists and the hand surgeon without knowledge of the MRI findings. The initial treatment protocol was based on evaluation of plain films and clinical findings by the hand surgeon. Treatment protocol was changed after MRI examination if necessary. In 31 of 56 wrists MRI findings resulted in a change of diagnosis. There were false-positive diagnoses on plain radiographs in nearly one half ( n=25) of the patients. False-negative diagnoses on plain radiographs resulted in 6 cases. Magnetic resonance imaging detected additional injuries of soft tissue in more than one third ( n=20). In 22 of 56 wrists the period of immobilization could be shortened or ended, in 12 of 56 it was prolonged, and in 3 of 56 a surgical intervention was necessary. In 19 wrists MRI had no therapeutic consequences. Our data demonstrate the high clinical impact of MRI in the detection of acute wrist fractures. We recommend MRI of the wrist immediately on the day of trauma if there is clinical suspicion and normal plain radiographs. Accurate diagnosis by MRI examination within the first days following trauma may reduce economic costs due to shortened immobilization time in cases with a suspected fracture but plain radiographs. [ABSTRACT FROM AUTHOR]

Bone defects remain a challenge for patients and orthopaedic surgeons. Autologous transfer of cancellous bone grafts remains the standard of care. However, in recent years various osteoinductive substitute materials, such as platelet rich plasma (PRP) and hyperbaric oxygen therapy (HBO) have been shown to improve bone healing. This study evaluates the effects of a combined application of PRP and HBO with autologous bone grafting in an animal model. In 48 New Zealand White rabbits bone defects at the radius were filled with autologous bone harvested at the iliac crest. This was combined with application of autologous PRP and/or HBO treatment for the duration of this study. After 3 and 6 weeks histomorphometric, immunohistochemical and radiologic evaluations were performed. All animals tolerated the treatment well. Improved bone regeneration was shown in all groups at 6 weeks compared to 3 weeks. Additional application of PRP and HBO resulted in an increase in new bone formation and increased neovascularization at 3 and 6 weeks. There was no statistical significant difference between PRP and HBO application in these regards. A combinatory use of PRP and HBO resulted in an increased bone regeneration and neovascularization compared to all other groups. This study provides evidence for an improvement of bone regeneration with the combinatory application of PRP and HBO to autologous cancellous bone grafts in a model of weight bearing bone defects in rabbits. Also synergistic effects of these two measures on angiogenesis were evident. [ABSTRACT FROM AUTHOR]

Purpose: Cinematic rendering (CR), a recently launched, FDA-approved rendering technique converts CT image datasets into nearly photorealistic 3D reconstructions by using a unique lighting model. The purpose of this study was to compare CR to volume rendering technique (VRT) images in the preoperative visualization of multifragmentary intraarticular lower extremity fractures.Method: In this retrospective study, CT datasets of 41 consecutive patients (female: n = 13; male: n = 28; mean age: 52.3 ± 17.9y) with multifragmentary intraarticular lower extremity fractures (calcaneus: n = 16; tibial pilon: n = 19; acetabulum: n = 6) were included. All datasets were acquired using a 128-row dual-source CT. A dedicated workstation was used to reconstruct CR and VRT images which were reviewed independently by two experienced board-certified traumatologists trained in special trauma surgery. Image quality, anatomical accuracy and fracture visualization were assessed on a 6-point-Likert-scale (1 = non-diagnostic; 6=excellent). The regular CT image reconstructions served as reverence standard. For each score, median values between both readers were calculated. Scores of both reconstruction methods were compared using a Wilcoxon-Ranksum test with p < 0.05 indicating statistical significance. Inter-reader agreement was calculated using Spearman's rank correlation coefficient.Results: Compared to VRT, CR demonstrated a higher image quality (VRT:2.5; CR:6.0; p < 0.001), a higher anatomical accuracy (VRT:3.5; CR:5.5; p < 0.001) and provided a more detailed visualization of the fracture (VRT:2.5; CR:6.0; p < 0.001). An additional benefit of CR reconstructions compared to VRT reconstructions was reported by both readers in 65.9 % (27/41) of all patients.Conclusions: CR reconstructions are superior to VRT due to higher image quality and higher anatomical accuracy. Traumatologists find CR reconstructions to improve visualization of lower extremity fractures which should thus be used for fracture demonstration during interdisciplinary conferences. [ABSTRACT FROM AUTHOR]