TRACP 5b and CTX as osteological markers of delayed fracture healing

Radiological studies are the standard method to monitor fracture healing but they do not allow a timely assessment of bone healing. Biochemical markers react rapidly to changes in bone metabolism during fracture healing and could be an additional tool to monitor this process. The goal of this study was to observe changes in serum biomarkers and evaluate the possible differences in the serum levels of tartrate-resistant acid phosphatase 5b (TRACP 5b), total N-terminal propeptide of type I collagen (PINP), bone-specific alkaline phosphatase (BAP), and C-terminal cross-linking telopeptide of type I collagen (CTX) in patients with normal and delayed fracture healing. Several serum samples were collected for one year after the surgical treatment of long bone fractures in 248 patients. From this large pool, 15 patients with atrophic nonunion were matched to 15 patients with normal bone healing. Post-operative changes in osteological markers were monitored during the 1st, 2nd, 4th, 8th, 12th and 52nd weeks. The patients were followed both clinically and radiologically for the entire one-year duration of the study. In the first week, the absolute values of CTX decreased significantly (p=0.0164) in cases of delayed fracture healing. The relative values of TRACP 5b were significantly decreased at weeks 4 (p=0.0066) and 8 (p=0.0043). BAP and PINP levels decreased in the first week followed by an increase, but there were no significant differences in the absolute or relative values during the healing process in both patient groups. For the first time, we have demonstrated changes in serum concentrations of TRACP 5b, PINP, BAP, and CTX during normal and delayed fracture healing. Characteristic changes in systemic TRACP 5b and CTX levels could reflect the initial process of successful fracture healing and may be used in clinical practice to monitor the healing process. Furthermore, it could be very important for determining the beneficial effects of additional treatments such as ultrasound or BMPs in clinical trials.

Comparison of angle stable plate fixation approaches for distal radius fractures

INTRODUCTION

The aim of the study was to compare radiological and functional outcomes between volar and dorsal surgical fixation of distal radius fractures using low-profile, fixed-angle implants.

PATIENTS AND METHODS

A total of 305 distal radius fracture patients were treated with Synthes locking compression plate (LCP) 2.4- or 3.5-mm fixation using either a volar (n=266) or dorsal (n=39) approach. The patients were examined at 6 months, 1 and 2 years for radiological assessment of fracture healing, alignment, reduction and arthritis, as well as the determination of various functional outcome scores.

RESULTS

Both groups were comparable with respect to baseline and injury characteristics. The complication rate was higher for the volar approach (15%). No significant differences were observed for Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form (36) Health Survey (SF-36) scores, pain, arthritis grade, grip strength and radiological measurements. However, a significantly better functional outcome represented by a low mean Gartland and Werley score was observed for the volar approach after 6 and 12 months. Significantly higher percentages of dorsal extension, palmar flexion, ulnar deviation and supination angle (relative to the mean contralateral healthy wrist) were also reported for volar approach patients at the 6-month follow-up.

CONCLUSIONS

Volar internal fixation of distal radius fractures with LCP DR implants can result in earlier and better functional outcome compared with the dorsal approach, yet is associated with a higher incidence of complications. After 2 years, these differences are no longer observed between the two surgical methods.

Cigarette smoking decreases TGF-b1 serum concentrations after long bone fracture

TGF-b1 serum concentrations are considered to be one of the most promising markers of fracture healing. Previously, we demonstrated significant differences in the post-traumatic time courses of patients with timely and delayed fracture healing. The aim of this study was to evaluate possible differences in the serum concentrations of TGF-b1 in cigarette-smoking vs. non-smoking patients with timely and delayed fracture healing in order to understand pathophysiological pathways through which smoking impairs fracture healing.Serum samples were collected from 248 patients undergoing surgical treatment for long bone fractures within 1 year of surgery. Samples from 14 patients with atrophic-type delayed fracture healing were compared with 14 matched patients with normal bone healing. Each group included seven smokers and seven non-smokers. Post-operative serum concentrations were analysed at 1, 2, 4, 8, and 12 weeks as well as 1 year after surgery. The patients were monitored both clinically and radiologically for the entire duration of the study.All patients increased TGF-b1 serum concentrations after surgery. In patients with normal fracture healing, significantly higher TGF-b1 levels were observed in non-smokers (70 ng/ml) than in smokers(50 ng/ml) at the 4th week after surgery (p = 0.007). Also at the 4th week, in patients with delayed healing, significantly lower TGF-b1 levels were observed in smokers than in non-smokers (38 ng/ml vs.47 ng/ml, p = 0.021). However, no significant differences between non-smokers with delayed healing and smokers with normal healing (p = 0.151) were observed at the 4th week after surgery. TGF-b1 serum concentrations reached a plateau in all groups from the 6th to the 12th week after surgery, with a slight decrease observed in the final measurement taken 1 year after surgery.This study demonstrates that, after fracture, TGF-b1 serum concentrations are reduced by smoking,and this reduction is statistically significant during the 4th week after surgery. Our findings may help reveal the mechanism by which smoking impairs fracture healing. Furthermore, these results may help to establish a serological marker that predicts impaired fracture healing soon after the injury. Surgeons will not only be able to monitor the bone healing, but they will also be able to monitor the success of additional treatments such as ultrasound and bone morphologic proteins (BMPs).

[Outpatient surgery in hospital. An instrument for resource optimization?]

