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Purpose A new software application can be used without fixed reference markers or a registration process in wire placement. The aim was to compare placement of Kirschner wires (K-wires) into the proximal femur with the software application versus the conventional method without guiding. As study hypothesis, we assumed less placement attempts, shorter procedure time and shorter fluoroscopy time using the software. The same precision inside a proximal femur bone model using the software application was premised. Methods The software detects a K-wire within the 2D fluoroscopic image. By evaluating its direction and tip location, it superimposes a trajectory on the image, visualizing the intended direction of the K-wire. The K-wire was positioned in 20 artificial bones with the use of software by one surgeon; 20 bones served as conventional controls. A brass thumb tack was placed into the femoral head and its tip targeted with the wire. Number of placement attempts, duration of the procedure, duration of fluoroscopy time and distance to the target in a postoperative 3D scan were recorded. Results Compared with the conventional method, use of the application showed fewer attempts for optimal wire placement (p = 0.026), shorter duration of surgery (p = 0.004), shorter fluoroscopy time (p = 0.024) and higher precision (p = 0.018). Final wire position was achieved in the first attempt in 17 out of 20 cases with the software and in 9 out of 20 cases with the conventional method. Conclusions The study hypothesis was confirmed. The new application optimised the process of K-wire placement in the proximal femur in an artificial bone model while also improving precision. Benefits lie especially in the reduction of placement attempts and reduction of fluoroscopy time under the aspect of radiation protection. The software runs on a conventional image intensifier and can therefore be easily integrated into the daily surgical routine.

Medical images are essential in modern traumatology and orthopedic surgery. Access to images is often cumbersome due to a limited number of workstations. Moreover, due to the tremendous increase of data, the time to review or to communicate images has also become limited. One approach to overcome these problems is to make use of modern mobile devices, like tablet computers, to facilitate image access and associated workflows. Ten orthopedic surgeons were equipped with an Apple iPad mini 2 and specialized viewing software for medical images. The surgeons were able to send images from a workstation onto the tablets or to search for patient images directly. The software enabled the physicians to share images, annotated key slices, and messages instantly with their colleagues. The surgeons carried the tablets within or in the periphery of the hospital. The participants evaluated the software by means of daily questionnaires. Data was collected for a period of 9 months. Nearly 25 images were viewed in total by the surgeons per day. The tablet viewer was used for accessing approximately 30% of these images. On average, the surgeons were asked 1.7 times per day by a colleague for a second opinion. They used the tablets in approximately 29% of these cases. Furthermore, the mean time for accessing images was significantly lower using mobile software compared to conventional methods. Tablet computers can play a vital role for image access and communication in the daily routine of an orthopedic surgeon. Mobile image access is an important aspect for surgeons, especially in larger facilities, to facilitate and accelerate the clinical workflows.

Seit uber 15 Jahren steht die intraoperative 3‑D-Bildgebung bei der Versorgung komplexer Gelenkverletzungen zur Verfugung. Sie ermoglicht die Darstellung anatomischer Strukturen in komplexen Regionen ebenso wie die dreidimensionale Abbildung knocherner Strukturen in Fus und Sprunggelenk. Mit diesem Verfahren lassen sich Repositionsergebnis, Implantatlage sowie Stellung der Syndesmose beurteilen. Unter Einbezug samtlicher anatomischer Regionen werden in unserer Klinik nach der Kontrolle im 3‑D-Scan in ca. einem Funftel der Falle intraoperative Revisionen durchgefuhrt. Den grosten Anteil nehmen dabei Fersenbein, Sprunggelenk und Pilon tibiale ein. Diese Verhaltnisse decken sich mit anderen Angaben in der Literatur. Die intraoperative 3‑D-Bildgebung hat sich somit in vielen Kliniken bei bestimmten Indikationen als Routineverfahren etabliert.

Distal biceps brachii tendon rupture can lead to 30–40% power loss of elbow flexion and up to 50% of forearm supination. Re-fixation of the distal biceps brachii tendon is recommended to warrant an adequate quality of the patient’s life. This study reports the isometric and isokinetic results after anchor re-fixation 2.5 years after surgery. Between 2007 and 2010, 69 patients with distal biceps brachii tendon tear underwent a suture anchor reattachment. During the follow-up examination, a questionnaire and DASH score were filled in, the circumferences of the arm were measured, range of motion was collected, and different trials were conducted at the BTE Primus RS™ (Baltimore Therapeutic Equipment) on both arms. 49 patients (71%) were reinvestigated with a follow-up of 32 months (11–58 months). A significant difference was found in the ability of elbow flexion between the affected arm and the opposite side as well as in pronation and supination. In elbow flexion and extension as well as in pronation and supination of the forearm, the strength was significantly diminished. 32 months after surgical re-fixation of the distal biceps brachii tendon rupture, strength in all exercises is marginally reduced in comparison to the opposite arm. Re-fixation of the distal biceps brachii tendon is an adequate method to return the range of motion and the strength in the elbow joint to an almost normal level and that gives rise to a high level of patient satisfaction. Level III, case–control study.

Ein Uberrolltrauma ist fur das Unfallopfer meist mit multiplen Verletzungen verbunden. Eine pragmatische Blutungskontrolle ist essenziell. Die typischen Druck- und Scherkrafte konnen an der Grenzflache von Subkutis und Faszie eine Minderperfusion des Gewebes und auch die Entstehung von grosen flussigkeitsgefullten Hohlraumen verursachen, das Vollbild einer sogenannten Morel-Lavallee-Lasion. In den Hohlraumen ist die Bildung von Infektionen und Nekrosen moglich, die den Krankheitsverlauf nachhaltig negativ beeinflussen konnen. Daher sollte zur Vermeidung lokaler und auch systemischer Komplikationen, wie einer Sepsis, eine adaquate Entlastung mit entsprechender Befundsanierung herbeigefuhrt werden.

Verletzungen der Fuse fuhren haufig aufgrund von Fehlstellungen, schmerzhaften Pseudarthrosen und Instabilitaten zu bleibenden Funktionsbeeintrachtigungen. Ursachen fur korrekturbedurftige Fusfehlstellungen sind ubersehene oder inadaquat therapierte Verletzungen. Komplizierte postoperative Verlaufe mit posttraumatischen Arthrosen, Infekten, Osteonekrosen, ausbleibenden knochernen Heilungen oder muskularen Imbalancen konnen auch nach initial korrekter Behandlung zu korrekturbedurftigen Fehlstellungen fuhren. Korrekturen mussen dabei alle Funktionen des Fuses berucksichtigen. Das Augenmerk muss insbesondere auf die Achsausrichtung des Ruckfuses und die Koppelung des Vorfuses gelegt werden. Idealerweise werden Korrektureingriffe vor Auftreten von Anschlussarthrosen benachbarter Gelenke durchgefuhrt. Zur Wiederherstellung der Funktion des Fuses sollten Arthrodesen auf die unmittelbar betroffenen Gelenke beschrankt bleiben. Deformierende Krafte der motorisch uberwiegenden Muskelgruppen mussen neutralisiert werden, um erneute Deformitaten zu vermeiden. Der Beitrag gibt eine Ubersicht uber korrigierende Eingriffe am Ruckfus.

