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Background: There has been an increasing number of fragility fractures of the sacrum in the recent decade. With rates of up to 28%, the complication rates after surgical treatment are still at an unacceptably high level, and new treatment strategies are urgently needed. Therefore, the purpose of this study was to evaluate the potential of 3D-navigated trans-sacral bar osteosynthesis in the surgical treatment of fragility fractures of the sacrum. Methods: Retrospectively, from 2017 to 2023, all cases with confirmed fragility fractures of the sacrum in patients > 65 years of age that were surgically treated with navigated 3D-navigated trans-sacral bar osteosynthesis were included, and epidemiological data and the course of treatment analyzed in comparison to a matched control group. Results: Finally, 21 patients (18 women and 3 men) were included in this study. The average age of the patients was 82.6 (SD 6.3) in the intervention group and 79.4 (SD 6.7) in the control group. There were postoperatively detected complications in two cases (18%) in the intervention group and in four cases (40%, p = 0.362) in the control group. The postoperative in-hospital stay was 10 days (SD 3.8) vs. 11.4 days (SD 3.8) in the control. None of the patients in the intervention group and two in the control group needed revision surgery. Conclusions: Overall, 3D-navigated trans-sacral bar osteosynthesis seems to be a promising technique, enabling an accurate implant positioning while offering a low complication rate with an excellent short-term outcome in elderly patients with fragility fractures of the sacrum. [ABSTRACT FROM AUTHOR]

Purpose: Intraoperative 3D imaging has become a valued tool in assessing the quality of reduction and implant placement in orthopedic trauma surgery. In our institution, 3D imaging is used routinely since 2001. To evaluate the intraoperative findings and consequences of this technique, intraoperative revision rates in cases with 3D imaging were analyzed. Methods: All operative procedures carried out with intraoperative 3D imaging between August 2001 and December 2016 were included. The scans were assessed intraoperatively and documented thereafter. In case of malreduction or misplaced implants, an immediate revision was performed. The number of scans per case as well as the findings and consequences drawn regarding the anatomical region were analyzed. Results: 4721 cases with 7201 3D scans were included in this study. The most common anatomical regions were the ankle (22.3%), the calcaneus (14.8%) and the tibial head (9.5%). In 19.1% of all cases, an intraoperative revision was performed. The highest revision rates were found with 36.0% in calcaneal fractures, 24.8% in fractures of the tibial plateau, 22.3% in injuries of the ankle. In 52.0% of revisions, the reduction was improved regarding intra-articular steps or joint congruency. In 30.5% an implant was corrected. Conclusion: Intraoperative revision due to results of 3D imaging was performed in almost one-fifth of cases. This illustrates the improved possibilities to detect malreduction and implant misplacements intraoperatively and thus the abilities to improve surgical outcome. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Previous studies have demonstrated a frequent occurrence of screw/K-wire malpositioning during surgical fracture treatment under 2D fluoroscopy and a correspondingly high revision rate as a result of using intraoperative 3D imaging. In order to facilitate and accelerate the diagnosis of implant malpositioning in 3D data sets, this study investigates two versions of an implant detection software for mobile 3D C-arms in terms of their detection performance based on comparison with manual evaluation. The 3D data sets of patients who had received surgical fracture treatment at five anatomical regions were extracted from the research database. First, manual evaluation of the data sets was performed, and the number of implanted implants was assessed. For 25 data sets, the time required by four investigators to adjust each implant was monitored. Subsequently, the evaluation was performed using both software versions based on the following detection parameters: true-positive-rate, false-negative-rate, false-detection-rate and positive predictive value. Furthermore, the causes of false positive and false negative detected implants depending on the anatomical region were investigated. Two hundred fourteen data sets with overall 1767 implants were included. The detection parameters were significantly improved (p<.001) from version 1 to version 2 of the implant detection software. Automatic evaluation required an average of 4.1±0.4 s while manual evaluation was completed in 136.15±72.9 s (p<.001), with a statistically significant difference between experienced and inexperienced users (p=.005). In summary, version 2 of the implant detection software achieved significantly better results. The time saved by using the software could contribute to optimizing the intraoperative workflow. [ABSTRACT FROM AUTHOR]