The societies of western countries are facing enormous economic and social challenges. Despite a declining population size the number of elderly patients is growing and will lead to an increase in cases of trauma in the near future. In addition, the health care system will have to be financed by a reduced labor force. To realize the ambitious political goal of providing comprehensive medical care an economization of hospital treatment must be achieved. The bottleneck within the surgical specialties in case of efficient scheduling will be the capacity utilization of the operating theatres. Additional separate outpatient operating theatres adjacent to hospitals could be an efficient instrument for using resources and economizing medical procedures. Considering the socio-demographic alterations of our society an adequate discussion regarding the general medical conditions is essential.

[Standardised primary care of multiple trauma patients. Prehospital Trauma Life Support und Advanced Trauma Life Support]

INTRODUCTION

Standardised management improves treatment results in seriously injured patients. For conditions like stroke or acute coronary syndrome (ACS) there are set treatment pathways which have been established for prehospital and primary hospital care. The treatment of critical trauma patients, however, follows varying procedures in both the prehospital and primary hospital phases. From an analysis of the trauma register of the German Society for Trauma Surgery (DGU), we know that a seriously injured patient remains on the road for 70 min on average before transferral to hospital. This requires improvement. With the 2003 introduction of the ATLS programme in Germany, the initial clinical phase could be improved upon simply by means of standardised training. PHTLS und ATLS complement one another.

RESULTS

PHTLS und ATLS represent training concepts which teach standardised, priority-based prehospital and hospital trauma management. The aim is to make an initial rapid and accurate assessment of the patient's condition, thereby identifying the"critical" patient. The concepts also make priority-based treatment possible and facilitate decision-making as to whether patients can receive further on-the-spot treatment or whether immediate transport is necessary. The procedure is identical in the shock room. The primary consideration is to prevent secondary damage, not to lose track of time and to ensure consistent quality of care. The courses teach systematic knowledge, techniques, skills and conduct in diagnosis and therapy. The courses are oriented to all medical specialities associated with trauma care. With the support of the German Society for Trauma Surgery (DGU) and the German Society for Anesthesiology and Intensive Medicine (DGAI), the German Professional Organisation of Rescue Services (DBRD) has adopted the PHTLS course system on licence from the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and has been offering it in Germany since late 2007. ATLS was established by the DGU in 2003 and represents successful and similarly structured shock-room management.

CONCLUSION

PHTLS und ATLS are established and standardised concepts, which are constantly reviewed and updated according to the latest medical knowledge. They provide the opportunity to standardise prehospital and primary clinical trauma management for all specialties and hospitals, while incorporating own knowledge.

Treatment of tibial shaft non-unions: bone morphogenetic proteins versus autologous bone graft

Fractures of the tibial shaft are likely to result in delayed union or non-union; 10-30% of these fractures will not heal properly and are commonly treated with autologous bone grafting. BMP-7 is a recombinant bone growth factor that can be applied locally as an alternative or in addition to autologous bone grafting, and this study aimed to compare the efficiency of the two procedures. From January 1995 to December 2002, 82 people with delayed union of a tibial fracture at least 4 months after primary stabilisation underwent autologous bone grafting. Successful healing was defined as radiological bony consolidation. Between May 2002 and June 2005, 26 similar cases were treated after the failure of the graft with local implantation of BMP-7, and were followed up for at least 1 year. Of the 82 people receiving autologous bone grafts only, 24 (28%) still had no signs of consolidation after 4 months and required revision surgery. Of the 26 people with BMP-7 implantation after failed graft, bony consolidation was seen after 4 months in 24 cases and only 2 (8%) required revision surgery. The BMP-7 group, although including more complicated cases, showed a significantly higher (p = 0.025) success rate compared with the group that did not receive BMP-7.

Cystic pseudotumours in both upper ankle joints in gouty arthritis

This case demonstrates a yet unreported clinical entity of bilateral tophaceous cystic lesions of the tibiotalar joints of an 37-year-old white male who presents with moderate painful swelling in both upper ankle joints for 2 years. Radiodiagnostic studies show cystic lesions in both upper ankle joints and the right talus considering neoplastic processes in the differential diagnosis. The incisional biopsy reveals chalk-like material of the intraosseous lesions which was pathognomonic for tophaceous gout. Antihyperuricemic medication led to a stagnation of growth of the lesions without a sign of osseous remodeling. However, due to limitation of discomfort, personal preferences and a lack of surgical options conservative treatment was maintained.

[Prehospital Trauma Life Support (PHTLS): An interdisciplinary training in preclinical trauma care]

INTRODUCTION

There is clinical evidence that standardized management of trauma patients in the emergency department improves outcome. Standardized prehospital management has been established for stroke patients and those suffering acute coronary syndrome. Prehospital treatment of trauma patients differs quite significantly from one system to another. The data from the German Trauma Registry show that the average time from accident until arrival in the emergency department is 72 min. This needs improvement.

RESULTS

PHTLS is a training course that teaches a systematic approach to the trauma patient in the preclinical setting. The aim is to rapidly and accurately assess the patient's physiologic status, treat according to priorities, and decide whether the patient is critical and needs rapid rescue and transport. Above all, it is important for caregivers to prevent secondary injury, to realize the relevance of timing in the initial treatment, and to assure a high standard of care. PHTLS provides the participant with knowledge, skills, and necessary behaviors. The course is open to persons in all specialties involved in the initial management of severely injured patients. The German Board of Emergency Technicians e.V. inaugurated the course concept in cooperation with the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and is authorized to organize PHTLS courses in Germany.