Introduction Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. Material and methods A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. Results 17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. Conclusion While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey.The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department.The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used.Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants.Die Immobilisation der Wirbelsäule beim unfallverletzten Patienten ist eine Standardmaßnahme in der präklinischen Notfallmedizin. Einheitliche Empfehlungen zur Immobilisation des Patienten während der Akuttherapie im Krankenhaus existieren nicht. Ziel der aktuellen Studie ist die Analyse der unterschiedlichen Vorgehensweisen bei der Wirbelsäulenimmobilisation in den überregionalen Traumazentren Deutschlands mittels einer internetbasierten Umfrage.Bei der aktuellen Studie handelt es sich um eine umfragebasierte Analyse der aktuellen Durchführung der Immobilisation der Wirbelsäule in den 107 überregionalen Traumazentren Deutschlands. Die internetbasierte Umfrage enthielt insgesamt 6 Fragen zur innerklinischen Lagerung der Patienten.Die Rücklaufquote betrug 47,7%. In 14 (28,6%) Traumazentren verbleiben die Patienten in der Art und Weise immobilisiert, wie dies durch das Rettungsfachpersonal durchgeführt wurde. In 19 (38,8%) Traumazentren werden die Patienten auf eine Liege mit Weichlagerungsmatratze umgelagert. Die Umlagerung auf das Spineboard und die TraumaMattress erfolgt in 11 (22,4%) bzw. 7 (14,3%) Traumazentren. Eine Umlagerung des Patienten auf die Vakuummatratze erfolgt in keinem Fall. Die Halswirbelsäule wird meist mittels einer Zervikalstütze immobilisiert (n = 48; 98,0%). Im Mittel geben die Befragten eine hohe Zufriedenheit (Median = 84 von 100) mit der derzeit durchgeführten Immobilisation der Patienten an. Am höchsten ist diese bei der Nutzung des Spineboards.Die Lagerung von Patienten während der initialen Notfallbehandlung in den deutschen überregionalen Traumazentren ist uneinheitlich. Sowohl die Ganzkörperimmobilisation als auch die komplette Aufhebung der Immobilisation wurden beschrieben.

The aim of this study was to identify to what extent a dissection of the syndesmosis and an avulsed posterior edge of the tibia can change the tibiofibular diastasis and fibular rotation. Three-dimensional scans with a mobile C-arm of 22 cadaver legs were taken of the intact fibula, after dissection of the anterior part of the syndesmosis and the interosseous membrane, osteotomy of the posterior malleolus, and osteosynthesis. The tibiofibular diastasis as well as the angle of fibular rotation was identified in the four steps and the means compared to each other using a t test for paired samples. The distinction between the intact fibula vs. the osteotomy of the posterior tibia was 0.082 ± 0.332 mm for the tibiofibular distance in the incisura tibiofibularis (p 0.261) and 0.046 ± 0.486 degrees for the angle of the fibular rotation (p 0.665). Neither the dissection of the syndesmosis nor the osteotomy of the posterior malleolus significantly influenced the position of the fibula in the incisura tibiofibularis in the cadaveric model. However, in the nonweight-bearing situation, a lesion of the syndesmotic complex might not be evident in intraoperative three-dimensional imaging.

Background The aim of the study was to evaluate the impact of reduction quality, using intraoperative 3D imaging, on quality of life and functional outcome in the operative treatment of tibial plafond fractures. Methods A group of patients with tibial plafond fractures was postoperatively examined. The operative treatment was performed between September 2001 and October 2011 under reduction control using an intraoperative 3D C-arm. A categorization with regard to the type and the size of joint surface irregularities was carried out after intraoperative reduction. Postoperative results were evaluated using: Olerud and Molander (O & M) score, Short-Form-36 (SF-36) score, leg circumference, movement deficit, Kellgren and Lawrence grade of osteoarthritis, and pain intensity. Results 34 patients with osteosynthetically treated tibial plafond fracture could be re-examined. Reduction quality had the greatest influence on functional result measured by the O & M score (P=0.001) and the PCS domain of the SF-36 score (P=0.018). Significant differences with regard to O & M score (P=0.000), SF-36 score (P=0.001 to P=0.02; without MCS domain), circumferential difference below the knee joint gap (P=0.012), movement deficit (P=0.001), grade of osteoarthritis (P=0.005) and pain (P=0.001) could be verified under consideration of the reduction quality. The group with the preferred reduction also showed a better result for clinical follow-up and quality of life. Conclusions Despite other relevant factors, it appears that reduction quality - which can be analyzed with intraoperative 3D imaging - plays the most important role in postoperative quality of life and functional outcome.

