[Show abstract][Hide abstract] ABSTRACT: Study Design. A biomechanical study calf cadaver studyObjective. The purpose of this study was to determine the intradiscal pressure gradient of bridged healthy intervertebral segments in correlation with intraoperative distraction force.Summary of Background Data. Bisegmental dorsal stabilization and anatomic reduction is a common treatment option for incomplete burst fractures of the lumbar spine. However, it remains unknown to what extent bridging and intraoperative distraction compromises an intact intervertebral disc.Methods. The L2-3 intervertebral disc level was evaluated in six fresh frozen calf cadaver spines. Pressure measurements were taken with the spine uninstrumented, after dorsal segmental instrumentation from L1 to L3, and after distraction with 400 N and 800 N. Pressure gradient measurements were accomplished with a balloon pressure sensor placed within the nucleus pulposus of the L2-L3 intervertebral disc. Pressure data were recorded by computer data acquisition. Flexion, extension, and lateral bending moments were applied continuously by a testing machine up to a load moment of 7.5 Nm. The pressure gradients were compared with respect to the effects of added instrumentation and distraction.Results. After segmental bridging the mean pressure gradients were significantly reduced in all movement directions (p < 0.001). However, after dorsal stabilization a continuously rising intervertebral disc pressure was recordable. In contrast, no relevant additional reduction of the intradiscal pressure gradient was detectable after applying distraction forces of 400N or 800N.Conclusions. In a calf model, a distraction force of up to 800N leads to no additional reduction of the pressure gradient of bridged healthy lumbar segments under flexion and extension moments.
[Show abstract][Hide abstract] ABSTRACT: The number of patients with symptomatic metastases increases from year to year. Especially spinal metastases often lead to severe pain which often cannot be treated adequately by conservative treatment. Surgeons are confronted with the risk of instability, pathological fractures and neurological failure and the surgical treatment necessary in most cases is nowadays becoming an even greater challenge. The surgical procedure has changed considerably in recent years. The therapy is patient-individualized, the selection of implants and technology is adapted to the physical condition of the patient and the progression of the underlying disease. The main targets of the surgical treatment of spinal metastases have to be sufficient pain reduction with restoration of mobility as well as with the prevention of neurological deficits caused by progressive osteolysis. There are two minimally invasive stabilization procedures which can basically be applied. Under certain circumstances a single kyphoplasty/vertebroplasty procedure can be sufficient, in contrast to the possibility of short or long percutaneous posterior stabilization in combination with selective decompression of neural structures. These percutaneous surgical procedures currently have an important place in the surgical treatment of spinal metastases. The advantages are a less traumatic intervention for patients with advanced malignant diseases and poor general condition. Low intraoperative loss of blood means less intraoperative stress for the patient and minor surgical approaches lead to rapid mobilization and effective pain relief. As a result the hospital stay is shorter, adjuvant therapy can be started earlier and patients can be discharged sooner.
Der Orthopäde 09/2013; 42(9):755-64. · 0.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: The huge amount of information on the internet about orthopaedic and trauma surgical issues is very often unclear and hard to control in reliability, autonomy and expertise. The aim of this work is to evaluate German-speaking internet sites with orthopaedic and trauma surgical contents. Material and Methods: Over a period of two months (from May to June) in 2012 different websites about 20 common orthopaedic and trauma surgical diseases were analysed on the internet by Google search engine. The first ten search results were evaluated for the HON code principles (Health On the Net Foundation). Furthermore there was an evaluation about qualification of the first 50 websites. The best 1,000 placed websites on Google were analysed for the authoritative value: academic, commercial, media, non-medical, physicians, non-profit and miscellaneous. Results: Only 194 from 200 websites could be evaluated by the HON code principles. Overall 188 websites complied the principle of transparency, followed by privacy with 150 sites and authoritative with 134 sites. Only 90 websites give information about financial disclosure. Medical articles of the website Wikipedia appear most frequently. In the second part of this work it is shown that non-profit sites and sites by physicians are the most frequent. The fewest results are given by academic and commercial sites with 93 and 85 online hits. Conclusion: In summary, it is shown that most of the websites about medical information have inadequate quality. This statement is in accord with some U. S. American publications. It is clear that Wikipedia has a top-ranking on the internet when it is about medical information. Wikipedia almost achieves all of the HON code principles. It is possible to give better medical online information about orthopaedic and trauma surgical issues published by professionals.
