ABSTRACT: This study was conducted to evaluate whether intraoperative procedure and/or early postoperative results after open reduction and internal fixation (ORIF) of displaced acetabulum fractures are influenced by the use of a three-dimensional (3D) image intensifier in combination with a navigation system.
From January 2004 until December 2008, all patients with acetabular fractures were followed prospectively. From January 2004 until October 2006, all operations were performed under fluoroscopic control using a conventional two-dimensional image intensifier. Since October 2006, we regularly operate acetabular fractures with the intraoperative use of a navigation system and a 3D image intensifier. Pre- and postoperative computed tomography scans of the affected hip were obtained in all patients as were standard anterior-posterior radiographs and ala- and obturator views. All data collection was performed according to the guidelines of the "German Pelvic fracture study group."
In total, 68 patients with acetabular fractures were included in the study. A conventional image intensifier was used in 37 patients (group A) and a 3D image-based navigation was used in the remaining 31 patients (group B). In the navigated group, seven patients were assessed incapable of partial weight bearing. These patients underwent computer-assisted percutaneous screwing of their acetabular fracture. Using a navigation system in combination with a 3D image intensifier for ORIF of displaced acetabular fractures led to a significant increase in skin-to-skin time. Postoperative radiolographic analysis revealed an improvement in the quality of fracture reduction in the 3D navigation group. Navigation in combination with the 3D images of the ISO-C 3D limited the need for extended approaches. In addition, the complication rate in the navigated group was significantly lower.
We support the use of navigation systems and a 3D image intensifier as helpful tools during ORIF of displaced acetabular fractures.
Therapeutic study, level III.
The journal of trauma and acute care surgery. 06/2012; 73(4):950-6.
ABSTRACT: Die Monteggia-Verletzung ist definiert als eine Ulnaschaftfraktur im proximalen Drittel in Kombination mit einer Luxation
im proximalen Radioulnargelenk. Bado klassifizierte die Monteggia-Verletzung in vier Frakturtypen entsprechend der Luxationsrichtung
des Radiusköpfchens und der Angulation der Ulnafraktur. Bei der Typ I Läsion zeigt sich eine anteriore Luxation des Radiusköpfchens,
bei Typ II nach posterior und bei Typ III nach lateral. Der Typ Bado IV ist definiert als Unterarmschaftfraktur mit Radiusköpfchenluxation.
Posteriore Monteggia- Verletzungen vom Typ II nach Bado werden nach Jupiter in weitere Untergruppen subklassifiziert. Ziel
der Arbeit ist die Korrelation der Klassifikationen nach Bado und Jupiter mit den Langzeitergebnissen nach Monteggia-Frakturen
beim Erwachsenen sowie die Ermittlung prognoserelevanter Faktoren.
Im Zeitraum 01/1990 bis 12/2000 wurde bei 63 Patienten eine Monteggia-Fraktur osteosynthetisch versorgt. 47 Patienten konnten
nach durchschnittlich 8.4 ± 2.4 Jahren nachuntersucht werden. Das funktionelle Ergebnis wurde anhand des Broberg and Morrey
Scores ermittelt. Als validierter, patientenorientierter Outcome-Score wurde der DASHFragebogen verwandt. Die radiologische
Beurteilung umfasste das Ausmaß des posttraumatischen Gelenkschadens. Die statistische Analyse erfolgte mit Hilfe des Mann-Whitney-
und des Kruskal-Wallis-Tests. Zur Korrelation der funktionellen Ergebnisse mit der Bado- und der Jupiter-Klassifikation wurde
der Korrelationskoeffizient nach Pearson berechnet.
Entsprechend der Bado-Klassifikation lagen 19 Typ I, 37 Typ II, 5 Typ III und 2 Typ IV Verletzungen vor. 13 von 16 Radiusköpfchenfrakturen
und alle 14 Frakturen des Proc. coronoideus fanden sich in Kombination mit einer Bado Typ II Fraktur. Sämtliche Bado Typ II
Frakturen wurden nach Jupiter klassifiziert (10 Typ IIa, 20 Typ IIb, 3 Typ IIc und 4 Typ IId Frakturen). Nach operativer Versorgung
erreichten 22 von 47 nachuntersuchten Patienten ein „sehr gutes“, 12 ein „gutes“, 9 ein „befriedigendes“ und 4 Patienten ein
„schlechtes“ Ergebnis. Der Broberg und Morrey Score betrug 87.2 ± 15.6 und der DASH Score 17.4 ± 18.3. Es zeigte sich eine
signifikante Korrelation zwischen den beiden Scores (Korrelationskoeffizient nach Pearson = –0.84, p = 0.01). Revisionspflichtige
Komplikationen traten bei 12 Patienten (26 %) auf (3 × Wundinfekt, 3 × Repositionsverlust nach Radiusköpfchenosteosynthese,
6 × Pseudarthrose der Ulnafraktur). Folgende Faktoren korrelierten mit einem schlechten klinischen Ergebnis: Bado Typ II Fraktur
(p = 0.02), Jupiter Typ IIa Fraktur (p = 0.04), Radiusköpfchenfraktur (p = 0.03), Fraktur des Processus coronoideus (p = 0.01),
und Vorliegen einer revisionspflichtigen Komplikation (p = 0.001).