Objective: Dorsal stabilization is a frequently used procedure in the treatment of acute traumatic vertebral body fractures. Besides the traditional open surgical procedure, the percutaneous positioning of pedicle screws is now widely used. The aim of the current study is to compare pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture of the thoracic and lumbar spine and to assess possible risk factors associated with pedicle screw misplacement. Methods: All patients who suffered a traumatic spinal fracture that were treated with dorsal stabilization in our level I trauma center in the period from 01/2007 to 03/2014 were included in this retrospective therapeutic cohort study. From 01/2007 to 06/2009, an open surgical procedure was used, and from 06/2009 to 03/2014, the percutaneous procedure was used for all types of fractures. Retrospectively, the positioning of every single pedicle screw was evaluated in the post-operative computed tomography scan and classified. Epidemiological data were also documented to compare the two treatment groups. Results: A total of 491 patients with 681 vertebral body fractures were included. Of 733 pedicle screws placed during the open surgery procedure, 96.0% were within the safe zone. There was no significant difference compared with pedicle screws placed percutaneously (95.3% of 1884 screws). In all other categories, the number of misplaced pedicle screws also showed no differences between the two treatment groups. There is a positive correlation between pedicle screw misplacement and duration of the operation. Most pedicle screws are misplaced at the levels T12, L1 and T7, T8. Conclusion: The current study shows that percutaneous surgery using dorsal stabilization allows the positioning of pedicle screws in an equivalently safe manner compared with an open surgical procedure in the acute care of spinal trauma. [ABSTRACT FROM AUTHOR]

Objective: The diagnosis of instability of the injured upper cervical spine remains controversial, due to its complicated anatomical configuration and biomechanical property. Since identifying unstable injuries of the upper cervical spine is essential for immediate stabilizing therapy, this article reviews the current classification systems of upper cervical spine injuries and their statements towards instability.Methods: A systematic review of literature concerning upper cervical spine injuries was performed on the PubMed database from inception to December 2019. An English literature search was conducted using various combinations of keyword terms.Results: Numerous separate classification systems for each specific injury of the upper cervical spine were obtained. The early classifications are based primarily on injury morphology and mechanism. The recent classifications pay more attention to the investigation of ligamentous status. Various instability criteria were established as well. The determinants involve translation, vertical distraction, angulation, rotation, obliquity of fracture line, comminution, and ligamentous disruption. The status of crucial ligaments plays a key role in determining instability of upper cervical spine injuries. CT scan is more sensitive and reliable than X-ray in detecting misalignment of the upper cervical spine.Conclusion: Only a few classification systems support decision-making concerning instability leading to early operative treatment. The ligamentous integrity is the key element of impacting the stability of the upper cervical spine injuries. The transverse ligament serves as the most crucial element in determining the stability of occipital condyle fractures and atlas fractures as well as atlanto-axial injury. The integrity of anterior longitudinal ligament, disc, and facet joint attributes to the stability of axis fractures. The integrity of tectorial membrane and alar ligaments determines the stability of atlanto-occipital dislocation. The development of a newly classification system concerning ligamentous instability with a high clinical and scientific impact is recommended. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to analyze the functional and radiological outcome of Monteggia-like lesions in adults with unreconstructible fracture of the radial head and treatment with radial head arthroplasty. Methods: Twenty-seven patients (mean age 56 years; range 36 to 79 years) with a Monteggia-like lesion and treatment with radial head replacement were included in this retrospective study. Minimum follow-up was 2 years. Clinical assessment included the pain level with the visual analog scale in rest (VASR) and under pressure (VASP), range of motion, Mayo Elbow Performance Score (MEPS), and Disability of the Arm, Shoulder, and Hand score (DASH). A detailed radiological evaluation was performed. Complications and revisions were also analyzed. Results: After a mean follow-up period of 69 months (range, 24 to 170) the mean DASH score was 30 ± 24, the MEPS averaged 77 ± 20 points, the mean VASR was 2.1 ± 2.4, and VASP was 4.5 ± 3.5. Mean loss of extension was 24° ± 18 and flexion was 124° ± 20. Heterotopic ossifications were noted in 12 patients (44%). A total of 17 complications were noted in 11 patients (41%), leading to 15 revision surgeries in 9 patients (33%). Patients with a complicated postoperative course showed a worse clinical outcome compared with patients without complications measured by MEPS (68 ± 22 vs. 84 ± 16), DASH (49 ± 16 vs. 20 ± 22) and ulnohumeral motion (77° ± 31 vs. 117° ± 23). Conclusions: Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the current study is to analyze perioperative data and complications of open vs. percutaneous dorsal instrumentation after dorsal stabilization in patients suffering from fractures of the thoracic or lumbar spine.Methods: In the time period from 01/2007 to 06/2009, open surgical approach was used for dorsal stabilization. The percutaneous surgical approach was used from 05/2009 to 03/2014. In every time period, all types of fractures were treated only by open or by percutaneous approach, respectively, to avoid any selection bias. Retrospectively, epidemiological data, complications and perioperative data were documented and statistically analyzed.Results: A total of 491 patients met the inclusion criteria. Open surgery procedure was carried out on 169 patients, and percutaneous surgery procedure was carried out on 322 patients. Fracture level ranged from T1 to L5, and fractures were classified types A, B, and C. In 91.4% of all patients, no complication occured following dorsal stabilization after traumatic spine fracture during their hospital stay. However, 42 complications related to dorsal stabilization have been documented during the hospital stay. The complication rate was 14.8% if open surgical approach has been used and was significantly reduced to 5.3% using percutaneous surgical approach. Post-operative hospital stay was also reduced significantly using the percutaneous surgical approach.Conclusions: According to the current study, percutaneous dorsal stabilization of the spine could also be safely used in trauma cases and is not restricted to degenerative spinal surgery. [ABSTRACT FROM AUTHOR]