Technical development lead to an enhancement of clinical movement analysis in the last few decades and expanded its research and clinical applications. Since the mid 20th century, human movement analysis has made its way into clinical practice, e.g. in treating poliomyelitis and infantile cerebral palsy. Today, it has a wide range of applications in various clinical areas. The aim of this narrative review is to illustrate the variety of camera-based systems for human movement analysis and their clinical applications, specifically in the field of orthopaedics and trauma surgery (O/U). Benefits and limitations of each system are shown. Future development and necessary improvements are discussed.A selective literature review was undertaken with the databases PubMed and Google Scholar using keywords related to clinical human movement analysis in the field of orthopaedics and trauma surgery. Furthermore standard book references were included.Common video camera systems (VS) are used for basic visual movement analysis. Instrumented movement analysis systems include marker-based systems (MBS), markerless optical systems (MLS) and rasterstereographic analysis systems (VRS). VS, MBS and MLS have clinical use for dynamic examination of patients with various disorders in movement and gait. Among such are e.g. neuro-orthopaedic disorders, muscular insufficiencies, degenerative and post-trauma deficiencies with e.g. resultant pathologic leg axis. Besides the measurement of kinematic data by MBS and MLS, the combination with kinetic measurements to detect abnormal loading patterns as well as the combination with electromyography (EMG) to detect abnormal muscle function is a great advantage. Validity and reliability of kinematic measurements depend on the camera systems (MBS, MLS), the applied marker models, the joints of interest and the observed movement plane. Movements in the sagittal plane of the hip and knee joint, pelvic rotation and tilt as well as hip abduction are generally measured with high reliability. In the frontal and transverse planes of the knee and ankle joint substantial angular variabilities were noted due to the small range of motion of the joints in these planes. Soft tissue artefacts and marker placement are the biggest sources of errors. So far MLS did not improve these limitations. MBS are most accurate and remain the gold-standard in clinical and scientific movement analysis. VRS is used clinically for static 3D-analysis of the trunk posture and spine deformities. Current systems allow the dynamic measurement and visualisation of trunk and spine movement in 3D during gait and running. Planar x-ray-imaging (Cobb's angle) and to some extent cross sectional imaging with CT-scan or MRI are commonly used for the evaluation of patients with spinal deformities. VRS offers functional 3D data of trunk and spine deformities without radiation exposure, thus allowing safer clinical monitoring of the mainly infantile and adolescent patients. The accuracy, validity and reliability of measurements of different VRS-systems for the clinical use has been proven by several studies.The instrumented movement analysis is an additional tool that aids clinical practitioners of O/U in the dynamic assessment of pathologic movement and loading patterns. In conjunction with common radiologic imaging it aids in the planning of type and extent of corrective surgical interventions. In the field of orthopaedics and trauma surgery movement analysis can help as an additional diagnostic tool to develop therapeutic strategies and evaluate clinical outcomes.Technische Weiterentwicklungen haben in den vergangenen Jahren zu einer enormen Ausweitung des medizinischen Anwendungsspektrums der klinischen Bewegungsanalyse geführt. Das Ziel dieser Übersichtsarbeit ist es, verschiedene kamerabasierte technische Systeme zur Bewegungsanalyse darzustellen. Ihre jeweiligen Vor- und Nachteile sowie ihre sinnvollen klinischen Anwendungsmöglichkeiten in der Orthopädie und Unfallchirurgie (O/U) sollen aufgezeigt werden.Narrative Übersichtsarbeit anhand einer selektiven Literaturrecherche auf den Datenbanken PubMed und Google Scholar sowie in Standardwerken.Neben einfachen Kamerasystemen zur visuellen kinematischen Analyse (VS) finden markerbasierte Systeme (MBS), markerlose Systeme (MLS) sowie videorasterstereografische Systeme (VRS) Anwendung. Klinisch werden die VS, MBS und MLS zur dynamischen Untersuchung (Gang, Funktionstests) bei Patienten mit neuroorthopädischen, degenerativen und posttraumatischen Achs- und Rotationsabweichungen des gesamten Bewegungsapparats und Rumpfes angewendet. Die VRS dient der statischen Haltungsanalyse und z. T. der Untersuchung der dynamischen Wirbelsäulenstellung. Die VRS ergänzt die klassischen bildgebenden Verfahren um eine 3-dimensionale Beurteilung und kann die Anzahl radiologischer Verlaufskontrollen reduzieren. Vorteile der MBS und der MLS sind insbesondere die dynamische Beurteilung von kinematischen Störungen sowie die Möglichkeit, kinetische Daten (Gelenkmomente und -belastungen) sowie Daten der Elektromyografie (EMG, Muskelaktivität) zu kombinieren. Die instrumentelle Bewegungsanalyse hilft, komplexe Gangbildpathologien, Fehlbelastungen und Kompensationsmuster zu beurteilen. Daraus können konkrete Therapieentscheidungen abgeleitet werden, wie z. B. über das operative Ausmaß und Begleitprozeduren bei Single-Event-Multilevel-Surgery-Eingriffen (SEMS) bei komplexen neuroorthopädischen Krankheitsbildern.Die verschiedenen Systeme der kamerabasierten instrumentellen Haltungs- und Bewegungsanalyse sind unter Beachtung der systemspezifischen Limitationen ein relevantes, hilfreiches und dynamisches diagnostisches Verfahren in der Orthopädie und Unfallchirurgie. Die Reliabilität und Validität der Systeme hängt von verschiedenen Faktoren ab, wie dem Kamerasystem, dem Markermodell, dem zu untersuchenden Gelenk und der zu betrachtenden Bewegungsebene, was durch geschultes Personal interpretiert werden sollte.

Fracture reduction and fixation of syndesmotic injuries is a common procedure in trauma surgery. An intra-operative evaluation of the surgical outcome is challenging due to high inter-individual anatomical variation. A comparison to the contralateral uninjured ankle would be highly beneficial but would also incur additional radiation and time consumption. In this work, we pioneer automatic contralateral side comparison while avoiding an additional 3D scan.We reconstruct an accurate 3D surface of the uninjured ankle joint from three low-dose 2D fluoroscopic projections. Through CNN complemented 3D shape model segmentation, we create a reference model of the injured ankle while addressing the issues of metal artifacts and initialization. Following 2D-3D multiple bone reconstruction, a final reference contour can be created and matched to the uninjured ankle for contralateral side comparison without any user interaction.The accuracy and robustness of individual workflow steps were assessed using 81 C-arm datasets, with 2D and 3D images available for injured and uninjured ankles. Furthermore, the entire workflow was tested on eleven clinical cases. These experiments showed an overall average Hausdorff distance of [Formula: see text] mm measured at clinical evaluation level.Reference contours of the contralateral side reconstructed from three projection images can assist surgeons in optimizing reduction results, reducing the duration of radiation exposure and potentially improving postoperative outcomes in the long term.

We investigated whether mobile C-arm cone beam computer tomography (CBCT) could be used to measure radioulnar translation. The study was conducted on 31 Thiel-fixed intact cadaver arms. Three-dimensional scans of each wrist were carried out in pronation and supination. Four established measurement methods were used (radioulnar line, subluxation ratio, epicentre and radioulnar ratio methods) to measure radioulnar translation. The intraclass correlation coefficient for inter-observer and intra-observer reliability were excellent in three of four methods (>0.94). The reference ranges for physiological radioulnar translation were between −30% and 91% (radioulnar line method), −32% and 87% (subluxation ratio method), −40% and 23% (epicentre method), and 2% and 73% (radioulnar ratio method). Our results indicate that radioulnar translation in the distal radioulnar joint can be determined reliably using mobile C-arm CBCT. The normal values provide a basis for further experimental and clinical studies.

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P.001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P.001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P.001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

It remains controversial how to immobilize the cervical spine (CS) in trauma patients. Therefore, we analyzed different CS immobilization techniques during prehospital patient transport. In this explorative, biomechanical analysis of immobilization techniques conducted in a standardized setting, we recorded CS motion during patient transport using a wireless human motion tracker on a volunteer. To interpret spinal movement a benchmark called motionscore (MS) was developed based on biomechanics of the injured spine. We found the best spinal motion restriction using a spine board, head blocks and immobilization straps with and without a cervical collar (CC) (MS 45 vs. 27). Spinal motion restriction on a vacuum mattress with CC and head blocks was superior to no CC or head blocks (MS 103 vs. 152). An inclined vacuum mattress was more effective with head blocks than without (MS 124 vs. 187). Minimal immobilization with an ambulance cot, CC, pillow and tape was slightly superior to a vacuum mattress with CC and head blocks (MS 92 vs. 103). Minimal immobilization without CC showed the lowest spinal motion restriction (MS 517). We suggest an immobilization procedure customized to the individual situation. A spine board should be used whenever spinal motion restriction is indicated and the utilization is possible. In some cases, CS immobilization by a vacuum mattress with CC and head blocks could be more beneficial. In an unstable status of the patient, minimal immobilization may be performed using an ambulance cot, pillow, CC and tape to minimize time on scene caused by immobilization.

Background Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes. Method Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence. Finding Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes. Interpretation Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence.

Die Diskussion uber die optimale Versorgung von subaxialen Verletzungen der Halswirbelsaule (HWS) wird kontrovers gefuhrt, ein evidenzbasierter Goldstandard existiert nicht. Das gilt sowohl fur die optimale initiale Strategie, insbesondere bei der Versorgung luxierter Verletzungen der HWS, aber auch fur die sekundare Stabilisierung. Moderne Schrauben-Stab-Systeme ermoglichen eine sichere und komplikationsarme dorsale Stabilisierungsoption speziell bei hoch instabilen Verletzungskonstellationen, sei es durch Schraubenplatzierung in der Massa lateralis oder in den Pedikeln. Dorsale Stabilisierungstechniken bieten dabei biomechanisch Vorteile gegenuber einer ventralen Stabilisierung und sind allein oder in Kombination mit ventraler Fusion eine wichtige Therapieoption in der Versorgung subaxialer Verletzungen der HWS.