Monteggia-Frakturen im Erwachsenenalter führen bei korrekter Klassifikation und stabiler anatomischer Reposition häufig zu
guten oder sehr guten funktionellen Ergebnissen. Dennoch sind diese komplexen Frakturen des Unterarms mit einer hohen Komplikationsrate
verbunden. Insbesondere Bado Typ II Frakturen und innerhalb dieser Gruppe Jupiter Typ IIa Verletzungen sind häufig assoziiert
mit Frakturen des Radiusköpfchens oder des Proc. coronoideus. Diese Frakturen sind als negative prognostische Faktoren für
das funktionelle Langzeitergebnis zu werten. Patienten mit diesen Frakturtypen sollten über das erhöhte Risiko eines funktionellen
Defizits sowie evtl. nötiger zusätzlicher Eingriffe informiert werden.
Monteggia-type fracture-dislocations of the forearm represent osseous failure of the ulna together with ligamentous failure
on the radial side and resultant dislocation of the radial head. Bado classified the Monteggia lesion into four types, depending
on the direction of the dislocation of the radial head and the angulation of the ulna fracture. In the type I lesion, the
direction of the dislocation is anterior; in type II posterior; and in type III lateral. A type IV lesion is defined as a
fracture of both forearm bones with a dislocation of the radial head. The posterior Monteggia lesion (Bado type II) has been
divided into four groups by Jupiter. The objective of this study is to correlate the Bado and Jupiter classifications with
the long-term results after operative treatment of acute Monteggia lesions in adults and to determine prognostic factors for
the functional outcome.
In this study, 47 of 63 adult patients who sustained a Monteggia fracture between January 1990 and December 2000 were available
for a clinical reexamination after an average follow-up of 8.4 ± 2.4 years. The functional result was evaluated according
to the Broberg and Morrey Score and the disabilities of the arm, shoulder or hand (DASH) questionnaire was used as a validated
patient-focused outcome tool. Radiographs were evaluated for the presence of osteoarthritis according to the rating system
of Broberg and Morrey. Statistical analysis was performed using the independent samples Mann-Whitney-U test and the Kruskal-Wallis
test. To determine prognostic factors for the functional outcome the correlation between the Broberg and Morrey and DASH score
and the Bado and Jupiter classification was tested.
According to the Bado classification there were 19 type I, 37 type II, 5 type III and 2 type IV injuries. Thirteen of the
16 fractures of the radial head and all 14 coronoid fractures were associated with a Bado type II fracture. All posterior
Monteggia fractures were classified according to Jupiter: 10 type IIa fractures, 20 type IIb, 3 type IIc and 4 type IId. After
operative treatment 22 out of 47 reexamined patients had excellent results, 12 patients had good results, 9 patients had fair
results, and 4 patients had poor results. The mean Broberg and Morrey score was 87.2 ± 15.6 and the mean DASH score was 17.4
± 18.3. There was a significant correlation between the two scores (Pearson coefficient of correlation = –0.81, p = 0.01).
12 patients (26 %) needed a second operation within 12 months after the initial operation (3 wound infections, 3 loss of reduction
after radial head osteosynthesis, 6 nonunion of the ulna fracture). The following factors were found to be correlated with
a poor clinical outcome: Bado type II fracture (p = 0.02), Jupiter type IIa fracture (p = 0.04), radial head fracture (p =
0.03), coronoid fracture (p = 0.01), and complication requiring revision surgery (p = 0.001).
