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Objective: To evaluate the potential benefit of a new injectable mineral bone cement (Norian SRS, Cupertino, CA, USA) for the treatment of tibial plateau fractures OTA types 41.B2-B3 and C3., Design: Prospective study with established protocol., Setting: University hospital; university teaching hospital., Patients: Twenty-six patients gave informed consent to participate in this study and were available for follow-up examinations. All patients had sustained intraarticular tibial plateau fracture types OTA B2-B3 and C3. All cases were followed with a mean follow-up time of 19.7 months (6 to 36 months, median eighteen months)., Intervention: Twenty-five cases were treated with open reduction, osteosynthesis with screws or plate, and injection of Norian SRS in the subchondral bone defect. One case had closed reduction, screw osteosynthesis, and percutaneous cement injection., Main Outcome Measurements: Radiographs in two planes were evaluated prospectively at six, twelve, and twenty-six weeks postoperatively and at last follow-up using Rasmussen's radiologic score. Clinical parameters were measured at the same time intervals using Lysholm's and Tegner's knee scores., Results: Two cases required early wound revisions because of sterile drainage. Two cases developed partial loss of reduction of the fracture between four and eight weeks after surgery, requiring revision surgery in one case (total complication rate 15.3 percent). No other patients had complications, and all other fractures healed without any displacement. The high mechanical strength of the cement allowed early weight bearing after a mean postoperative period of 4.5 weeks (1 to 6 weeks)., Conclusions: An injectable mineral bone cement with high initial mechanical strength was used to fill bone defects in unstable tibial plateau fractures with good success. This material offers new perspectives in the treatment of tibial plateau fractures.

Primary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named "borderline patients". In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.

Objective: To evaluate arthroscopic versus fluoroscopic reduction and percutaneous fixation of lateral tibial plateau fractures of AO/OTA Types 41.B1 to 41.B3., Design: Prospective study., Setting: University hospital., Patients and Intervention: One hundred sixty-eight patients underwent operative treatment for a tibial plateau fracture from 1988 to 1995. Thirty-three of these patients had monocondylar fractures of the lateral plateau that were treated by percutaneous reduction and fixation techniques. In the first ten cases, arthroscopic control of reduction was used. The following twenty-three consecutive cases were treated by reduction and fixation solely under fluoroscopic control. The arthroscopy group was followed for a mean of fifty-two months and the fluoroscopy group for thirty-eight months., Results: Nine of ten cases of the arthroscopy group had an excellent or good result in Rasmussen's knee score at follow-up. One patient with an unreduced anterolateral depression zone despite arthroscopic surgery required a total knee prosthesis after eighteen months. Sixteen cases in the fluoroscopy group met the follow-up criteria. Fifteen were graded good or excellent in Rasmussen's clinical score; sixteen were excellent or good in the radiological score. One patient claimed chronic medial joint line pain after a lateral split fracture and had arthroscopy revealing chondral degeneration on the medial side but had no pathological findings in the lateral compartment. No secondary meniscus or ligament surgery was performed in the follow-up period., Conclusions: Percutaneous treatment of fractures of the tibial plateau can be performed using arthroscopy as well as image intensification to control reduction of the joint surface. We were not able to demonstrate any significant benefit from arthroscopy compared with fluoroscopic reduction. Reduction under image intensification is technically easier in our practice, especially in serial fractures and multiply injured patients. We reserve arthroscopy for cases with significant ligament injuries and for children with fractures of the median eminence.

In an effort to limit the amount of soft tissue dissection at the fracture site, indirect reduction and minimally invasive fixation techniques have been developed to treat femoral and tibial fractures. These techniques, which do not rely upon anatomical reduction of the fracture fragments, are technically difficult. Correct limb length, axial alignment in the frontal and sagittal plane, and rotation must be assessed using means other than open reduction. In this technical note, some simple and effective intraoperative clinical examination and radiographic techniques to determine limb alignment are described. These include: the 'cable techniques' for the determination of varus-valgus malalignment; the 'hypertension test', 'radiographic recurvatum sign', 'tibial plateau sign', and 'meterstick technique' for length analysis; and the 'hip rotation test', 'lesser trochanter shape sign', 'cortical step sign', and 'diameter difference sign' for rotational analysis. For each of the listed techniques, basic principles, technical instructions, limitations, advantages, and disadvantages are described.

Open reduction and internal fixation of unstable pelvic ring fractures provides the best stability of fixation as well as the best late clinical results. Whereas several studies have supported this both in biomechanical studies and clinical trials, there is still controversy about the long-term outcome of these injuries. A series of 58 patients who had received surgical stabilization of Tile B- and C-type fractures between 1985 and 1990 were followed up for an average of 28 months. The follow-up included a detailed clinical and radiological examination, an evaluation of the patient's general social status and a detailed neurological and urological screening. The data were summarized in a new scoring system rating radiological, clinical and social results independently. Patients suffering B-type fractures showed 79% good and excellent results. Despite the fact that after C-type fractures 50% healed anatomically and 30% healed with a 5 mm or less residual posterior displacement, only 27% of the patients were rated good or excellent. Further studies must be conducted for closer evaluation of risk factors influencing the results after anatomical reconstruction of the pelvic ring.