Es wird uber den Fall einer hochgradigen Deformitat der thorakolumbalen Wirbelsaule nach Resektion eines Sarkoms berichtet. Nach adjuvanter Radiatio bestand ein ausgedehnter Strahlenschaden im Bereich der Haut mit chronischer Fistelung. Es erfolgte die Korrektur uber eine Closing-Wedge-Osteotomie von L3 und Verlangerung der vorhandenen dorsalen Instrumentierung (Th10-L4) auf Th8 und das Os ileum. Am Folgetag erfolgte eine Weichteildeckung durch eine freie Latissimus-dorsi-Lappenplastik, welche an eine arterio-venose Gefasschleife in der Axilla angeschlossen wurde. Durch dieses interdisziplinare Vorgehen konnte eine nahezu vollstandige Korrektur und eine sichere Weichteildeckung erreicht werden.

Das Ellenbogengelenk ist eine komplexe Verbindung drei verschiedener Gelenke. Die Kongruenz und Stabilitat hangen von der Integritat der knochernen Artikulationspartner sowie von ligamentaren, kapsularen und muskularen Strukturen ab. Instabilitaten des Ellenbogens resultierten am haufigsten infolge akuter Verletzungen der knochernen und weichteiligen stabilisierenden Strukturen. Rezidivierende Mikrotraumata oder Uberlastungen z. B. bei Wurfsportarten konnen zu chronischen Instabilitaten mit hieraus resultierenden Beschwerden am Ellenbogengelenk fuhren. Das primare Ziel bei der Behandlung von Instabilitaten des Ellenbogengelenkes ist die Wiederherstellung eines kongruenten und stabilen Gelenkes. Im vorliegenden Beitrag werden die wichtigsten diagnostischen und therapeutischen Schritte bei akuten und chronischen Instabilitaten des Ellenbogens dargestellt.

In orthopedic surgeries, it is important to avoid intra-articular implant placements, which increase revision rates and the risk of arthritis. In order to support the intraoperative assessment and correction of surgical implants, we present an automatic detection approach using cone-beam computed tomography (CBCT). Multiple active shape models (ASM) with specified articular surface regions are used to isolate the joint spaces. Fast and easy-to-implement methods are integrated in the ASM segmentation to optimize the robustness and accuracy for intraoperative application. A cylinder detection method is applied to determine metal implants. Intersections between articular surfaces and cylinders are detected and used to find intra-articular collisions. Segmentations of two calcaneal articular surfaces were evaluated on 50 patient images and have shown average surface distance errors of 0.59 and 0.46 mm, respectively. The proposed model-independent segmentation at the specified articular surface regions allowed to significantly decrease the error by 22 and 25 % on average. The method was able to compensate suboptimal initializations for translations of up to 16 mm and rotations of up to 21 $$^{\circ }$$ . In a human cadaver test, articular perforations could be localized with an accuracy of 0.80 mm on average. A concept for automatic intraoperative detection of intra-articular implants in CBCT images was presented. The results show a reliable segmentation of articular surfaces in retrospective patient data and an accurate localization of misplaced implants in artificially created human cadaver test cases.

Eine traumatische Makroamputation im Bereich der oberen Extremitat stellt einen gravierenden Einschnitt im Leben des Betroffenen mit weitreichenden funktionellen sowie psychosozialen Folgen dar. Aufgrund des hohen technischen und personellen Aufwands ist die Behandlung von Makroamputationsverletzungen den dafur spezialisierten Fachkliniken vorbehalten. Der Schwerpunkt dieses Artikels liegt auf dem therapeutischen Algorithmus bei der Behandlung von traumatischen Majoramputationen der oberen Extremitat mit Darstellung der wichtigsten Prinzipien bei der Makroreplantation und der Makroamputation.

Methods Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. Results A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. Discussion The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: Bone Joint J 2016;98-B:81–7.

In order to achieve a clinically satisfying result and to prevent posttraumatic osteoarthritis in the treatment of unstable syndesmotic injuries, anatomically correct reduction is crucial. The objective of the study was to investigate three different reduction methods of the ankle mortise in unstable syndesmotic injuries. In a specimen model with 38 uninjured fresh-frozen lower legs, a complete syndesmotic dissection was performed. The ankle mortise was reduced with either a collinear reduction clamp, a conventional reduction forceps or manually with crossing K-wires. The reduction clamps and the K-wires were placed in a 0°-angle to the leg axis. The clamps were positioned on the posterolateral ridge of the fibula 20 mm proximal to the ankle joint line. A cone beam computed tomography was performed after dissection and after each reduction. Tibio-fibular distances and angles were determined. Despite significant differences in terms of overcompression (0.09–0.33 mm; p = 0.000–0.063) and the slight external rotation (0.29–0.47°; p = 0.014–0.07), the results show a satisfying reduction of the ankle mortise. There were no considerable differences between the reduction methods. It can therefore be concluded that the ankle mortise can be reduced with any of the methods used, but that the positioning and the contact pressure must be considered.

BACKGROUND In professional motorbike racing falls with high velocities are common. Nonetheless, severe injuries or deaths are rare when compared to regular road traffic. METHODS In this study, falls in all courses of the largest German race series IDM*Superbike between 2007 and 2013 were analyzed regarding injury patterns and hospital admissions. All races were accompanied by a medical team, including at least one physician who assessed every patient. RESULTS A total of 728 falls were included. A specific fall mechanism could be determined in 45.5% of the cases. 40.5% were admitted to a trauma center for further diagnostics. A definitive diagnosis was found in 45.4%. In most cases (29.9%) the injury pattern was a fracture of the extremities. In collisions a significantly higher odds ratio of 2.52 (P=0.0001) and in undetermined falls a significantly lower odds ratio of 0.47 (P

We evaluated the neurologic, psychological and vegetative outcome, the health status and changes of the personal and occupational status of patients after traumatic brain injuries (TBIs). Correlations between outcome parameters and basic demographic factors and initial clinical status parameters of the patients were assessed.Monocentric, retrospective follow-up analysis.We evaluated the neurologic, psychological and vegetative outcome and health status of patients, who survived TBI with a mean follow-up time of 54 months. Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and a questionnaire on Quality of Life were used for outcome measurement. The personal and occupational status, trauma-derived changes to that status and medical and demographic factors that have an impact on the health condition of patients after TBI were assessed.With a median GOS of 5.0 and median DRS of 3.0, our patients showed just moderate disabilities. Fifty-six per cent of the patients felt 'very good' or 'good'. Age, gender, the preclinical Glasgow Coma Scale (GCS), state of pupil reaction and surgical treatment did not seem to affect the GOS or DRS. Correlations between body mass index, age and gender and distinct neurologic, psychological and vegetative symptoms were found. The personal status did not change significantly after TBI. Changes to occupational and socioeconomic status were evident.One-third of the patients are heavily affected by neurological, psychological and vegetative symptoms after surviving TBI. Some demographic factors affected this integrity.