CONCLUSION

PHTLS teaches a standardized and established approach to the trauma patient in the emergency department. It has been established in 36 countries and the content is reviewed regularly to consider new scientific evidence. Healthcare personnel in Germany have the chance to participate in this international standard of care and to introduce their own experiences into the review process.

[Therapeutic outcome in tibial pseudarthrosis: bone morphogenetic protein 7 (BMP-7) versus autologous bone grafting for tibial fractures]

Depending on the type and localisation, nonunions of tibial fractures will occur in 10-40% of cases. Bone morphogenetic protein 7 (BMP-7; Osigraft), a recombinant bone growth factor, can be implanted locally as an alternative to autologous bone grafting. The objective of our study was to compare the efficiency of the two procedures. From January 1995 to December 2002, 82 patients (group 1) with delayed union of a tibial fracture received autologous bone grafting as their first procedure. To compare their results with the efficiency of BMP-7, between May 2002 and June 2005 we followed up on 26 patients (group 2) who had local implantation of BMP-7 after having had, on average, four surgical procedures. Healing was considered successful if x-rays showed bony consolidation and if no further procedure was necessary. Group 1 had no signs of consolidation in 24 cases (28%), whereas group 2 had only two (8%) such patients (p=0.025). The BMP-7 group showed a significantly higher success rate compared with patients with autologous bone grafting, despite the fact that the BMP-7 group contained more complicated cases.

[TGF-beta1 as a pathophysiological factor in fracture healing]

AIM

TGF-beta1 is an important local and systemic regulatory molecule during fracture healing. Various authors have shown differences in the systemic levels of TGF-beta1 over the time taken for bone healing in distraction osteogenesis and osteotomies. Previous studies have shown characteristic differences in the physiological levels of growth factors between normal fracture healing and delayed fracture union. The aim of the present study was to evaluate possible differences in sera levels of patients with normal and delayed union fracture healing.

METHODS

Patients with long bone shaft fractures were recruited prospectively. Peripheral blood samples were collected over a period of 1 year using a standardized time schedule. At the end of the individual's investigation period, TGF-beta1 levels were determined. To achieve a homogeneous collective of patients, only those with a maximum of two fractures were included in the study. After matching for four criteria, we compared patients with normal fracture healing to patients with delayed unions. The fact of delayed union was accepted in case of failed consolidation 4 months after trauma.

RESULTS

During a prospective study period of 1 year, 15 patients with normal fracture healing could be compared to 15 patients suffering from delayed union. By determining the absolute sera levels we found a typical increase of TGF-beta1 up to 2 weeks after fracture in both groups, with a subsequent decrease up to the sixth week after fracture. However, a decline in serum concentration occurred earlier in patients with delayed union, causing significantly lower TGF-beta1 levels in the non-union group 4 weeks after trauma (P=0.00006).

CONCLUSION

Even with a relatively small number of patients, we could show a significant difference in serum concentrations of TGF-beta1 between the investigated groups. If these results can be verified within a larger collective, TGF-beta1 could be used as a predictive cytokine for delayed fracture healing.

The value of laboratory and imaging studies in the evaluation of long-bone non-unions

Delayed union and non-union are common but definitive diagnosis is difficult. Few studies have evaluated imaging methods and laboratory parameters in the distinction between normal and prolonged heating specifically of long-bone fractures. The values of newer imaging methods have been analysed in some cases and should be the subject of further clinical trials. Biological markers may facilitate the earliest diagnosis of delayed union. Preliminary studies of these are limited and more trials are needed. To date it is still difficult to predict accurately a normal consolidation of bone.

Der Bewegungsfixateur zur frühfunktionellen Behandlung komplexer osteoligamentärer Verletzungen des Ellenbogengelenks

BACKGROUND

The treatment of complex injuries of the elbow joint by a hinged fixator is a new concept of external transfixation with guided movement in a defined monocentric axis. Biomechanical investigations using cadaver specimens showed that the monocentric guidance ensures additional stability in these unstable osteoligamentous injuries, allows early functional treatment, and can be used in primary but also in revision surgery.

PATIENTS AND METHODS

Between 1997 and 2004, 23 patients with complex fractures of the elbow joint were treated with a hinged monocentric external fixator after open reduction and internal fixation. The early functional treatment started 6.4 days (mean) postoperatively; the average range of motion (ROM) was 58 degrees.

RESULTS

The early functional treatment using a hinged fixator resulted in a mean increase in the range of motion of up to 71 degrees within an average time course of 34.7 days. In 18 patients a significant increase in the ROM was seen; in 4 patients no improvement in the ROM could be achieved. Only one patient showed a decrease in ROM (5 degrees). Follow-up examinations after 10 months revealed a mean ROM of 88 degrees.

CONCLUSION

In agreement with the literature, our results provide evidence that the use of a hinged monocentric external fixator in combination with early functional therapy results in an increase in the ROM and represents a beneficial device and concept in the treatment of complex injuries of the elbow joint.

[Implant-associated post-traumatic osteomyelitis. Bacterial biofilms and the immune defence as protagonists of the local inflammatory process]

BACKGROUND

Formation of bacterial biofilms on implants is a severe complication following orthopaedic surgery. In the present study we addressed the role of the immune response, particularly with regard to the pathogenesis of the disease.

METHODS

In a prospective study comprising 74 patients with implant-associated post-traumatic osteomyelitis, peripheral blood cells as well as cells recovered from the infected site during surgery were characterised phenotypically and functionally.