Introduction: Although open procedures are the gold standard, the alternative approach of minimal invasive reduction using percutaneous screws for thoracic and lumbar spine fractures is under discussion. Aim of this study was to investigate the results of reduction and the accuracy of screw placement in minimally invasive percutaneous posterior instrumentation for these fractures.Materials and methods: One hundred and twenty-seven patients with thoraco-lumbar and lumbar burst fractures and minimal invasive dorsal instrumentation were analyzed retrospectively in terms of the accuracy of pedicle screw placement and results of fracture reduction.Results: In total, 542 screws were placed. Thirty-four (6.3%) screws of 22 patients (17.3%) were misplaced, but misplacement was minimal, replacement of any screw position due to instability was not necessary, and no new neurological deficit occurred. In thoraco-lumbar fractures (82/64.5%), reduction succeeded from 2.5 ± 6° kyphosis to 5.6 ± 5.7° lordosis (p < 0.001) and in lumbar spine fractures from 6.9° ± 10.3° lordosis to 14.5° ± 8.8° lordosis (p < 0.001).Conclusion: Minimal invasive percutaneous dorsal instrumentation of burst fractures of the thoraco-lumbar and lumbar spine provides adequate reduction and reliable regular screw placement.Level of evidence: Level IV (retrospective series). [ABSTRACT FROM AUTHOR]

Introduction: In operative treatment of distal radius fractures satisfying outcome mainly relies on anatomical fracture reduction and correct implant placement. Examination with two-dimensional fluoroscopy may not provide reliable information about this. The aim of this study was to determine the effectiveness of additional intraoperative three-dimensional imaging in the operative treatment of comminuted distal radius fractures.Materials and Methods: From August 2001 to June 2015, patients with a distal radius fracture who were treated operatively and received intraoperative three-dimensional scan were included. The findings of the three-dimensional scan were documented by the operative surgeon and analyzed retrospectively with regard to incidence and the need for intraoperative revisions. Clinical evaluation included the patient's medical history, the injury pattern of the affected wrist (according to the OTA/AO fracture classification) and concomitant injuries. Intraoperative and postoperative complications and revision surgeries were evaluated as well.Results: Of 4515 operatively treated distal radius fractures, 307 (6.8%) received additional intraoperative three-dimensional imaging during surgery. 263 of 307 patients (85.7%) had a distal radius fracture type C. Intraoperative three-dimensional imaging revealed findings in 125 patients (40.7%) that were not detected on conventional two-dimensional fluoroscopy. In 54 patients (17.6%) these findings led to an immediate revision. Most commonly, revision was done in the case of remaining steps in the articular surface ≥ 1 mm (n = 25, 8.1%) followed by intra-articular screw placement (n = 23, 7.5%).Conclusions: Intraoperative three-dimensional imaging can provide additional information compared to conventional two-dimensional fluoroscopy in the operative treatment of distal radius fractures with the possibility of immediate intraoperative revision. [ABSTRACT FROM AUTHOR]