Introduction The trace element selenium (Se) is crucial for the biosynthesis of selenoproteins. Both neurodevelopment and the survival of neurons that are subject to stress depend on a regular selenoprotein biosynthesis and sufficient Se supply by selenoprotein P (SELENOP). Hypothesis Neuro-regeneration after traumatic spinal cord injury (TSCI) is related to the Se status. Study design Single-centre prospective observational study. Patients and methods Three groups of patients with comparable injuries were studied; vertebral fractures without neurological impairment (n = 10, group C), patients with TSCI showing no remission (n = 9, group G0), and patients with remission developing positive abbreviated injury score (AIS) conversion within 3 months (n = 10, group G1). Serum samples were available from different time points (upon admission, and after 4, 9 and 12 h, 1 and 3 days, 1 and 2 weeks, and 1, 2 and 3 months). Serum trace element concentrations were determined by total reflection X-ray fluorescence, SELENOP by ELISA, and further parameters by laboratory routine. Results Serum Se and SELENOP concentrations were higher on admission in the remission group (G1) as compared to G0. During the first week, both parameters remained constant in C and G0, whereas they declined significantly in the remission group. Similarly, the concentration changes between admission and 24 h were most pronounced in this group of recovering patients (G1). Binary logistic regression analysis including the delta of Se and SELENOP within the first 24 h indicated an AUC of 90.0% (CI: 67.4%–100.0%) with regards to predicting the outcome after TSCI. Conclusion A Se deficit might constitute a risk factor for poor outcome after TSCI. A dynamic decline of serum Se and SELENOP concentrations after admission may reflect ongoing repair processes that are associated with higher odds for a positive clinical outcome.

BACKGROUND A virtual guidance framework is used to assist the conventional method of virtual implant planning system (VIPS). The study null hypothesis was that its screw placement accuracy is equal to that of conventional VIPS. METHODS In 34 distal radius sawbone models, 3D implant planning was performed. A camera attached to the surgical drill was used to support screw positioning. Differences of angles/tip distances between planned and placed screws were identified in intraoperative cone beam Computer tomography (CT) and compared with already existing data from 22 patients treated by conventional VIPS. RESULTS The virtual guidance group showed tip distances of 1.02 ± 0.56 mm, azimuth of 3.69° ± 4.34°, and inclination of 1.75° ± 1.37°, whereas the VIPS group showed tip distances of 2.23 ± 0.99 mm (P

Background: Indirect screw fixation of the sustentaculum tali in the lateral-medial direction can be challenging due to the complex calcaneal anatomy. A novel 2-dimensional (2D) projection-based software application detects Kirschner wires (K-wires) and visualizes their intended direction as a colored trajectory. The aim of this prospectively randomized cadaver study was to investigate whether the software would facilitate the indirect K-wire placement in the sustentaculum tali. Methods: In 20 cadaver foot specimens, K-wires were placed indirectly in the sustentaculum tali by an experienced and an inexperienced surgeon, with and without using the application. Number of placement attempts, duration of procedure, fluoroscopy time, and number of individual fluoroscopy images were recorded. Each wire’s position was analyzed in a 3-dimensional (3D) C-arm scan by an experienced blinded investigator. Results: Use of the software by the inexperienced surgeon significantly reduced the number of placement attempts from 3.2 to 1.2 ( P = .006). The application also reduced operating time, from 273 s to 199 s ( P = .15), and fluoroscopy time, from 41 s to 29 s ( P = .15). Using the software, the experienced surgeon had a longer operating time (139 s to 183 s; P = .30), longer fluoroscopy time (5.6 s to 9.2 s; P = .17), and more individual fluoroscopy images (11.6 to 14.8; P = .30). Wire position did not show significant differences in both cases. Conclusion: During indirect K-wire placement in the sustentaculum tali, the software appeared to be a useful tool for the inexperienced surgeon. In our chosen study setting, the experienced surgeon did not benefit from the software. Clinical Relevance: Possible indications for the software would be fractures of the proximal femur, sacrum, sacroiliac instabilities, vertebral bodies, scaphoid, Lisfranc joint, talus and calcaneus.

With the help of an intra-operative mobile C-arm CT, medical interventions can be verified and corrected, avoiding the need for a post-operative CT and a second intervention. An exact adjustment of standard plane positions is necessary for the best possible assessment of the anatomical regions of interest but the mobility of the C-arm causes the need for a time-consuming manual adjustment. In this article, we present an automatic plane adjustment at the example of calcaneal fractures. We developed two feature detection methods (2D and pseudo-3D) based on SURF key points and also transferred the SURF approach to 3D. Combined with an atlas-based registration, our algorithm adjusts the standard planes of the calcaneal C-arm images automatically. The robustness of the algorithms is evaluated using a clinical data set. Additionally, we tested the algorithm’s performance for two registration approaches, two resolutions of C-arm images and two methods for metal artifact reduction. For the feature extraction, the novel 3D-SURF approach performs best. As expected, a higher resolution ( $$512^3$$ voxel) leads also to more robust feature points and is therefore slightly better than the $$256^3$$ voxel images (standard setting of device). Our comparison of two different artifact reduction methods and the complete removal of metal in the images shows that our approach is highly robust against artifacts and the number and position of metal implants. By introducing our fast algorithmic processing pipeline, we developed the first steps for a fully automatic assistance system for the assessment of C-arm CT images.

Seit mehr als einem Jahrzehnt werden 3-D-C-Bogen in unfallchirurgischen Zentren regelmasig zur Beurteilung von intraoperativen Stellungskontrollen betrieben. Die Verwendung von 3-D-C-Bogen ermoglicht die intraoperative detaillierte Beurteilung von knochernen anatomischen Regionen, welche mithilfe von konventionellen Bildverstarkern nicht ausreichend dargestellt werden konnen. Dies betrifft v. a. die intraoperative Darstellung von grosen Gelenken sowie des Beckens und der Wirbelsaule. Im Rahmen einer Osteosynthese kann mithilfe der 3-D-Bildgebung intraoperativ eine unzureichende Reposition der Fraktur oder eine ungunstige Platzierung des Implantats erkannt und umgehend korrigiert werden. Dadurch kann eine Folgeoperation, die bei einer unzureichenden Erstversorgung erforderlich ware, vermieden werden. Somit stellt die intraoperative 3-D-Bildgebung ein suffizientes Hilfsmittel dar, um die Ergebnisqualitat der Frakturversorgung in schwierigen anatomischen Bereichen zu verbessern. Die Durchfuhrung eines intraoperativen 3-D-Scans bedarf eines geschulten OP-Teams sowohl von pflegerischer als auch arztlicher Seite, sodass eine routinemasige Anwendung eines 3-D-C-Bogens als sinnvoll erachtet wird.

Zur subaxialen Halswirbelsaule wird der Abschnitt ab dem Bandscheibenraum C2/C3 bis in den zervikothorakalen Ubergang (C7/Th1) gerechnet. Grund fur die Unterteilung in Verletzungen der subaxialen HWS und solche der oberen HWS ist der einheitliche anatomische Aufbau unterhalb von C2 mit hieraus gleich wirkenden biomechanischen Grundprinzipien fur die einzelnen Bewegungssegmente. Entsprechend ergibt sich eine fur alle Verletzungen unterhalb von C2 ahnlich anzuwendende Therapieoption. Im Gegensatz zu den Verletzungen der oberen HWS steht bei der Behandlung von traumatischen subaxialen Instabilitaten ein primar ventrales Vorgehen im Vordergrund. Dies gilt auch fur die Reposition von Subluxationen oder Luxationsverletzungen. Nach einem ventral fusionierenden Eingriff ist ein kombiniertes ventrodorsales Vorgehen erforderlich, wenn eine hohergradige posteriore Instabilitat verbleibt.