RESULTS

We found massive infiltration of polymorphonuclear neutrophils (PMN), which were highly activated, particularly regarding their bactericidal potential, such as increased production of superoxides and upregulation of activation-associated surface receptors.

CONCLUSION

PMN are activated in response to the implant-associated osteomyelitis; they also infiltrate the infected tissue, but cannot control the infection. By release of their cytotoxic entities they could contribute to tissue destruction and eventually to osteolysis.

[Trauma centers in Germany. Status report]

BACKGROUND

In Germany, a total of more than 30,000 polytraumatized patients are treated in level I-IV trauma centers. The exact number of hospitals fulfilling the requirements for the treatment of severely injured patients is unknown. We analyzed the number of hospitals in Germany capable of managing polytraumatized patients. We further analyzed the influence of various geographic and infrastructure conditions on the management of severely injured patients in the various Federal States in Germany.

METHODS

First we conducted a nationwide research of all hospitals specialized in trauma management. Points of interest were structural and personnel requirements. These data were compared to the data obtained by the Federal Statistical Office. With a special software program we were able to conduct for the first time a geographic visualization of all trauma hospitals.

RESULTS

There are 108 level I trauma centers, 209 level II trauma centers, and 431 level III and IV trauma centers in Germany. The geographic concentration of hospitals fulfilling the requirements for the treatment of severely injured patients differs regionally. There is an obvious correlation between trauma deaths and a low hospital concentration and less developed infrastructure.

CONCLUSION

Objectively, the number of trauma centers for the treatment of severely injured patients seems to be adequate in Germany. Nevertheless, there are substantial differences between various Federal States in Germany concerning the distribution of hospitals as well as the geographic and infrastructure conditions. To optimize trauma management in Germany we think that the formation of regional trauma networks is mandatory.

Klinische Erfahrungen mit Bone Morphogenetic Protein 7 (BMP 7) bei Pseudarthrosen langer Röhrenknochen

BACKGROUND

Nonunions of long bone fractures are considerable therapeutic and economic problems with increasing tendency. Basic surgical options are autogenous cancellous bone grafting, rod dynamization, reamed nailing, plate fixation with compression, and bone transport techniques. If these methods fail to work, alternative treatment options are needed.

MATERIAL AND METHODS

Since May 2001 treatment with recombinant human (rh) bone morphogenic protein 7 [BMP-7 or osteogenic protein 1 (OP-1)] in combination with a type one collagen carrier has gained interest. BMP 7 induces the formation of new bone by differentiation of stem cells, thereby initiating the reaction cascade of osteogenesis. Nonunions over 9 months and unsuccessful bone grafting delineate the indication.

RESULTS

We report our experience with 21 patients and nonunion of long bone fractures. Between July 2002 and June 2004, 23 units of BMP 7 were implanted. The implantation sites were 7 femora, 12 tibias, 2 humeri, and 2 forearms. In ten cases BMP 7 was combined with a new osteosynthesis and bone grafting and in five patients with bone grafting alone. In contrast in eight patients BMP 7 was applied as a single procedure without any bone grafting or any change of the osteosynthesis.

CONCLUSION

There were no peri- or postoperative complications. Follow-up was obtained for a minimum of 6 months. Of 23 implantations, 22 were successful with bony healing revealed by clinical and radiological evaluation. In one patient no bony consolidation of the nonunion has been seen so far. In summary, based on our results we propose BMP 7 as an additional innovative therapy of long bone nonunions.

Cellular inflammatory response to persistent localized Staphylococcus aureus infection: phenotypical and functional characterization of polymorphonuclear neutrophils (PMN)

Persistent, localized Staphylococcus aureus infections, refractory to antibiotic treatment, can result in massive tissue destruction and surgical intervention is often the only therapeutic option. In that context, we investigated patients with S. aureus-induced infection at various sites, apparent as either olecranon bursitis, empyema of the knee joint or soft tissue abscess formation. As expected, a prominent leucocyte infiltrate was found, consisting predominantly of polymorphonuclear neutrophils (PMN) (up to 75%) and to a lesser extent of T lymphocytes and natural killer (NK) cells. In line with their bactericidal capacity, PMN expressed the high-affinity receptor for IgG, CD64 and the lipopolysaccharide (LPS) receptor CD14; moreover, the oxygen radical production in response to the bacterial peptide f-MLP was enhanced, while chemotactic activity was greatly reduced. The more intriguing finding, however, was that a portion of PMN had acquired major histocompatibility complex (MHC) class II antigens and CD83, indicative of a transdifferentiation of PMN to cells with dendritic-like characteristics. Of note is that a similar transdifferentiation can be induced in PMN in vitro, e.g. by gamma interferon or by tumour necrosis factor alpha. Co-cultivation of transdifferentiated PMN with autologous T lymphocytes resulted in prominent T cell proliferation, provided that S. aureus enterotoxin A was added. Taken together, persistent S. aureus infection induces PMN to acquire characteristics of dendritic cells, which in turn might promote the local immune response.

Stiffness measurement of the neocallus with the Fraktometer FM 100

INTRODUCTION

The assessment of fracture healing is subjective, and neither radiology nor manual examination allows a reliable determination of bone healing. Fracture healing control in the treatment of tibia shaft fracture with external fixator by a stiffness measurement system (Fraktometer FM 100) is known from clinical studies. The purpose of this study was to follow stiffness control at external fixator in healing of callotasis with the stiffness measurement system.