Monteggia fractures in adults often lead to good or excellent functional results if the injury is classified correctly and
a stable anatomic reduction is achieved. Nevertheless, there is a high complication rate associated with these complex fractures
of the forearm. Especially Bado type II Monteggia fractures and within this group Jupiter type IIa fractures are frequently
related with fractures of the radial head and the coronoid process and should be considered as negative prognostic factors
for the functional long-term outcome. Patients with these fracture types should be informed about the risk of functional deficits
and the need for further surgical interventions.
Obere Extremität 04/2012; 3(3):128-135.
ABSTRACT: The purpose of the present study was to carry out biomechanical testing of "new generation" volar plates and an intramedullary nail.
Four volar locking plates (Column Plate, VariAx distal radius, 2.4 mm-LCP and 3.5 mm-LCP) and the intramedullary nail, Targon-DR, were implanted in biomechanically validated artificial bones after simulation of a wedge osteotomy with total transection of the volar cortex to mimic a type 23 A3-fracture according to the AO-classification. Axial load (250 Newton [N]) and volar and dorsal bending loads (both 50 N) were applied. Axial load was increased to fixation failure. Gap motion was measured three-dimensionally directly at the fracture gap. The 3.5 mm-LCP was used for comparison as it currently represents an established locking implant that has been well tested biomechanically.
In this experimental setting, the 2.4 mm-LCP showed the lowest resistance under all three loading modi and, consequently, the highest level of motion at the osteotomy gap in comparison to all other implants (p < 0.05). Under axial loading, there were no significant differences between the other four implants. Under dorsal bending, the Targon-DR-nail and the VariAx-plate showed less gap displacement in comparison to the 3.5 mm-LCP (p < 0.05). Under volar bending, only the Targon-nail showed greater resistance than the 3.5 mm-LCP (p < 0.05) with no other significant differences between the Column Plate, the VariAx and the 3.5 mm-LCP.
In this experimental setting, all "new generation" implants for distal radius fractures with the exception of the 2.4 mm-LCP showed identical or higher stability compared to the 3.5 mm-LCP. The 2.4 mm-LCP showed the lowest resistance and this must be taken into consideration when planning postoperative functional therapy.
Archives of Orthopaedic and Trauma Surgery 07/2011; 131(11):1529-37. · 1.37 Impact Factor
ABSTRACT: This study investigated whether the Intramedullary Bone Endoscopy (IBE) procedure within the cavity of an intact long bone will interfere with the local endosteal blood supply. In a sheep model, 10 animals underwent the IBE procedure with complete perioperative anaesthesiology monitoring. After the femora were harvested, histological analysis was performed to examine destruction of the endosteum and consecutive reduction in perfusion. Only one animal showed evidence of detachment of the endosteum with destruction of several microns of the endosteum, although this did not interfere with the cortical perfusion. None of the vessels were occluded by fat or other causes of occlusion, e.g. blood coagulation. Our findings indicate that with the IBE procedure under visual control there is a potential risk to damage the endosteum. However, the interference was limited to a small part of the endosteum and did not lead to a reduction in the cortical perfusion. Clinical use could be in localized intramedullary lesions such as osteomyelitis or benign bone tumours.
Acta orthopaedica Belgica 02/2011; 77(1):103-9. · 0.40 Impact Factor
ABSTRACT: Comparison of the dose area product (DAP), the radiation time and the operation time during computer navigated and conventional balloon kyphoplasty procedures.
To compare the patients radiation exposure and operation time in a balloon kyphoplasty procedure with and without using a navigation system for the placement of working needles.
Minimal invasive spine surgery is associated with high radiation exposure for both the patient and the surgeon. The use of computer navigation has led to a reduced radiation exposure in experimental trials. To our knowledge, there is no clinical data determining the influence of computer navigation on radiation exposure and operation time in a balloon kyphoplasty procedure.
Twenty-nine patients with 30 osteoporotic vertebra fractures were treated with a computer-navigated kyphoplasty. The placement of the working needles in thoracic spine fractures was performed after acquiring an intraoperative three-dimensional data set. Fractures of the lumbar spine were treated using fluoroscopic three-dimensional navigation. During each procedure the operation time, the overall radiation time, and the DAP were documented. The data of the navigated operations were compared to a control group of consisting of 30 conventional balloon kyphoplasty procedures.
In the conventional kyphoplasty group the average operation times for thoracic spine (ts) and lumbar spine (ls) were 61 and 57 minutes, respectively. The average radiation times were 175 and 165 seconds. The DAP applied to the patient was 1972 and 2105 cGy cm. The average operation times in the navigated group were 67 minutes in the ts and 62 minutes in the ls. The average radiation time was reduced significantly in the navigated group (99 seconds ts and 74 seconds ls). The DAP applied to the patient was also significantly lower (1245 cGy cm (ts) and 1318 cGy cm (ls)).