Zeitschrift fur Orthopadie und Unfallchirurgie 07/2013; · 0.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures. MATERIALS AND METHODS: In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications. RESULTS: In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients. CONCLUSION: Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.
[Show abstract][Hide abstract] ABSTRACT: Background: Modular distal femur replacements originally were developed for reconstructing a full weight-bearing and functional extremity after resection of primary bone tumours with large bony defects located in proximity to joints. The aim of this study was to examine the use of the modular distal femur replacements for complex fractures and severe post-traumatic sequelae of the distal femur in context to comparable studies. Patients and Methods: Fourteen patients with complex fractures or post-traumatic sequelae and extensive bone defects requiring distal femur replacement were analysed retrospectively. Median age of the patients at the time of distal femoral replacement was 77 years and median follow-up interval was 27 months. Median follow-up was 27.0 (IQB 13.5-37.5) months (range 10-49 months). Results: The indication for distal femur replacement was a periprosthetic fracture in three cases. Three further periprosthetic fractures were treated with a megaendoprosthesis after failure of osteosynthesis. In eight patients a megaendoprosthesis was implanted due to complications following ostheosynthesis for distal femoral fractures. Distal femoral arthroplasty was performed as a two-stage procedure in five patients with implant-associated infections. A lateral approach was used in six patients and a medial arthrotomy was conducted in eight patients. The median Knee Society score (KSS) improved significantly from 20.0 (IQB 7.5-30.0) points preoperatively to 80.0 (IQB 62.3-89.0) points at follow-up (p < 0.001). Complications requiring surgical intervention were documented in seven of 14 patients (50 %). In two patients wound-healing disorders and superficial infections necessitated surgery. In one patient a rupture of the patellar tendon was diagnosed. This patient subsequently also sustained a periprosthetic fracture. Another patient developed early aseptic loosening of the femoral component. The most common complication was a periprosthetic fracture in four patients. Three patients died for reasons not related to distal femoral replacement. Conclusion: Distal femoral replacement is an important option in reconstituting a full weight-bearing and functional lower extremity after complex fractures and post-traumatic sequelae with massive bone destruction. Particularly elderly patients regain ambulatory ability in the vast majority of cases. The relatively high complication rate demands very thorough preoperative planning as well as prompt allocation of extensive surgical procedures in the case of an adverse event.
[Show abstract][Hide abstract] ABSTRACT: Injuries of the upper cervical spine with atlantoaxial instabilities often require posterior stabilizations, but the surrounding neurovascular structures make the screw fixation technically demanding. Minimal misplacements can lead to severe neurovascular complications. Thus, the intraoperative 3-dimensional guided navigation is an important tool to improve the precision of screw placement in this critical zone.
This article describes the posterior C1/2 screw fixation with C1 lateral mass screws and C2 pedicle screws with 3-dimensional C-arm-based navigation under regard of the current literature.
Operative Techniques in Orthopaedics 03/2013; 23(1):2–8.
[Show abstract][Hide abstract] ABSTRACT: Das Ziel dieser Studie über Patienten mit einem schweren Thorax- und Beckentrauma bestand in der Untersuchung des Einflusses des Operationszeitpunktes der Beckenfraktur auf den pulmonalen und allgemeinen klinischen Verlauf.Im Rahmen einer prospektiven bizentrischen Observationsstudie konnten 47 Patienten eingeschlossen werden. Es wurde der klinische Verlauf anhand der funktionellen Lungenparameter, SAPS II, SOFA sowie des Krankenhausaufenthalts in Abhängigkeit vom Operationszeitpunkt untersucht.Der ISS lag durchschnittlich bei 32±6, der PTS bei 34±11 und der TTSS bei 9±3 Punkten. Die Beckenfrakturen wurden nach 7±2 Tagen definitiv versorgt. Der frühe Operationszeitpunkt korrelierte signifikant mit einem geringen TTSS und SAPS II bei Aufnahme (pPatienten mit schwerem Becken- und Thoraxtrauma profitieren in dieser Studie positiv von einer eher frühzeitigen definitiven Stabilisierung der Beckenfraktur hinsichtlich einer geringeren Beatmungsdauer, einer geringeren intensivmedizinischen Verweildauer und einem geringeren Bedarf an Erythrozytenkonzentraten.