MATERIALS AND METHODS

From 1994 to 1997 stiffness measurements with the described system (Fraktometer FM 100) were performed in the BG-Clinic Ludwigshafen to assess the healing course in 11 cases of callotasis at lower limb.

RESULTS

In ten cases, regular healing could be followed by signal decrease; in one case, a persistent signal without tendency to decrease was able to reveal callotasis failure at an early point of time. The investigation could also show the importance of bending stiffness control. One case of late axis deformation after fixator removal occurred because of disregarding delayed bending signal decrease.

CONCLUSION

Measurements of the external fixator's stiffness after callotasis can provide useful additional information for further treatment strategy.

Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing

This retrospective study evaluated the results of plating versus intramedullary fixation in the management of unstable, diaphyseal fractures of both bones of the forearm in children. Of the 64 children included, 45 were treated with intramedullary fixation, 19 with plating. Only A3 forearm fractures of the middle third or the transition zones were included; Galeazzi, Monteggia, and Greenstick fractures were excluded. Full radiological follow-up to union was obtained in all cases and 60 patients returned for clinical evaluation 32.3 months (plating) and 20.6 months (intramedullary fixation) after injury. The functional outcome did not differ significantly. In the intramedullary fixation group, we found two major complications (refracture and non-union) and nine minor complications (two delayed unions, three thumb neuropathies, two rod migrations, two skin infections). In the plate group, there were two major complications (refractures) and one minor complication (thumb neuropathy). Plating resulted in significantly worse results for surgical approach, operating times, frequency and duration of hospitalisation, and cosmetic outcome. In conclusion, intramedullary fixation of an unstable forearm fracture in skeletally immature patients is a safe, child-friendly, minimally invasive technique that allows early functional treatment with an excellent functional and cosmetic outcome.

TGF-beta1 as a marker of delayed fracture healing

Mitogens of the TGF-beta superfamily have been shown to be crucial local and systemic regulatory molecules involved in fracture healing. However, there exists only little information about systemic regulation of bone regeneration by growth factors and no reports comparing serum levels of bone growth factors between normal and failed fracture healing have been published so far. We hypothesized that quality of fracture healing might be reflected by systemic alterations of key regulatory growth factors involved in bone formation and remodeling. Therefore, the aim of this study was to evaluate possible differences in serum levels of BMP-2, BMP-4, and TGF-beta1 in patients with normal and delayed fracture healing. 103 patients with diaphyseal fractures of long bones were recruited prospectively. Peripheral blood samples were collected over a period of 6 months following a standardized time schedule. At the end of the individual investigation period, growth factor serum levels were measured using commercially available enzyme immunoassays. For the elimination of disturbing influences, patients in both groups were matched by gender, age, fracture type, and localization as well as applied technique of osteosynthesis. During a study period of 1 year, 10 patients with an atrophic type of delayed union could be retrieved and matched to 10 patients with normal fracture healing. The diagnosis of delayed union was assumed in case of failed consolidation 4 months after trauma. We found an increase of TGF-beta1 serum levels up to 2 weeks after fracture in both groups with a following return to the reference value within 6 weeks after trauma. However, decline of serum concentration occurred earlier in patients with delayed fracture healing. At 4 weeks after trauma, serum levels of TGF-beta1 were significantly lower in patients of the delayed union group. Serum levels of BMP-2 and BMP-4 were below detection level in all patients, respectively. These findings support the critical role of TGF-beta1 in fracture healing. Events during the consolidation phase seem to be dependent on sufficient availability of TGF-beta1.

Navigation an der Brust- und Lendenwirbelsäule mit dem 3D-Bildwandler

The mobile SIREMOBIL Iso-C(3D) C-arm (Siemens, Erlangen, Germany) is the first device permitting intraoperative, three-dimensional representation of bone structures. A high-resolution, isotropic 3D data cube in the isocenter with sides of approximately 12 cm is calculated simultaneously. The SIREMOBIL Iso-C(3D) is linked to the navigation system. This makes it possible to transfer the generated 3D data directly to the linked navigation system without the need for surgeon-dependent registration. In this prospective clinical trial, we evaluated the accuracy of pedicle screw placement using this device. In 61 patients, a total of 302 pedicle screws were placed. Only in five cases (1.7%) were misplacements of > or =2 mm shown in postoperative control CT. The average fluoroscopy time was 1.28+/-0.56 min, and the average operative duration was 103.26+/-23.3 min. There were no postoperative neurological complications in any of the 30 patients. From these data, we conclude that Iso-C(3D) navigation is a very accurate method for the placement of pedicle screws.

[Postoperative and bacterial osteitis. New possibilities for therapy]

Current therapy concepts for post-trauma osteitis include radical debridement, stabilization of bone and soft tissue care using early flap transfers. With this more radical approach, the long term results are improved, however, total treatment time still is very long. In addition to the physical, mental and social consequences for the patient, treatment costs are also very high. Antibiotic therapy as an adjuvant is still standard and effective although the development of worldwide antibiotic resistance has increased treatment difficulties. One of the main aims of research is to reduce these problems or to prevent the development of osteitis entirely. However, research has not yet elucidated the complex immunologic changes involved. In addition, most results are obtained from animal studies and clinical investigations are required.