Die computerbasierte Planung von Implantaten wird in den meisten Fallen praoperativ durchgefuhrt. Mit der VIPS-Methode (Virtual Implant Planning System) wurde eine Applikation fur mobile C-Bogen entwickelt, mit der intraoperativ virtuell gelenknahe Schrauben bei der Versorgung distaler Radiusfrakturen mit volarer Plattenosteosynthese geplant werden konnen. Ziel dieser prospektiv randomisierten Studie war es, erste klinische Erfahrungen zu sammeln und VIPS mit der konventionellen Technik zu vergleichen. Hierzu wurden in einer Pilotphase 10 Patienten und dann 30 Patienten mit distalen Radiusfrakturen Typ A3, C1 und C2 in 2 Gruppen eingeschlossen. In der VIPS-Gruppe wurde nach Einbringen der Platte und Reposition der Fraktur ein virtuelles 3-D-Modell der Platte mit der Abbildung der Platte in den Durchleuchtungsbildern gematcht. In der virtuellen Platte wurden nun Lage und Lange der gelenknahen Schrauben geplant. Die Kontrollgruppe wurde mit dem gleichen Implantat konventionell versorgt. Erhoben wurden Schraubenwechsel, intraoperative Durchleuchtungszeit und Schnitt-Naht-Zeit. In die VIPS-Gruppe wurden 6 A3-, eine C1- und 8 C2-Frakturen eingeschlossen, in die Kontrollgruppe 6 A3- und 9 C2-Frakturen. In der VIPS Gruppe wurden 3 Schrauben neu platziert, in der konventionellen Gruppe 2 (p = 0,24). Die intraoperative Durchleuchtungszeit lag in der VIPS-Gruppe bei 2,58 ± 1,38 min, in der Kontrollgruppe bei 2,12 ± 0,73 min (p = 0,26). Die Schnitt-Naht-Zeit betrug in der VIPS-Gruppe 53,3 ± 34,5 und in der Kontrollgruppe 42,3 ± 8,8 min (p = 0,23). VIPS ermoglicht bei Gelenkfrakturen des distalen Radius eine prazise Positionierung der gelenknahen Schrauben. Fur den Routineeinsatz ist jedoch eine Weiterentwicklung notwendig.

A 12-year-old boy suffered a rare occurrence of a traumatic spondylolisthesis (L5/S1) without neurological alterations after being partially buried underneath a collapsing brick wall. Additionally he sustained a third degree open fracture of the left distal fibula and epiphysiolysis of the left distal tibia. A closed reduction and percutanous dorsal instrumentation L5/S1 as well as an open reduction and osteosynthesis of the tibia and fibula were performed. After 6 months the instrumentation was completely removed and an unrestrained range of motion of the lumbar spine and the upper ankle joint was regained.

To evaluate the accuracy of computer-assisted sacral screw fixation compared with conventional techniques in the dysmorphic versus normal sacrum.Review of a previous study database.Database of a multinational study with 9 participating trauma centers.The reviewed group included 130 patients, 72 from the navigated group and 58 from the conventional group. Of these, 109 were in the nondysmorphic group and 21 in the dysmorphic group.Placement of sacroiliac (SI) screws was performed using standard fluoroscopy for the conventional group and BrainLAB navigation software with either 2-dimensional or 3-dimensional (3D) navigation for the navigated group.Accuracy of SI screw placement by 2-dimensional and 3D navigation versus conventional fluoroscopy in dysmorphic and nondysmorphic patients, as evaluated by 6 observers using postoperative computerized tomography imaging at least 1 year after initial surgery. Intraobserver agreement was also evaluated.There were 11.9% (13/109) of patients with misplaced screws in the nondysmorphic group and 28.6% (6/21) of patients with misplaced screws in the dysmorphic group, none of which were in the 3D navigation group. Raw agreement between the 6 observers regarding misplaced screws was 32%. However, the percent overall agreement was 69.0% (kappa = 0.38, P0.05).The use of 3D navigation to improve intraoperative imaging for accurate insertion of SI screws is magnified in the dysmorphic proximal sacral segment. We recommend the use of 3D navigation, where available, for insertion of SI screws in patients with normal and dysmorphic proximal sacral segments.Therapeutic level I.

To analyze the compression of the dural sac and the cervical spinal movement during performing different airway interventions in case of atlanto-occipital dislocation. In six fresh cadavers, atlanto-occipital dislocation was performed by distracting the opened atlanto-occipital joint capsule and sectioning the tectorial membrane. Airway management was done using three airway devices (direct laryngoscopy, video laryngoscopy, and insertion of a laryngeal tube). The change of dural sac’s width and intervertebral angulation in stable and unstable atlanto-occipital conditions were recorded by video fluoroscopy with myelography. Three-dimensional overall movement of cervical spine was measured in a wireless human motion track system. Compared with a mean dural sac compression of − 0.5 mm (− 0.7 to − 0.3 mm) in stable condition, direct laryngoscopy caused an increased dural sac compression of − 1.6 mm (− 1.9 to − 0.6 mm, p = 0.028) in the unstable atlanto-occipital condition. No increased compression on dural sac was found using video laryngoscopy or the laryngeal tube. Moreover, direct laryngoscopy caused greater overall extension and rotation of cervical spine than laryngeal tube insertion in both stable and unstable conditions. Among three procedures, the insertion of a laryngeal tube took the shortest time. In case of atlanto-occipital dislocation, intubation using direct laryngoscopy exacerbates dural sac compression and may cause damage to the spinal cord.

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.

Rund 5 % aller Traumapatienten erleiden eine Verletzung der Wirbelsaule. Im Falle von instabilen mehrsegmentalen Wirbelkorperfrakturen wird die Kombination der dorsalen Instrumentierung mit der ventralen Abstutzung empfohlen. Ziel der Studie war die Analyse der radiologischen Befunde nach der Implantation eines hydraulisch distrahierenden Wirbelkorperersatzimplantats sowie die Evaluation des Outcome 3 Jahre nach der Implantation. Alle Patienten, welche im Zeitraum 09/2009–09/2012 eine traumatisch bedingte, mehrsegmentale Fraktur im Bereich der Brust- und Lendenwirbelsaule erlitten, wurden in die Studie eingeschlossen, sofern sie keine initial bestehenden neurologische Defizite oder Begleitverletzungen zeigten. Es erfolgte die dorsale, perkutane Instrumentierung und die Implantation eines Wirbelkorperersatzes durch Mini-open-Technik. In der radiologischen Bildgebung wurde pra- und postoperativ der traumatische Segmentwinkel bestimmt. Durch einen Fragebogen erfolgte 3 Jahre nach der Implantation die Erhebung der Patientenzufriedenheit und des VAS-Spine-Score. Im genannten Zeitraum konnten 7 Patienten (4 Frauen; 3 Manner) in die Studie eingeschlossen werden. Das mittlere Alter der Patienten betrug 53,0 ± 13,2 Jahre. Am haufigsten traten Verletzungen im Bereich des thorakolumbalen Ubergangs auf. Der mittlere praoperative traumatische Segmentwinkel von 18,1 ± 14,9° konnte durch die Reposition auf 6,4 ± 1,7° verkleinert werden. Nach 3 Jahren konnten 3 der genannten Patienten nochmals im Rahmen einer Nachuntersuchung beurteilt werden. Die Reposition blieb stabil. Es zeigte sich bei einem Patient eine Implantatsinterung von 1,5 mm. Diese hatte keinen Einfluss auf die Zufriedenheit der Patienten mit dem OP-Ergebnis (alle 3 Patienten waren „sehr zufrieden“). Die Werte des VAS-Spine-Score lagen zwischen 62,4 und 70,2. Die vorliegende Studie konnte zeigen, dass bei mehrsegmentalen Wirbelkorperfrakturen eine vollstandige Reposition durch Ligamentotaxis und das perkutane Instrumentationssystem moglich ist. Die dorsale Instrumentierung und die ventrale Fusionsoperation scheinen dieses Korrekturergebnis auch uber einen Zeitraum von 3 Jahren zu erhalten. Die Patienten zeigen sich mit dem Operationsergebnis „sehr zufrieden“, was durch die Erhebung des VAS-Spine-Score bestatigt wird.