Der Unfallchirurg 01/2013; 116(10). · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: The aim of the study was to identify risk factors of failed two-stage procedures in cases of chronic posttraumatic periprosthetic hip infections. PATIENTS AND METHODS: Between 2006 and 2008, 26 patients with chronic posttraumatic periprosthetic infections after hip arthroplasty were included. In all cases operative bacterial eradication was initiated. The therapy was carried out according to a standardized treatment protocol including the eradication of the bacterial infection and the prosthetic replacement after three negative intra-operative specimens as a two-stage procedure. Follow-up was performed at least 2 years after revision procedure. RESULTS: Twelve patients showed no signs of infectious recurrence 2 years after prosthetic hip revision therapy (46 %) and were assigned to group I. Group II is constituted by the other 14 patients (54 %). Four of them (16 %) suffered from an infectious recurrence after prosthetic hip replacement, ten patients (38 %) were characterised by a failed bacterial eradication. The spectrum of pathogens showed a significantly higher resistance pattern (p = 0.001) in group II, with a majority of methicillin-resistant Staphylococcus epidermidis (MRSE) and highly resistant Pseudomonas. In addition, patients of group II offered significantly higher American Society of Anesthesiology (ASA) scores (p = 0.015), the body mass index (BMI) was significantly elevated (p = 0.031) and received a significantly higher number of operative procedures (p = 0.016). CONCLUSIONS: A reduced general state of health, a high BMI and highly resistant pathogens are the main risk factors for a failed two-stage procedure after chronic posttraumatic periprosthetic hip infections. Therefore, different treatment strategies are required for a defined subgroup of patients.
Archives of Orthopaedic and Trauma Surgery 12/2012; · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The incidence of osteoporotic pelvic fractures is rapidly increasing. Following low energy trauma fractures are frequently classified as pelvic girdle fractures. Based on the pelvic expert group database of the German Trauma Society the estimated rate of osteoporotic pelvic ring fractures is about 51%. In cases of fractured pubic rami standard X-ray in anterior-posterior, inlet and outlet views should be carried out by computed tomography (CT) scanning to identify fractures of the sacrum. Only if pain persists and no fracture is evident with CT is magnetic resonance imaging (MRI) indicated. Therapy should be carried out under biomechanical instability aspects. Pubic rami fractures are stable and treated conservatively with sufficient pain medication, thromboembolic prophylaxis and physiotherapy. In cases of persisting pain or biomechanical instability operative treatment is indicated and stabilization methods should be chosen under biomechanical aspects. Therefore external fixator for pubic rami fractures and iliosacral screws, optionally with cement augmentation for posterior pelvic girdle fractures are the preferred techniques. Sacral fractures with severe osteolysis should be stabilized by lumbopelvic fixation techniques.
Der Chirurg 10/2012; 83(10):875-81. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: The incidence of pelvic ring fractures in elderly patients increases continuously. Several studies showed that the complexity of injury is often underestimated and a fracture of the posterior pelvic ring not visible with conventional X-rays. The aim of this study was to determine the influence of routine CT on incidence, classification of and therapy for pelvic ring fractures in patients aged over 65 years. Patients and Methods: Between 2004 and 2010, 310 elderly patients with a pelvic ring fracture were admitted to a German university level 1 trauma centre. Patients of group 1 (2004-2006) were examined with CT only if a pelvic ring fracture was diagnosed by X-ray and pain in the posterior pelvic ring persisted so that mobilisation was impossible. In group 2 (2007-2010) CT was used for routine examination. Demographic data, injury mechanism and severity (ISS) were documented as well as time and type of diagnostic procedure. Also fracture classification (AO), time and type of treatment were investigated in correlation with total hospital stay. Results: 252 (82 %) patients were female, the median age was 81 years (65-100 years). 228 (74 %) had a low energy trauma, 41 (13 %) a traffic accident and 12 (4 %) had fallen from heights over 3 m. Only in 29 (9 %) cases was no trauma evident. 35 (11 %) patients were injured with an ISS over 16 and classified as polytrauma. The mean ISS was 26.8 ± 11.7. In group 2 the incidence of type A fractures decreased from 64 % to 36 %, whereas the incidence of type B fractures increased from 25 % to 49 % as did isolated sacrum fractures from 1 % to 6 %. Also the indication for operative stabilisation changed in type B fractures from 33 % to 40 % and in isolated sacrum fractures to 71 %. Total hospital stay was between eight and ten days in non-operative and between 20 and 22 days in operative treatment. Conclusion: A low energy trauma is the major cause of injury for patients of an age over 65 years with a pelvic ring fracture. With the routine CT examination type B fractures and isolated sacrum fractures are seen more often than expected and resulting in a change of treatment procedures.