[Iso-C(3D0-assisted) navigated implantation of pedicle screws in thoracic lumbar vertebrae]

The mobile Siremobil Iso-C(3D) C-arm (Siemens AG, Medical Solutions, Erlangen) is the first device that permits the intraoperative three-dimensional (3D) representation of bone structures. A high-resolution isotropic 3D data cube in the isocenter with an edge length of approximately 12 cm is calculated simultaneously. The Siremobil Iso-C(3D) is linked to navigation with the integrated NaviLink interface (Siemens AG, Medical Solutions, Erlangen). This makes it possible to transfer the generated 3D data directly to the linked navigation system Surgigate (Medivision, Oberndorf, Switzerland). In this prospective clinical trial we evaluated the accuracy of pedicle screw placement using the Siremobil Iso-C(3D) C-arm. The results were compared to the conventional approach and other computer-assisted procedures (CT-based navigation, C-arm-based 2D navigation) in historical control groups. A total of 141 pedicle screws were placed in 30 patients (70 thoracic spine, 71 lumbar spine). Only in one single case was misplacement shown in the postoperative control CT scan (0.71%), the lowest rate of incorrect placements of all techniques. Also the lowest average fluoroscopy time (1.28+/-0.56 min) was achieved during the placement of pedicle screws on the spine with Iso-C(3D) navigation at a comparable average OR duration (103.26+/-23.3 min). There were no postoperative neurological complications in all 30 patients. From these data we conclude that Iso-C(3D) navigation of pedicle screws is a very accurate method in the correct placement of pedicle screws.

Five years' clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures

With the development of interlocking nail systems especially designed for the upper arm, standards for the operative treatment of humeral shaft fractures have appeared to change. The trumpet-like shape of the medullary cavity does not allow stable splinting with a nail alone, and therefore the bone--nail complex is commonly stabilized with interlocking bolts. Between June 1996 and June 2001, 51 fractures of the humeral shaft were treated operatively at the BG Unfallklinik Ludwigshafen with the unreamed humeral nail (UHN; Synthes). All nails were inserted by the retrograde technique. Ninety-five percent of the patients showed excellent or good shoulder function at follow-up examinations. For elbow function, 91.4% of the patients showed excellent or good results. Three out of four patients with poor elbow function had suffered from an additional injury to the brachial plexus; one patient developed heterotopic ossification. Intraoperative complications were: one iatrogenic lesion of the radial nerve, two intraoperative shaft fractures, one split at the insertion point, and one supracondylar fracture. As implants we used 7.5 mm nails in 36 cases and 6.7 mm nails in 15 cases. Among the 47 patients undergoing follow-up examinations, we found two cases of non-union. All patients were pain-free. Thirty-seven patients were very satisfied, six satisfied and four dissatisfied with the therapy. Decisive criteria for the use of a new implant are a high safety standard and simple reproducibility; these appear to be fulfilled by retrograde nailing of humeral fractures with the UHN. Interlocking nailing with the UHN enriches the range of therapeutic options for humeral shaft fractures.

Die CT-freie bildgesteuerte Pfannennavigation in der klinischen Routine

After experimental and preclinical evaluation (HAP Paul Award 2001) of the CT-free image-guided surgical navigation system for acetabular cup placement (SurgiGATE C-arm cup" by Medivision, Switzerland), the system was introduced into clinical routine. The computation of the angular orientation of the cup is based on reference coordinates from the anterior pelvic plane concept. A hybrid strategy for pelvic landmark acquisition has been introduced involving percutaneous pointer-based digitization with the noninvasive biplanar landmark reconstruction using multiple registered fluoroscopy images. From January 2001 to December 2002, a total of 256 consecutive patients with primary osteoarthrosis (mean age 69 years, 161 male, 95 female, 132 left, and 124 right hip joints) were operated on with the hybrid CT-free navigation system. During each operation the angular orientation of the inserted implant was recorded. To determine the placement accuracy of the acetabular components, 50 consecutive patients underwent a CT scan 7-10 days postoperatively to analyze the cup position related to the anterior pelvic plane. This was all done blinded by the same investigator with the planning software of the CT-based navigation system of Medivision. There was no significant learning curve observed for the use of the system. The mean value for postoperative inclination was 43 degrees (SD 3.0, range: 37 degrees -49 degrees ) and for anteversion 19 degrees (SD 3.9, range: 10 degrees -28 degrees ). The resulting system accuracy, i.e., the difference between intraoperatively calculated cup orientation and postoperatively measured implant position showed a mean error of 1.5 degrees for the inclination (maximum 5 degrees, SD 1.1) and 2.4 degrees for the anteversion (maximum 6 degrees, SD 1.3). An accuracy of better than 5 degrees inclination and 6 degrees anteversion was achieved under clinical conditions, which implies that there is no significant difference in performance from the established CT-based navigation methods. Image-guided CT-free cup navigation provides a reliable solution for future THA.

[Comparative examination between an angle stable, monokortikal osteosynthesis technique with the conventional plate osteosynthesis at the anterior arm shaft fracture]

With a retrospective Follow-up essay under the use of Matched peer variables the wellbeing course was examined by patient pairs (128 patients) assigned to 64 individually with fractures of the anterior arm shaft. A group which treats others with 2.7 or 3.5 mm DCP/LC-DCP got with the AO Point Contact basic gate (PC-Fix). The well-being course data count after the implantation on a period of 18 months. The Follow-up-rate was 100% for this time period. The patients became for each other on reason of the criteria: assigned to fracture classification, soft partial loss, accompanying injuries and age. Possible complications were: implantation conditional nerve damages, infections, implant failures, delayed healings, pseudarthroses, motion reductions and synostoses. Complications appeared (PC-Fix at 13 patients: respect, DCP: 5). The statistical testing didn't yield any statistically significant advantage for one for the two implants at a p-value of 0.5811 for.