The use of computer navigation systems in balloon kyphoplasty procedures reduces the radiation exposure of patients and surgeons significantly. The increased technical effort did not lead to a significant longer operation time. Hence, the use of computer navigation systems in balloon kyphoplasty procedures is recommended.
Spine 06/2009; 34(12):1325-9. · 2.08 Impact Factor
ABSTRACT: We present a study designed to investigate whether the intramedullary bone endoscopy (IBE) procedure within the cavity of an intact long bone will create embolic loads on the lungs similar to that of other orthopedic procedures (e.g., stem implantation in total hip arthroplasty [THA]). In a sheep model, 10 animals underwent the IBE procedure with complete perioperative anesthesiology monitoring. The lungs were harvested postoperatively and examined for fat embolisms. One animal showed evidence of intraoperative fat embolism with temporary increases in mean pulmonary arterial pressure (MPAD) and the mean CO(2)-gradient. The histological examination in this animal revealed fat embolism with a 2% surface area of the investigated fields covered with fat vacuoles. All peri- and postoperative data on the other nine animals were normal. Our findings indicate that, as with other intramedullary manipulation in intact long bones, there is a potential risk for systemic fat excavation during IBE. However, the embolic load is much lower than the rates reported for other orthopedic interventions.
Journal of Orthopaedic Research 02/2009; 27(8):1060-6. · 2.81 Impact Factor
ABSTRACT: Insertion of percutaneous iliosacral screws with fluoroscopic guidance is associated with a relatively high screw malposition rate and long radiation exposure. We asked whether radiation exposure was reduced and screw position improved in patients having percutaneous iliosacral screw insertion using computer-assisted navigation compared with patients having conventional fluoroscopic screw placement. We inserted 26 screws in 24 patients using the navigation system and 35 screws in 32 patients using the conventional fluoroscopic technique. Two subgroups were analyzed, one in which only one iliosacral screw was placed and another with additional use of an external fixator. We determined screw positions by computed tomography and compared operation time, radiation exposure, and screw position. We observed no difference in operative times. Radiation exposure was reduced for the patients and operating room personnel with computer assistance. The postoperative computed tomography scan showed better screw position and fewer malpositioned screws in the three-dimensional navigated groups. Computer navigation reduced malposition rate and radiation exposure. LEVEL OF EVIDENCE: Level II, therapeutic study.
Clinical Orthopaedics and Related Research 12/2008; 467(7):1833-8. · 2.53 Impact Factor
ABSTRACT: INTRODUCTION: Within a 15-month period, 64 patients underwent 71 primary total knee arthroplasties in a randomized trial comparing the navigated versus the conventional implantation technique. CT scans were chosen for use as imaging procedures pre- and post-operatively to collect data concerning alignment and rotation of the leg as well as the prosthesis. RESULTS: There was no difference between pre- and post-operative data in rotation of the femoral component for navigated versus conventional implantation. The average deviation from the correct long-leg axis was found to be 1.8 +/- 1.3 degrees in the navigated group and 2.5 +/- 1.6 degrees in the conventional group (P < 0.05).
Archives of Orthopaedic and Trauma Surgery 06/2008; 128(6):561-6. · 1.37 Impact Factor
ABSTRACT: Scaffolds play a key role in the field of tissue engineering. Particularly for meniscus replacement, optimal scaffold properties are critical. The aim of our study was to develop a novel scaffold for replacement of meniscal tissue by means of tissue engineering. Emphasis was put on biomechanical properties comparable to native meniscus, nonimmunogenecity, and the possibility of seeding cells into and cultivating them within the scaffold (nontoxicity). For this purpose, native ovine menisci were treated in vitro in a self-developed enzymatic process. Complete cell removal was achieved and shown both histologically and electron microscopically (n = 15). Immunohistochemical reaction (MHC 1/MHC 2) was positive for native ovine meniscus and negative for the scaffold. Compared to native meniscus (25.8 N/mm) stiffness of the scaffold was significantly increased (30.2 N/mm, p < 0.05, n = 10). We determined the compression (%) of the native meniscus and the scaffold under a load of 7 N. The compression was 23% for native meniscus and 29% for the scaffold (p < 0.05, n = 10). Residual force of the scaffold was significantly lower (5.2 N vs. 4.9 N, p < 0.05, n = 10). Autologous fibrochondrocytes were needle injected and successfully cultivated within the scaffolds over a period of 4 weeks (n = 10). To our knowledge, this study is the first to remove cells and immunogenetic proteins (MHC 1/MHC 2) completely out of native meniscus and preserve important biomechanical properties. Also, injected cells could be successfully cultivated within the scaffold. Further in vitro and in vivo animal studies are necessary to establish optimal cell sources, sterilization, and seeding techniques. Cell differentiation, matrix production, in vivo remodeling of the construct, and possible immunological reactions after implantation are subject of further studies.