Background: Fractures of the extremities are often complicated by a variable degree of swelling secondary to hemorrhage and soft tissue injury. Patients typically require up to 7 days of inpatient bed rest and elevation to reduce swelling to an acceptable level for operative treatment with internal fixation. Alternatively, an intermittent pneumatic compression device, such as the Vascular Impulse Technology (VIT) system, can be used at the injured extremity to reduce the posttraumatic swelling. The VIT system consists of a pneumatic compressor that intermittently rapidly inflates a bladder positioned under the arch of the hand or the foot, which results in compression of the venous hand or foot plexus. That intermittent compression induces an increased venous velocity and aims to reduce the soft tissue swelling of the affected extremity.Methods/design: The VIT study is a prospective, monocenter, randomized controlled trial to compare the VIT system with elevation in the treatment of posttraumatic swelling in the case of a fracture of the upper and lower extremity. This study will include 280 patients with fractures of the upper and the lower extremity with nine different injury types. For each of the nine injury types a separate randomization to the two intervention groups (VIT group or control group) will be performed. The primary outcome parameter is the time taken for the swelling to resolve sufficiently to permit surgery. A separate analysis for each of the nine injury types will be performed.Discussion: In the proposed study, the effectiveness of the VIT system in the treatment of posttraumatic swelling of upper and lower extremity fractures will be evaluated.Trial Registration: German Clinical Trial Register, No. DRKS00010510 . Registered on 17 July 2016. [ABSTRACT FROM AUTHOR]

The incidence of osteoporotic fractures increases as our population ages. Until now, the exact biochemical processes that occur during the healing of metaphyseal fractures remain unclear. Diagnostic instruments that allow a dynamic insight into the fracture healing process are as yet unavailable. In the present matched pair analysis, we study the time course of the osteoanabolic markers bone specific alkaline phosphatase (BAP) and transforming growth factor β1 (TGFβ1), as well as the osteocatabolic markers crosslinked C-telopeptide of type-I-collagen (β-CTX) and serum band 5 tartrate-resistant acid phosphatase (TRAP5b), during the healing of fractures that have a low level of bone mineral density (BMD) compared with fractures that have a normal BMD. Between March 2007 and February 2009, 30 patients aged older than 50 years who suffered a metaphyseal fracture were included in our study. BMDs were verified by dual energy Xray absorptiometry (DXEA) scans. The levels of BTMs were examined over an 8-week period. Osteoanabolic BAP levels in those with low levels of BMD were significantly different from the BAP levels in those with normal BMD. BAP levels in the former group increased constantly, whereas the latter group showed an initial strong decrease in BAP followed by slowly rising values. Osteocatabolic β-CTX increased in the bone of the normal BMD group constantly, whereas these levels decreased significantly in the bone of the group with low BMD from the first week. TRAP5b was significantly reduced in the low level BMD group. With this work, we conduct first insights into the molecular biology of the fracture healing process in patients with low levels of BMD that explains the mechanism of its fracture healing. The results may be one reason for the reduced healing qualities in bones with low BMD. [ABSTRACT FROM AUTHOR]