[Kinematic investigations of the talocrural joint in human cadaver specimens. Basic studies for the development of a hinged fixator]

To determine the specifications of a hinged fixator for the upper ankle joint, biomechanical investigations were performed on 20 human cadaver specimens and the talocrural axis was recorded by X-ray cinematography in all levels of the space. The results showed a medium variation of the axis in zero position (mean: 5.8 degrees ) from 3 degrees to 10 degrees in the anterior-posterior view. The span of the axis migration around zero position amounted to a minimum of 3 degrees and a maximum value of 10 degrees (mean: 7.2 degrees ). It could be ascertained that the axis kinetics does not move linearly in all cases. The talus rotation (the axle deviation from the sagittal plane) amounted to a minimum value of 2 degrees and a maximum value of 12 degrees (mean: 5.3 degrees ). In the transverse level, the axis kinetics was tracked by separate X-ray markings of the lateral and medial cortical of the talus in the zero point of the talocrural axis. The results were typical migration curves of the X-ray markings, demonstrating a ventral convex curve at the medial and lateral cortex. This migration of the cortex crossing point of the axis was geometrically entered in a coordinate system. The variance of the axis cortex crossing point at the medial cortical was X(M)=4.2 mm (min: 2 mm, max: 7 mm) and Y(M)=4.7 mm (2-7 mm), at the lateral cortical X(L)=3.7 mm (1-9 mm) and Y(L) =4.1 mm (1-8 mm). Regarding the clinical relevance for the development of a hinged fixator for the upper ankle joint, the results indicate that an external axis guidance of these axoids is not possible, but that an adjusted axis is necessary taking into consideration the values measured using ligamentotaxis.

Monitoring and healing analysis of 100 tibial shaft fractures

BACKGROUND

We assessed the value of measuring biomechanical stiffness by assessing the fixator's external deformation as an objective means for monitoring fracture healing and determining the postoperative treatment regime, as compared to clinical and radiographic means of evaluation.

PATIENTS AND METHODS

One hundred patients with tibial shaft fractures managed by unilateral external fixation had their fracture stiffness monitored. Stiffness was measured and clinical and radiological examinations were performed every 3-4 weeks.

RESULTS

The time required for healing as indicated by stiffness measurement was an average of 2.5 weeks earlier than by radiological assessment. Eighty-two patients healed within 19 weeks (12.1+/-3.3 weeks) and ten patients in the following 6 weeks (24+/-4.3 weeks). Eight patients did not show an increase in fracture stiffness and received intramedullary nailing at a second operation. The average healing time was 11.3+/-4 weeks for type A, 13.1+/-3.6 weeks for type B fractures, and 15.1+/-5.9 weeks for type C fractures. The healing time for closed fractures was 11.3+/-3.2 weeks and for open fractures 14+/-4.9 weeks.

CONCLUSIONS

The measurement of fracture stiffness allows the detection of patients at risk for nonunions. The healing time increased with increasing fracture gap size and was less in patients with younger age, less complex fractures, and lesser degrees of soft tissue damage.

[Quality of life after acetabulum and pelvic ring fractures. Correlation of long-term results with the "Injury Severity Score" (ISS)]

Patients with acetabular (AF) and pelvic ring fractures (BrF) make heavy demands on hospital resources and face difficulties in rehabilitation. From the patients' point of view, milestones in recovery are quality of life and return to productivity. We studied 42 patients with acetabular and 64 patients with pelvic ring fractures over a period of 10 years. The average follow-up took place 4 years after discharge. The injury severity score (ISS) did not correlate to long-term disability and quality of life (QoL) based on the Rosser index, data on return to productivity, or to radiological and clinical outcome. This study emphasizes the need for new injury scoring systems that better predict the recovery and ability to return to work of trauma patients after surviving pelvic fractures. Proper follow-up evaluations should analyze the patients' quality of life and working activity beside traditional items such as radiological and clinical findings.

[Computer-assisted screw osteosynthesis of the posterior pelvic ring. Initial experiences with an image reconstruction based optoelectronic navigation system]

Injuries of the posterior pelvic with combined anterior and posterior instability require the stabilisation of both the anterior and posterior pelvic ring. If the injury only involves the ligamental connections, then a transileosacral osteosynthesis with screws is the minimal invasive and biomechanically suitable method of choice. The difficulty with this approach is the correct placement of the screws. Their position must be monitored intraoperatively in 3 planes (inlet, outlet and lateral viewing). This denotes that conventional methods involve high radiation dosages for the patient and the surgical staff. Having the system readily available and being able to perform updates during the operation, fluoroscopically supported navigation for the treatment of fresh injuries becomes possible. Between October 1999 and December 2000 7 patients with traumatic instability of the posterior pelvic ring were treated by computer assisted percutaneous transileosacral screw osteosynthesis. In each case the osteosynthesis of the ileosacral joint was performed with two cannulated AO 7.3 mm titanium screws. After the operation the screw position was controlled by CT scanning and compared to the data acquired intraoperatively. No patients had infection, and there were no postoperative neurological defects. The postoperative CT scans showed no intraspinal or intraforminal malplacement of the screws. In two cases a slight tangential screwthread penetration through the ventral sacrum was found. Our first experiences with this novel technology are encouraging and clearly demonstrate the advantages of fluoroscopic supported passive navigation systems for the optimal placement of ileosacral screws.