[Show abstract][Hide abstract] ABSTRACT: In cases of severe osteoporosis vertebral body fractures of the thoracolumbar spine can occur without any relevant trauma. Initially, a standardized diagnostic algorithm is recommended to detect acute vertebral body fractures and to be able to interpret the individual fracture stability. Aim of the therapy is to assure a relatively pain-free mobilization while maintaining vertebral spine alignment. A conservative therapy concept is initiated in patients with stable fractures. In cases of persistent pain, reduced mobility or increased kyphotic misalignment minimally invasive cement augmented therapy strategies are chosen. In cases of unstable fracture morphology a more complex therapy concept has to be chosen such as hybrid stabilization. A great deal of experience is needed for revision surgery. In such cases reconstructive, multi-segmental techniques might be necessary and the instrumentation should surpass the apex of kyphosis.
Der Chirurg 10/2012; 83(10):866-74. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Treatment of full-thickness cartilage defects remains a challenge in musculoskeletal surgery. Autologous osteochondral transplantation represents a possible solution for the repair of affected areas. However, some problems like degenerative changes of the transplanted cylinders and the surrounding cartilage or lack of cylinder integration to the surrounding cartilage arise with this method. Thus mid-term results respecting the quality of life are useful for assessment of the method.
We investigated 22 patients with a mean follow-up of 88 ± 14.5 months after autologous osteochondral transplantation due to a full-thickness cartilage defect of the medial femoral condyle. Beside clinical scores we assessed at follow-up the quality of life using the SF-36 health survey and the EQ-5D. Furthermore, radiological changes were detected and MRI was performed in 21 patients. A control group of 19 patients, treated with microfracture, was matched in terms of BMI, gender and age. Exclusion criteria for this group were tibial kissing lesion, ligament instability, arthrosis and malalignment.
In a longitudinal comparison with results 13.5 months after operation, no difference in Lysholm score was found. In plain radiographs higher degrees of arthritic changes in the medial compartment compared to the unaffected knee were observed. MRI revealed a mean modified MOCART score of 41.2 ± 7.7 for the OAT group and of 39.4 ± 16.1 for the microfracture group, without being significant. For OAT patients all cylinders showed an osseous integration. However, cylinder oedema was found in 9 patients. Those patients had a higher intensity of pain on a visual analogue scale. Quality of life was better for OAT patients in the physical scale of SF-36, but not in the mental scale.
Autologous osteochondral transplantation has an unaltered significance in treating full-thickness cartilage defects and leads to satisfying mid-term results. The development of early arthritic changes might not be preventable by this method. Oedema of the transplanted cylinders is attended by higher pain intensity and might be an indirect sign of cartilage degeneration.
[Show abstract][Hide abstract] ABSTRACT: This study aims to analyse the outcome and the complications after total knee arthroplasty in post-traumatic osteoarthritis in comparison to TKA in patients with degenerative osteoarthritis.
In a period of six years 43 patients with a post-traumatic osteoarthritis were treated with a total knee arthroplasty (group PT). 38 (88 %) patients (age median 55 years, 22 female, 16 male) were investigated clinically and radiologically after an average follow-up time of 2.7 years. The OKS (Oxford Knee Score, max. 48 points), the Knee Society Scores "function" (max. 100 points) and "knee" (max. 100 points) as well as the visual analogue scale (VAS, 0 to 10 points) were recorded preoperatively and at follow-up. For comparison we chose a matched-pair selection of patients with degenerative osteoarthritis and TKA (group DO, age median 63 years, 22 female, 16 male). For statistical analysis we used common parametric tests (Wilcoxon and U test) and a level of significance of 0.05.
