H.-J. Egbers’s research while affiliated with Universitätsklinikum Schleswig - Holstein and other places

The aim of this study was to examine the impact of our multidisciplinary therapeutical concept (MTC) on the clinical outcome in posttraumatic defect injuries of the lower extremity. Since 1999, we have performed a free tissue transfer in 37 patients. In group 1 (n = 21), our MTC was started more than two weeks (range: 17 to 83 days) after trauma and in group 2 (n = 16) within two weeks (range: four to twelve days) after trauma. Both groups were comparable with respect to trauma severity. 100 % patients of group 1 and 25 % patients of group 2 had clinical and microbiological manifestations of wound infection after admission in our clinic. Significantly more operations were necessary in group 1 compared to group 2 (7.3 +/- 2.6 versus 2.9 +/- 0.8; p < 0.05), until definitive wound closure could be achieved. The postoperative course was uneventful in 35 cases. All injured extremities could be salvaged. Multistaged bone reconstructions by means of spongious or tricortical bone from the iliac crest were successful in all cases. Hospital stay after admission to our clinic was significantly longer in group 1 compared to group 2 (57 +/- 12 days versus 31 +/- 7 days, p < 0.05). In our study, the early start of MTC significantly reduced the risk for wound infection, the number of surgical revisions before definite wound closure and time until bone and wound healing was completed.

Hintergrund: Diese Studie evaluiert die klinischen Ergebnisse bei schweren Defektverletzungen der unteren Extremität in Abhängigkeit von der zeitnahen Umsetzung eines interdisziplinären Therapiekonzeptes. Patienten und Methoden: 37 Patienten im Alter zwischen 16 und 57 Jahren erhielten innerhalb von drei Monaten nach Primärtrauma eine definitive Weichteildeckung durch freie mikrovaskuläre Gewebetransplantationen. Bei 21 Patienten hatte die stationäre Verweildauer vor Verlegung mehr als zwei Wochen (17 bis 83 Tage) betragen (Gruppe 1). Bei 16 Patienten waren es weniger als zwei Wochen (vier bis zwölf Tage) gewesen (Gruppe 2). Beide Gruppen waren hinsichtlich der Schwere ihrer Verletzungen vergleichbar. Ergebnisse: Bei Übernahme hatten alle Patienten der Gruppe 1 und vier Patienten der Gruppe 2 Wundinfekte in der Defektzone. In Gruppe 1 waren signifikant mehr operative Eingriffe bis zur definitiven Weichteildeckung notwendig als in Gruppe 2 (7,3 ± 2,6 versus 2,9 ± 0,8; p < 0,05). Bei 35 Patienten heilten die Transplantate komplikationslos ein. Ein mehrzeitiger ossärer Aufbau durch Spongiosa oder trikortikale Späne des Beckenkammes war in allen notwendigen Fällen erfolgreich. In allen Fällen konnte die betroffene Extremität erhalten werden. Die stationäre Aufenthaltsdauer nach Übernahme lag bei den Patienten der Gruppe 1 signifikant höher als in der Gruppe 2 (p ≤ 0,01). Schlussfolgerung: Ein frühzeitiges interdisziplinäres Vorgehen senkte in unserem Patientengut signifikant das lokale Infektrisiko, die Anzahl notwendiger Revisionseingriffe und die Zeitdauer bis zur definitiven Sanierung der Frakturen und Weichteile.

The problem of preventing malrotation after closed intramedullary nailing of femoral shaft fractures has not been solved yet. As clinical tests and radiologic criteria for intraoperative use provide little accuracy, the theoretical basis for a C-arm-based measurement of the femoral antetorsion was analysed. The directions of femoral neck axis and condylar axis can be identified by the radiologic views "knee joint, lateral view" and "hip joint, axial view". The rotation of the C-arm in relation to a horizontal axis to achieve these views can be measured in degrees. Theoretically, the difference between these rotation angles could be used to calculate the antetorsion. Intact plastic femora (Sawbone) and a femoral shaft fracture model were used to research optical and geometrical phenomena that influence a direct measuring technique. Several geometrical phenomena were observed, making direct measurement with arithmetic corrective factors not recommendable. For practical reasons, a data table was created, correlating the difference between the two C-arm angles with true antetorsion. In an interobserver trial with 18 trauma surgeons, the method proved to achieve high accuracy with a maximum interobserver variation of 5 degrees. The method is easily reproducible, reliable and can be recommended to every surgeon. Due to the wide range of physiological antetorsion angles in different individuals, fair results can be expected controlling the rotation with standard value tables, and excellent results can be expected using bilateral measurement.