Journal of Orthopaedic Research 12/2007; 25(12):1598-608. · 2.81 Impact Factor
Saudi medical journal 05/2007; 28(4):649-52. · 0.52 Impact Factor
ABSTRACT: In controlling the closed reduction of a shaft fracture of long bone during an operation, intraoperative radiography is essential. The amount of imaging needed depends on the patient, the fracture, and the surgeon. This article documents our first experimental results of closed fracture reduction performed under direct visual control with the endoscopic technique of intramedullary bone endoscopy (IBE), which eliminates the need for fluoroscopy. On 3 human tibial cadaveric bones, an artificial shaft fracture was set. The lower leg was fixed on a brace, and the endoscope was inserted at the standard entry point for intramedullary nailing. The endoscope was gently pushed distally to prepare the medullary canal under visual control with the use of endoscopic instruments. At the level of fracture, surgeons achieved a closed reduction by "looking around" for the distal part of the fracture by using the stiff endoscope similarly to a "joystick." Thus, the proximal fragment was automatically guided into the correct position, and the fracture was reduced. The endoscopic tool was pushed down the medullary canal into the distal fragment in the way that a guidewire would be placed. Through this technique, it has been possible in all patients to reduce fractures under visual control. Fluoroscopy can be eliminated in these cases.
Arthroscopy The Journal of Arthroscopic and Related Surgery 07/2006; 22(6):686.e1-5. · 3.02 Impact Factor
ABSTRACT: Traumatic atlantooccipital dislocation (AOD) is a severe injury which functionally separates the head from the spine. Neurological
compromise or death is the common sequela. We report on a survivor after AOD, who came back to sportive activities after operative
stabilization C0–2. Actually, due to the lack of large single institution series, there are no clearly recommended guidelines
concerning diagnostics and treatment of AOD. Overlooking a critical review of literature, the inferences of our case are illustrated
and diagnostic as well as operative treatment concepts are discussed.
European Journal of Trauma 05/2006; 32(3):271-279.
ABSTRACT: Modern computer assisted surgery (CAS) systems allow accurate positioning of the implants in navigated Total Knee Arthroplasty (TKA). However, when an operation is performed with a navigation system, it is important to know if the anatomical situation of the knee is reflected equally in both the preoperative image (e.g., CT) and the intraoperative navigation setup. In this study, we compared the preoperative anatomical situation to the virtual intraoperative situation of the navigation setup.
We analyzed 24 navigated operations. Intraoperatively, the condylar twist angle (CTA) was documented with the navigation system by measuring the angle between the transepicondylar axis (TEA) and posterior condyle axis (PCA). This data was compared with the preoperative data from the CT scan.
Statistical analysis revealed that there was no correlation between the pre- and intraoperative data (r = 0.095).
Statistically, there is no possibility of collecting the same angles and axes when using the two different methods (CT and navigation) on the same knee. It is not possible to copy the preoperative anatomical situation exactly with the virtual intraoperative data. Reasons for this include systematic errors, as well as inter- and intraobserver errors in both methods.
Computer Aided Surgery 04/2006; 11(2):87-91. · 0.30 Impact Factor
ABSTRACT: This study shows the local changes in intramedullary pressure during a new endoscopic technique for the medullary canal of the long bone. The procedure of intramedullary bone endoscopy (IBE) was performed on 4 tibial amputations. By slowly pushing the endoscope distally under visual control and endoscopic preparation of the medullary canal, a "neocavum" for endoscopy was created. During the procedure, the intramedullary pressure was continuously measured: Highest peak pressure was 125 mm Hg. We therefore conclude that the procedure of IBE is a safe intervention within the medullary canal of the long bone. Local or systemic side effects, common to intramedullary reaming in fracture treatment (fat-embolism, local bone necrosis, reduction in cortical blood flow) should not be expected.
Arthroscopy The Journal of Arthroscopic and Related Surgery 06/2004; 20(5):552-5. · 3.02 Impact Factor