Intraoperative mobile C-arm fluoroscopy is widely used for interventional verification in trauma surgery, high flexibility combined with low cost being the main advantages of the method. However, the lack of global device-to- patient orientation is challenging, when comparing the acquired data to other intrapatient datasets. In upper ankle joint fracture reduction accompanied with an unstable syndesmosis, a comparison to the unfractured contralateral site is helpful for verification of the reduction result. To reduce dose and operation time, our approach aims at the comparison of single projections of the unfractured ankle with volumetric images of the reduced fracture. For precise assessment, a pre-alignment of both datasets is a crucial step. We propose a contour extraction pipeline to estimate the joint space location for a prealignment of fluoroscopic C-arm projections containing the upper ankle joint. A quadtree-based hierarchical variance comparison extracts potential feature points and a Hough transform is applied to identify bone shaft lines together with the tibiotalar joint space. By using this information we can define the coarse orientation of the projections independent from the ankle pose during acquisition in order to align those images to the volume of the fractured ankle. The proposed method was evaluated on thirteen cadaveric datasets consisting of 100 projections each with manually adjusted image planes by three trauma surgeons. The results show that the method can be used to detect the joint space orientation. The correlation between angle deviation and anatomical projection direction gives valuable input on the acquisition direction for future clinical experiments.

PLOS ONE 12(1), e0170004 (2017). doi:10.1371/journal.pone.0170004, Published by PLoS, Lawrence, Kan.

Bei circa 11% aller Frakturen des oberen Sprunggelenks (OSG) treten akute Verletzungen der Syndesmose auf, die aufgrund ihrer Instabilitat einen operativen Eingriff erfordern [1]. Dabei kann die Stabilisierung mittels Stellschraube zu einer Fehlstellung der Fibula fuhren, welche ohne Korrektur mit einer Verschlechterung der Lebensqualitat des Patienten einhergehen kann. Der Einsatz mobiler 3D C-Bogen ermoglicht eine raumliche Interpretation der Anatomie bei der Verifikation des Repositionsergebnisses. Gleichzeitig stellt die variable Ausrichtung des Scanners zum Patienten eine grose Herausforderung beim Vergleich mit anderen Datensatzen dar. Bei der Beurteilung von OSG Frakturen mit Beteiligung der Syndesmose kann ein Vergleich mit der gesunden Gegenseite sinnvoll sein. Da ein weiterer Scan jedoch zusatzliche Strahlenbelastung sowie eine Erhohung der Operationsdauer bedeutet, sollen stattdessen Einzelprojektionen der gesunden Gegenseite analysiert werden. In der vorliegenden Arbeit wird die Ausrichtung des Datensatzes durch die Detektion des tibiotalaren Gelenkspaltes bestimmt [2]. Ein Quadtree-basierter hierarchischer Varianzvergleich identifiziert potentielle Konturpunkte. Aus diesen werden dann mit Hilfe von Hough Transformationen Schaftkonturen und der Gelenkspalt extrahiert. Die Methode wurde auf 13 C-Bogen Datensatzen mit jeweils 100 Einzelprojektionen angewandt. Dazu wurden die anatomischen Sichtebenen von jeweils drei Unfallchirurgen manuell eingestellt, auf die Einzelprojektionen projiziert und mit den berechneten Ebenen verglichen. Die resultierende Korrelation zwischen Winkelabweichung und korrespondierendem Winkel gibt Aufschluss uber bevorzugte Aufnahmerichtungen und dient als Basis fur weiterfuhrende klinische Experimente

Hintergrund: Die geschlossene Reposition und Osteosynthese des Femurs mit einem unaufgebohrten Marknagel gilt als Standardverfahren bei der Behandlung von diaphysaren Femurfrakturen (DFF). Eine in der Computertomografie (CT) gemessene postoperative Torsionsdifferenz (TD) des Femurs zur gesunden Gegenseite wird als eine Komplikation der operativen Therapie angesehen und ist in der Literatur mit 17–35 % angegeben. Die Messung mittels CT stellt eine objektivierbare, valide und reproduzierbare Methode zur postoperativen Bestimmung der Torsion des Femurs dar. Eine vermehrte TD von > 15° kann zu einer Reduktion des Aktivitatsausmases im postoperativen Verlauf und zu Beschwerden fuhren. Aus diesem Grund ist eine anatomische Rekonstruktion der Beinachse nach einer DFF von groser Wichtigkeit. Material/Patienten und Methoden: Im Zeitraum vom 01. 07. 2007 bis 31. 12. 2011 wurden die Falle von unilateralen DFF in die Studie eingeschlossen. Die Frakturen wurden geschlossen reponiert und mittels antegrader Marknagelosteosynthese operativ versorgt. Als Ausschlusskriterien wurden eine beidseitige Betroffenheit, eine Schwangerschaft, offene Epiphysenfugen oder Voroperationen am Femur angesehen. Zur Bestimmung der Torsion der Femora wurde bei samtlichen Patienten postoperativ eine CT durchgefuhrt. Bei einer TD > 15° wurde die Indikation zu einer operativen Derotation des Femurs zum Ausgleich der TD gestellt. Die Messergebnisse der CT-Diagnostik wurden retrospektiv, nicht randomisiert ausgewertet. Ergebnisse: Insgesamt wurde das Bildmaterial von 94 Patienten mit unilateralen DFF ausgewertet. 21 Patienten waren weiblich und 73 mannlich mit einem Durchschnittsalter von 33,15 ± 14,04 Jahren (Range 14–94). In der postoperativen CT-Diagnostik wurde eine TD im Mittel von 11,58 ± 9,41° (Range 0–38°) zur gesunden Gegenseite festgestellt. In 15 Fallen (15,95 %), 10 mannlich (13,7 %) und 5 weiblich (23,81 %), zeigte sich eine TD von > 15° (Mittelwert: 23,66 ± 5,74°). In diesen Fallen wurde zum Ausgleich der TD eine Revisionsoperation durchgefuhrt, mit der eine Reduktion der TD erzielt werden konnte. Im Mittel betrug die Korrektur 17,53 ± 6,83°. Nach der Revisionsoperation verblieb im Durchschnitt eine TD von 6,07 ± 5,61° zur gesunden Gegenseite. Schlussfolgerung: Nach einer geschlossenen Reposition und Osteosynthese einer DFF mit unaufgebohrtem antegradem Marknagel kann eine postoperative TD trotz intraoperativer klinischer Torsionskontrolle auftreten. Eine routinemasig angewendete postoperative Torsionskontrolle mittels CT kann auch eine klinisch okkulte TD darstellen. Die Auswertung der postoperativen Torsionsmessungen fuhrte eine korrekturbedurftige TD in nahezu 15 % aller Falle auf – trotz intraoperativer klinischer Kontrolle. Unseres Erachtens ersetzt somit die klinische Untersuchung der Torsion allein eine postoperative CT-Kontrolle nicht. Wir empfehlen daher nach einer geschlossenen Reposition und antegrader Marknagelosteosynthese einer Femurschaftfraktur eine CT-Kontrolle postoperativ zum Ausschluss einer TD.