Background: Until now the exact biochemical processes during healing of metaphyseal fractures of healthy and osteoporotic bone remain unclear. Especially the physiological time courses of 25(OH)D3 (Vitamin D) as well as PTH (Parathyroid Hormone) the most important modulators of calcium and bone homeostasis are not yet examined sufficiently. The purpose of this study was to focus on the time course of these parameters during fracture healing. Methods: In the presented study, we analyse the time course of 25(OH)D3 and PTH during fracture healing of low BMD level fractures versus normal BMD level fractures in a matched pair analysis. Between March 2007 and February 2009 30 patients older than 50 years of age who had suffered a metaphyseal fracture of the proximal humerus, the distal radius or the proximal femur were included in our study. Osteoporosis was verified by DEXA measuring. The time courses of 25(OH)D3 and PTH were examined over an eight week period. Friedmann test, the Wilcoxon signed rank test and the Mann-Withney U test were used as post-hoc tests. A p-value ⩽ 0.05 was considered significant. Results: Serum levels of 25(OH)D3 showed no differences in both groups. In the first phase of fracture healing PTH levels in the low BMD level group remained below those of the normal BMD group in absolute figures. Over all no significant differences between low BMD level bone and normal BMD level bone could be detected in our study. Conclusions: The time course of 25(OH)D3 and PTH during fracture healing of patients with normal and low bone mineral density were examined for the first time in humans in this setting and allowing molecular biological insights into fracture healing in metaphyseal bones on a molecural level. There were no significant differences between patients with normal and low BMD levels. Hence further studies will be necessary to obtain more detailed insight into fracture healing in order to provide reliable decision criteria for therapy and the monitoring of fracture healing. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to evaluate the intraoperative revision rate and reasons for revision following 3D imaging in the management of dislocated articular tibial plateau fractures based on a large patient sample. Methods: This retrospective cohort study included all patients who underwent open reduction and internal fixation due type B or C tibial plateau fracture according to the AO/OTA classification between August 2001 and December 2017 using intraoperative cone beam CT (3D imaging) for the analysis of fracture reduction and implant placement. The findings of the 3D scan were categorized regarding the amount and type of revision. Furthermore, demographic data was examined. Results: Five hundred and fifty-nine consecutive fractures were included in the study. Evaluation of the image data records revealed an intraoperative revision due to the usage of 3D imaging in 148 out of 559 cases (26.5%). The most common reasons for an intraoperative revision were insufficient fracture reduction (114 cases) and screw length (21 cases). Conclusion: This study reveals indications for a limited analysis of fracture reduction and implant placement during the operative treatment of dislocated articular tibial plateau fractures using conventional fluoroscopy. In view of the high revision rate during open reduction and internal fixation of tibial plateau fractures due to 3D imaging the usage of intraoperative cone beam, CT may be considered. If this is not possible, a postoperative computed tomography may therefore be reasonable. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to determine the functional long-term outcome after non-operative and operative treatment of radial neck fractures in adults. Methods: Thirty-four consecutive patients with a mean age of 46.4 (18.0 to 63.0) years with a fracture of the radial neck who were treated between 2000 and 2014 were examined regarding the clinical and radiological outcome. Twenty patients were treated non-operatively, and 14 patients underwent surgery. Results: After a mean follow-up of 5.7 (2.0 to 15.7) years, the clinical scores showed good results in both groups. The Disabilities of Arm, Shoulder and Hand score was 16.1 (0 to 71.6) in the non-operative group and 8.8 (0 to 50.8) in the operative group, respectively. The Mayo Elbow Performance Score was 80.0 (30 to 95) in the non-operative group and 82.5 (35 to 95) in the non-operative group, respectively. The initial angle of the radial head towards the shaft (RHSA) was significantly higher in the operative group in the anterior-posterior plane (12.8° [2 to 23] vs. 26.3° [1 to 90], p = 0.015). In the follow-up radiographs, the RHSA was significantly lower in the operative group (15.1° [3 to 30] vs. 10.9° [3 to 18], p = 0.043). Five patients developed 7 complications in the non-operative group, and 7 patients developed 12 complications in the operative group. Revision rates were higher in the operative groups as 1 patient received radial head resection in the non-operative (5%) group while 7 patients in the operative group (50%) needed revision surgery. Conclusion: A good functional long-term outcome can be expected after operative and non-operative treatment of radial neck fractures in adults. If needed due to major displacement, open reduction is associated with a higher risk of complications and the need for revision surgery but can achieve similar clinical results. Trial registration: DRKS DRKS00012836 (retrospectively registered) [ABSTRACT FROM AUTHOR]

Study Design: A prospective monocentric study.Objective: The aim of the current study was the analysis of patient outcome and radiological results 3 years after implantation of a hydraulic expandable vertebral body replacement (VBR) system.Summary Of Background Data: Around 70% to 90% of all traumatic spinal fractures are located in the thoracic and lumbar spine. Dorso-ventral stabilization is a frequently used procedure in traumatic vertebral body fracture treatment. VBR systems can be used to bridge bony defects. In the current study, a new VBR expanded by water pressure with adjustable endplates is used.Methods: All patients who suffered a singular traumatic fracture to a thoracic or lumbar vertebral body (Th 5-L 5) in the period from November 2009 to December 2010 and (i) underwent dorsal instrumentation and (ii) afterwards received the implantation of a hydraulic VBR were included in this study. The clinical outcome (visual analogue scale [VAS] spine score, questionnaire) and radiological findings (sagittal angle, implant subsidence, and implant position) 3 years after implantation were analyzed.Results: The follow-up was successful for n = 47 patients (follow-up rate: 89%). Most of the patients (n = 40) were "generally/very satisfied" with their outcome. The mean rating of the VAS spine score was 65.2 ± 23.1 (range: 20.5-100.0). The analysis of the radiological data showed an average subsidence of the implants of 1.1 ± 1.2 mm (range 0.0-5.0 mm). After the initial operation, the local sagittal angle remained stable in the follow-up 3 years later both for the thoracic spine and lumbar spine. Furthermore, no change in the implant's position was observed.Conclusion: The implantation of a hydraulically expandable VBR allows a permanent stable fixation after traumatic fractures of the thoracic and lumbar spine.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]