In 19 patients (50 %) of the group PT the osteoarthritis was caused by a bone injury. Furthermore in 19 patients a meniscal and/or ligamentous injury led to osteoarthritis. Out of all patients of group PT, 10 patients showed a preoperative valgus malalignment higher than 10°. KSS knee and KSS function added up to 76.9 and 84.9 points. So they are significantly less than in the matched group (DO, knee: 86.1; function: 94.4). Similarly, the OKS is significantly less in group PT after follow-up (PT: 32.3; DO: 38.4, p ≤ 0.05) although the preoperative values are equal in both groups. The VAS value decreased significantly in both groups. Initial level of pain was significantly higher in the group DO compared to the group PT. Patients with osteoarthritis after trauma showed complications in 17 cases (^ = 44.7 %) that led to 28 revision operations (^ = 0.7 operations per knee). The group with valgus malalignment had a revision rate of 1.4 operations per knee. In the group DO 8 complications occurred (^ = 21,1 %) that led to 11 revision operations (^=0.3 per knee). The deviation from the "ideal" leg axis could be reduced from 3.8° varus to 1.7° varus in the group DO and from 1.3° valgus auf 1.2° valgus in the group PT. Patients with a preoperative valgus deviation > 10° were reduced from 13.6° (± 3.9°) valgus to 0.5° (± 9.2°) varus.
Patients after TKA because of post-traumatic osteoarthritis show worse results concerning function and condition compared to patients with degenerative osteoarthritis. Heterogeneous pathogenesis and high rates of revision operations underline the complexity of this group of patients. The treatment has to be adjusted to the patient's requirements as well to the pathoanatomy.
[Show abstract][Hide abstract] ABSTRACT: Osteosyntheses to stabilize pelvic-ring fractures were developed for younger patients, and are not universally indicated for elderly people. We present the results of parallel-arranged numerical simulations of fixation treatment that an elderly patient with a bagatelle-injured pelvic ring fracture received using a patient-specific finite element model.
The clinical course of an osteosynthetic stabilized pelvic ring fracture, based on an actual case, was numerically simulated using a patient-specific finite element model.
A previously validated finite element model of a human pelvis was customized with computed tomography data from a patient with a stabilized pelvic-ring fracture. Numerical simulation was used to analyze primary stability. The clinical process, represented by radiologic examinations, was compared with the results from the finite element simulation. Implant loosening as well as newly-occurring fractures were shown to coincide with regions with the highest stress levels.
The results from the patient-specific finite element model closely resembled the actual clinical course especially in terms of the location of high strain concentration and subsequent implant loosening. This indicates that patient-specific finite element models have a potential to play an important role in planning osteosynthesis according to biomechanical stability.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function. METHODS: A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay. RESULTS: The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01). CONCLUSIONS: In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.
[Show abstract][Hide abstract] ABSTRACT: Recording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected.
From 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled.
The most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer.
It has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.
Der Unfallchirurg 11/2011; 114(11):1029-34. · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hintergrund
Durch die Erfassung von „diagnosis related groups“ (DRG) und Diagnosen lässt sich deren Verteilung im Jahresverlauf ableiten. Ein gehäuftes Auftreten von Erkrankungen zu bestimmten Zeiten kann so identifiziert werden.
Patienten und Methode
Für die Zeit von 2004–2010 erfassten wir 22.293 Hauptdiagnosen und DRG an der unfallchirurgischen Klinik. Verletzungen mit gleicher Lokalisation und Behandlung wurden zusammengefasst.
Die häufigsten Verletzungen waren das Schädel-Hirn-Trauma, Wirbelkörper- und Unterschenkelfrakturen. Für diese zeigte sich keine Häufung im Jahresverlauf. Proximale Humerusfrakturen traten im Winter etwa 25% häufiger auf als im Sommer, Frakturen des oberen Sprunggelenks etwa 33% häufiger. Die Gonarthrose ist im Winter doppelt so oft Behandlungsdiagnose wie im Sommer.
Es gilt zu prüfen, inwiefern logisitische Folgerungen aus diesen Ergebnissen eine Effizienzsteigerung bewirken können. Das zugrunde liegende Analyseverfahren ist generell für jedes Klinikum anwendbar und stellt ein valides Controlling-Instrument dar.
Der Unfallchirurg 11/2011; 114(11). · 0.64 Impact Factor