Background The problem of preventing malrotation after closed intramedullary nailing of femoral shaft fractures has not been solved yet. As clinical tests and radiologic criteria for intraoperative use provide little accuracy, the theoretical basis for a C-arm-based measurement of the femoral antetorsion was analysed. Methods The directions of femoral neck axis and condylar axis can be identified by the radiologic views “knee joint, lateral view” and “hip joint, axial view”. The rotation of the C-arm in relation to a horizontal axis to achieve these views can be measured in degrees. Theoretically, the difference between these rotation angles could be used to calculate the antetorsion. Intact plastic femora (Sawbone) and a femoral shaft fracture model were used to research optical and geometrical phenomena that influence a direct measuring technique. Results Several geometrical phenomena were observed, making direct measurement with arithmetic corrective factors not recommendable. For practical reasons, a data table was created, correlating the difference between the two C-arm angles with true antetorsion. In an interobserver trial with 18 trauma surgeons, the method proved to achieve high accuracy with a maximum interobserver variation of 5°. Conclusions The method is easily reproducible, reliable and can be recommended to every surgeon. Due to the wide range of physiological antetorsion angles in different individuals, fair results can be expected controlling the rotation with standard value tables, and excellent results can be expected using bilateral measurement.

During percutaneous iliosacral screw fixation, fluoroscopy with a conventional C-arm X-ray unit is still the standard procedure for intraoperative orientation. Lateral sacral images in combination with the inlet and outlet view are always necessary. Nevertheless, the complex pelvic anatomy makes it difficult to prevent malpositioning of screws. Defining the correct entry into the bone is the decisive step for ideal screw placement. The better this is defined, the larger safety margins will be concerning cortical perforation by the screws. In the lateral view, an entry ventral to the sacral canal has to be avoided as well as an entry into the cranial half of the first sacral vertebra. To improve the surgeon's three-dimensional orientation with the help of his personal experience and two-dimensional images, it is recommended to place the tip of the screws in the center of the sacrum (in AP view) whenever possible. Routinely performed postoperative CT imaging of 24 screws, consecutively implanted according to the standards described, revealed no case of malpositioning. Standard X-ray views in combination with standardized aiming of screw entry position and final screw thread position enable the surgeon to find the "safe zone" for iliosacral screw insertion and to prevent iliosacral screw malpositioning with high accuracy.

Hintergrund Die Schraubenfehllage ist eine relevante Komplikation der perkutanen SI-Verschraubung. Sie ist in erster Linie durch die komplexe Anatomie und die schwierige intraoperative Bildgebung bedingt. Moderne Navigationssysteme können die operative Präzision erhöhen, trotzdem gehört die Orientierung allein mittels konventionellem C-Bogen immer noch zum Standard. Operationstechnik Bereits die Wahl des Schraubeneintrittspunktes ist entscheidend für eine sichere Implantatlage. Je nach Eintrittspunkt und Schraubenverlauf sind die Sicherheitsabstände hinsichtlich Schraubenaustritt aus dem Knochen unterschiedlich groß. Zu vermeiden ist in seitlicher Projektion ein Eintrittspunkt ventral der Hinterkante des 1. Sakralwirbelkörpers, ebenso ein Eintritt auf Höhe der kranialen Hälfte des 1. Sakralwirbels. Um sich mit Hilfe von Erfahrungswerten dreidimensional anhand von zweidimensionalen (2D-)Bildern zu orientieren, sollten die Schraubgewinde regelhaft in Sakrummitte enden, sofern der Frakturverlauf dies zulässt. Im eigenen Vorgehen wurden bei postoperativen Routine-CT von 24 konsekutiv nach der beschriebenen Technik eingebrachten Schrauben keine Fehllagen beobachtet. Schlussfolgerung Unter genauer Kenntnis der Anatomie, Beachtung der richtigen Eintrittspunkte und Festlegung der geeigneten Zielpunkte lassen sich mit hoher Wahrscheinlichkeit Schraubenfehllagen vermeiden.