The aim of the study was to determine predictive risk factors for revision surgery in patients with septic orthopaedic implant removal of the lower leg. A total of 196 patients with septic removal of orthopaedic implants after primary trauma of the lower leg between 2008 and 2012 were evaluated. Patients with endoprosthesis infection were excluded from this study. Thirteen patients (22.4 %) had infectious complications with revision surgery. We found 14 patients with soft tissue infections, 10 patients with osteomyelitis, 19 patients with wound-healing problems, 10 patients with pin track infections and two patients with fistulas. High complication rates were associated with severity of the initial trauma, localisation, and the state of union or non-union. Patients with peripheral arterial disease, anaemia and smoking showed a significantly higher risk for revision surgery; whereas patients with diabetes and arterial hypertension did not. A total of 22.6 % had open fractures as an initial trauma. In 76 %, bacteria could be detected. The complication rate was 41.2 % after initial open fractures and 19.6 % after initial closed fractures. A higher grade of soft tissue damage showed no increasing complication rate (p > 0.05). In this study, complications after septic implant removal of the lower leg were evaluated and risk factors were determined. The awareness of the risks for complications after septic orthopaedic implant removal can lead to a better treatment for patients. Decision-making can be based on scientific results to prevent patients suffering from further severe disease progression.

Computer assisted surgery (CAS) has been applied more often within the last years. Multiple aspects of CAS have been important in orthopaedic and trauma surgery such as pre-operative planning, intraoperative imaging and navigation. In total four different methods of navigation within CAS exist. While imageless navigation is used more regularly in osteotomy, 3D-based navigation is applied in trauma surgery more commonly. CAS uses infrared signals sent from markers attached to the patient and the instruments which are detected by a camera and processed by a connected computer. The aim of CAS is a visual support during complex surgical procedures leading to an improvement of the operational result. The enhancement of the visualization permits surgical procedures with low soft tissue impairment especially in crucial anatomical regions. Hence CAS together with minimal invasive procedures and an improvement of digital imaging has the option to optimize surgical procedures. However there exist limitations to the application of CAS in trauma care which have to be considered.

Background Complete-pelvis segmentation in antero-posterior pelvic radiographs is required to create a patient-specific three-dimensional pelvis model for surgical planning and postoperative assessment in image-free navigation of total hip arthroplasty. Methods A fast and robust framework for accurately segmenting the complete pelvis is presented, consisting of two consecutive modules. In the first module, a three-stage method was developed to delineate the left hemipelvis based on statistical appearance and shape models. To handle complex pelvic structures, anatomy-specific information processing techniques were employed. As the input to the second module, the delineated left hemi-pelvis was then reflected about an estimated symmetry line of the radiograph to initialize the right hemi-pelvis segmentation. The right hemi-pelvis was segmented by the same three-stage method, Results Two experiments conducted on respectively 143 and 40 AP radiographs demonstrated a mean segmentation accuracy of 1.61±0.68 mm. A clinical study to investigate the postoperative assessment of acetabular cup orientations based on the proposed framework revealed an average accuracy of 1.2°±0.9° and 1.6°±1.4° for anteversion and inclination, respectively. Delineation of each radiograph costs less than one minute. Conclusions Despite further validation needed, the preliminary results implied the underlying clinical applicability of the proposed framework for image-free THA.

Aufgrund des demografischen Wandels gewinnen Frakturen bei alteren, an Osteoporose leidenden Patienten immer mehr an Bedeutung. Aufgrund des gestorten Knochenstoffwechsels sind die Anspruche an eine adaquate Therapie hoch. Der substanzgeschwachte, osteoporotische Knochen bricht meist im Rahmen eines Bagatelltraumas, aber auch das im Alter erhohte Sturzrisiko sowie die nicht selten vorhandene muskulare Atrophie spielen eine wichtige Rolle. Typische Lokalisationen dieser Knochenbruche sind die Wirbelsaule, der handgelenknahe Unterarm, der schulternahe Oberarm und, zu einem wesentlichen Anteil, der huftgelenknahe Oberschenkel. Fast immer ist ein operatives Vorgehen indiziert. Dieses sollte bei Patienten ohne gravierende Kontraindikation fur eine Operation innerhalb von 24 h erfolgen, da sich fur ein verlangertes praoperatives Zeitintervall deutliche Nachteile mit erhohter Morbiditat und Mortalitat zeigten. Ziel der Therapie ist eine belastungsstabile Osteosynthese, die eine funktionelle Nachbehandlung mit einer zugigen Mobilisation des Patienten erlaubt. Unter den vielen fur die Versorgung osteoporotischer proximaler Femurfrakturen in Frage kommenden Verfahren wurde die biomechanische Uberlegenheit dynamischer Implantate nachgewiesen. Eine fruhzeitige Mobilisation und intensive Physiotherapie stehen im Zentrum der Nachbehandlung. Trotz optimaler Versorgung konnen Komplikationen auftreten.

Background When performing minimally invasive spine surgery in trauma patients, a short operation time and a perfect positioning of pedicle screws are demanded. In this study, we show that a Minimally Invasive Pedicle Screw System allows both. Methods One hundred and twenty-one patients (131 fractures) with fractures between Th 3 and L 5 were treated. The most common fracture type was A3. We treated 52 females and 69 men with a mean age of 56.7 years. In 72% of the cases, the procedure was performed by two experienced spine surgeons. Postoperatively, all patients were examined using a CT-scan. In 61 patients, an anterior stabilization was additionally performed in 33 patients, vertebroplasty or cyphoplasty was performed. Fifteen patients underwent laminectomy. Results No patient postoperatively developed any additional neurological compromise. In total, 682 screws were placed. In the postoperative CT-scan, we found 16 screws (2.2%) in suboptimal position, 8 with medial and 8 with lateral deviation. Discussion With the Minimally Invasive Pedicle Screw System used in this study, spinal fractures can be treated in a short operation time with percutaneous stabilization and a correct positioning of the pedicle screws in almost 98%. In our study, no screw was so much malpositioned that revision surgery would have been necessary. Level of evidence Level III – Case-control study.