The operative treatment of intraarticular calcaneal fractures has three principal aims: restoration of height, length, and width of the calcaneus, reconstruction of the subtalar and calcaneocuboid joint surfaces, and stable osteosynthesis using an H-plate or screws. In 68% of the cases, the sustentacular fragment was the key to open reduction, making the medial approach mandatory. In complex fractures, a lateral approach is added. In "blow-out" fractures or cases with comminution of the sustentacular fragment, an extended lateral approach only is used. For precise preoperative planning of roentgenograms in three planes, four Brodén's views and axial plus coroneal or three-dimensional computed tomography scans are required. From July 1983 to July 1990, 157 intraarticular calcaneal fractures were treated by open reduction. The results in 123 cases are 61% good or excellent, 32.5% satisfactory, and 6.5% poor. The following early complications occurred: superficial wound edge necrosis (8.3%), hematoma (2.5%), nonunion (1.3%), and infection (1.9%). Four patients (3.3%) in the follow-up group have developed degenerative changes severe enough to require subtalar fusion. To facilitate the comparison of results, new fracture classification and follow-up scoring systems have been devised.

Non-operative management is still the treatment of choice for closed fractures of the femoral shaft in children. Indications for operative intervention would include: children with multiple injuries; severe soft tissue damage; cases where reduction is difficult to maintain; and children not suitable for management by traction. Since 1984, 16 children (mean age 10.3 years) have had stabilization of their femoral shaft fractures by external fixation (Monofixateur) in the Trauma Department of the Hannover Medical School. The external fixation remained in place for a mean of 63 days. Of the 16 children, 15 have been reviewed, with a mean follow-up of 28.2 months. No children who were completely managed with this fixation had any clinically relevant malalignment, but six cases had up to 2 cm difference in leg length. Our observations and experience show that external fixation is a useful alternative for the operative management of femoral shaft fractures in children. It produces good stability, is less invasive, and allows early mobilization. In order to avoid differences in leg length, we recommend a good anatomical reduction with the external fixation being carried out as early as possible.

One hundred thirty-two open tibial shaft fractures were treated by unilateral external fixation. In order to evaluate the usefulness of supplemental lag screw fixation, we compared forty-four reexamined fractures in which only external fixation was utilized with fifty-five reexamined fractures, stabilized with supplemental lag screws and external fixation. We did not find significant differences in time to full-weight bearing (17.1 vs. 15.6 weeks), time to union (18.7 vs 18.0 weeks), incidence of delayed union [as defined by time to union over 32 weeks (10.9% vs. 11.4%)], incidence of osteomyelitis (5.4% vs. 4.5%), or incidence of malunion [axial malalignment greater than 5 degrees (12.7% vs. 11.4%)]. Clinically significant differences were found demonstrating a twofold increase in refracture rate in the group with supplemental lag screws (10.9% vs. 4.5%) and requiring twice as many bone grafting procedures to achieve union (65.5% vs. 29.5) than did the group treated by external fixation alone. Therefore we do not recommend the routine use of supplemental lag screw fixation.

Non-operative management is still the treatment of choice today for femoral shaft fractures in children. Indications for operative intervention would include: - the child with multiple injuries, particularly with severe head injuries, in those patients with severe soft tissue damage associated with the fracture; in cases where the reduction is difficult to maintain, as in subtrochanteric fractures; and in children who are not suitable for management with traction. Since 1984, 16 children have had their femoral shaft fractures stabilized by external fixation (Monofixateur) here in the Trauma Department of the Hannover Medical School. The mean age of the patients was 10.3 years (seven to sixteen years). All cases were closed fractures with mild or moderate soft tissue damage. Eleven of the patients had a multiple injury, and four had subtrochanteric fractures. The external fixation remained in place for a mean of 63 days in those patients exclusively treated by this method. In four of the earlier cases there was a Schanz's screw infection and three of these required removal of the external fixation and treatment in a hip spica. After modifying the technique of Schanz's screw insertion, no further infections were seen. Fourteen of the sixteen children were reviewed, with a mean follow up of 21.7 months. None of the children who had been completely managed by this fixation had any clinically relevant malalignment. Six cases had leg lengthening of up to two centimetres. Leg length differences were seen more frequently and more severely in those cases where external fixation was delayed.

From 1982 to 1986, a total of 202 lower leg fractures (70 closed, 132 open fractures) were treated with a monoexternal fixation device, and 148 cases were included in the follow-up study. The mean healing time was 15.4 weeks for closed fractures and 18.4 weeks for open fractures. Infection was occurred in 3.4% of the patients followed up (5.1% open fractures, as 0% closed fractures), aseptic delayed in 8.8%, and pin tract infection in 2.5%. The group of patients with open fractures treated with additional lag screws (n = 74) showed a higher rate of refractures (10.9% vs 4.5%) and bone grafting (65.5% vs 29.5%) than the control group without lag screws (n = 58). The healing times (15.8% vs 15.5 weeks) and rates of non-union (10.9% vs 11.4%) were similar in both groups. Among 14 cases of secondary intramedullary nailing, osteitis occurred in 2. In the dynamized group (n = 53) healing time was reduced to 16.0 weeks, as against 18.0 weeks in the n-dynamized group (n = 95).

Functional treatment can be defined as a form of therapy in which the involved segment of the locomotor system is either not immobilized at all or the immobilization is incomplete and lasts only for a limited time. Function of the involved segment is therefore restored during the treatment. Many fractures, especially those of the upper extremity, stable fractures as well as a number of joint injuries such as AC-joint dislocation, ankle ligament rupture and Achilles tendon rupture can be treated functionally. Functional Treatment is an integral part of regular conservative fracture treatment and also important for the operative management of fractures and joint injuries.

Discusses the use of screw external and internal fixation for ankle arthrodesis. Biomechanics of the foot and ankle joint; Indications for an ankle fusion; Procedures for arthrodesis; Post-operative management.