A feasibility study of the classification of spine injuries by CT and MRI data according to the classification of Magerl for spine injuries. In 39 patients, 46 injured vertebrae were evaluated by means of CT and MRI. A single-slice helical CT (Somatom Plus S, Siemens, Erlangen, Germany) was used with a collimation and feed of 2 mm and 3 mm, respectively. Sagittal reformations were reconstructed from these data sets. MR imaging was performed with 1.5T and 1.0T machines (Magnetom Vision and Magnetom Impact, Siemens). Transverse and sagittal T1-w SE- images as well as sagittal T2-w TSE- and STIR-images were generated. Each fractured vertebra was independently categorized two times according to the classification of Magerl on the basis of CT- and MRI-images. The CT- and MRI-classifications were subsequently compared. Most fractures were classified as impaction fractures (A1) or burst fractures (A3). Only 5/46 injuries of vertebrae were not given the same classification by means of CT and MRI (r = 0.9). MRI showed more bony lesions than CT (n. s., p > 0.05) and was able to evaluate ruptures of the longitudinal ligaments in 5 patients. Classification of spine injuries according to the Magerl-classification showed a significant agreement between CT and MRI and therefore a comparable evaluation of stability. MRI was superior in delineating ligamental lesions.

Zusammenfassung Sprungbeinverletzungen sind seltene, aber schwere Verletzungen. Aufgrund der Anatomie handelt es sich meist um Gelenkfrakturen. Talushalsfrakturen machen etwa 50% aller Sprungbeinbrüche aus, es folgen die Korpusfraktur und die seltene Taluskopffraktur. Die sich aus Anamnese, Unfallmechanismus und klinischem Erscheinungsbild ergebende Verdachtsdiagnose Talusläsion wird durch Röntgenaufnahmen gesichert. Die CT dient zur Klärung des operativen Zugangs, der Frakturpathologie, der mehrdimensionalen Nachverarbeitung sowie der postoperativen Kontrolle. Die MRT wird bei persistierenden Beschwerden notwendig. Die Gelenkfrakturen sollten möglichst frühzeitig behandelt werden, um die häufige Komplikation Nekrose gering zu halten. Es können jedoch keine Aussagen zur Wahrscheinlichkeit des Auftretens derselben gemacht werden. Die vielfältigen Therapiemöglichkeiten werden dargestellt. Hinsichtlich der Nachbehandlung streben wir eine möglichst frühe funktionelle Therapie an.

In order to evaluate the special injury pattern of aggressive inline skating, a field study was conducted in a local, non-commercial skate park equipped with all the typical features like ramps, halfpipes, gully areas. 66 unselected aggressive inline skaters were randomly enrolled and interviewed concerning their skating habits and their skating injury history. Average age was 15 (10 to 41) years, skating was performed since 2.1 (0.1 to 6) years, as aggressive skating since 1.3 (0.1 to 4) years. Medical treatment in a doctor's practice or in a hospital had been necessary in 66 cases, averaging 1.4 times per skater and year, averaging one injury per 586 hours of aggressive skating. The injury pattern reflected the regions typically injured in fitness skating, too, with a higher percentage of injuries concerning knee, tibia and ankle region. The use of protective devices varied from 41 % (wrist guards) to 94 % (knee pads), with an average of 69 %. Only 32 % of skaters wore all protective devices. As the personal thrill is an important motivation for aggressive skating, safer skating campaigns are quite unlikely to decrease the risk of injury in aggressive skaters.