[Quality of life after surgical treatment of pelvic ring fractures. Are long-term results predictable?]

Patients with fractures of the pelvic ring and accompanying injuries special of the extremity make heavy demands on hospital resources and face difficulties in rehabilitation. From the patients point of view milestones in recovery are quality of live and return to productivity. We studied 64 patients with pelvic-ring-fractures in a period of 10 years. The follow up was taken 4 years after discharge. PTS-score and AO-classification correlate directly to long-term disability, based on Rosser-Index, and "return to productivity" figures but not always to radiological and clinical outcome. This study emphasizes the need for new injury scoring systems that better predict the recovery and ability to return to work of trauma patients after surviving unstable pelvic fractures. Proper follow-up evaluations should analyse the patient's quality of live and working activity beside traditional item like radiological and clinical findings.

[Surgical treatment of injuries of the thoracolumbar transition--3: Follow-up examination. Results of a prospective multi-center study by the "Spinal" Study Group of the German Society of Trauma Surgery]

OBJECTIVES

Prospective, multicenter study addressing late results after operative treatment of acute thoracolumbar spinal injuries.

METHODS

682 patients (T10-L2) were included and 372 (80%) were postoperatively followed for 2 1/4 years (4-61 months).

RESULTS

Comparing the initially included patients (n = 682) with the study group (n = 372), no differences were observed and results were assumed to be representative. A C-type lesion or polytrauma significantly prolonged the hospital stay. The method of operative treatment did not affect the length of the rehabilitation period. Neurological improvement was observed in 3 out of 7 patients with complete, and in 44 out of 64 (69%) with incomplete lesion. The operative method did not affect the improvement rate. The physical capacity significantly decreased. After a mean of 1/2 year of disability only 71% returned to work. 48% returned to their preoperative physical level. The mean Hannover Spine Score was 68 points (preoperative 94, p < 0.001), indicating permanent impairment of function. The angle-stable internal fixator was superior in restoration of spinal alignment and best radiological results were noted after combined stabilization. Posterior stabilization lead to high re-kyphosing. No correlations between radiologic and clinical parameters were observed.

CONCLUSIONS

All treatment methods under study were appropriate for achieving comparable clinical and functional outcome. The internal fixator is superior in restoration of the spinal alignment. Best radiological outcome is achieved by combined stabilization. Merely by direct reconstruction of the anterior column the postoperative re-kyphosing is prevented and a gain in segmental angle is achieved.

[Surgical treatment of injuries of the thoracolumbar transition. 2: Operation and roentgenologic findings]

The authors report on a prospective multicenter study with regard to the operative treatment of acute fractures and dislocations of the thoracolumbar spine (T10-L2). The study should analyze the operative methods currently used and determine the results in a large representative collective. This investigation was realized by the working group "spine" of the German Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18 different traumatology centers in Germany and Austria were included. Part 2 describes the details of the operative methods and measured data in standard radiographs and CT scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%) with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of the posterior operations, the instrumentation was combined with transpedicular bone grafting. The combined procedures were performed as one-stage operations in 38.1%. A significantly longer average operative time (4:14 h) was noted in combined cases compared to the posterior (P < 0.001) or anterior (P < 0.05) procedures. The average blood loss was comparable in both posterior and anterior groups. During combined surgery the blood loss was significantly higher (P < 0.001; P < 0.05). The longest intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with a significant difference compared to the anterior group. In almost every case a "Fixateur interne" (eight different types of internal fixators) was used for posterior stabilization. For anterior instrumentation, fixed angle implants (plate or rod systems) were mainly preferred (n = 22) compared to non-fixed angle plate systems (n = 12). A decompression of the spinal canal (indirect by reduction or direct by surgical means) was performed in 70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with neurologic deficit (Frankel/ASIA grade A-D). An intraoperative myelography was added in 22% of all patients. The authors found a significant correlation between the amount of canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA grades. The wedge angle and sagittal index measured on lateral radiographs improved from -17.0 degrees and 0.63 (preoperative) to -6.3 degrees and 0.86 (postoperative). A significantly (P < 0.01) stronger deformity was noted preoperatively in the combined group compared to the posterior one. The segmental kyphosis angle improved by 11.3 degrees (8.8 degrees with inclusion of the two adjacent intervertebral disc spaces). A significantly better operative correction of the kyphotic deformity was found in the combined group. In 101 (14.8%) patients, intra- or postoperative complications were noticed, 41 (6.0%) required reoperation. There was no significant difference between the three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be misplaced. This number included all screws, which were judged to be not placed in an optimal direction or location. In seven (1.0%) patients the false placement of screws was judged as a complication, four (0.6%) of them required revision. The multicenter study determines the actual incidence of thoracolumbar fractures and dislocations with associated injuries and describes the current standard of operative treatment. The efforts and prospects of different surgical methods could be demonstrated considering certain related risks. The follow-up of the population is still in progress and the late results remain for future publication.

[Patellar tendon rupture after anterior cruciate ligament reconstruction with autologous patellar tendon-bone transplant. A case report]

Patellar ligament ruptures due to a complication after usage of bone-tendon autograft for an anterior cruciate ligament reconstruction happens seldom. During surgeries to restore continuity a fascia-lata-strip may be wrapped in and fixated to secure the primary tendon suture. This may be done in addition to the usually employed patella-tibial wiring cerclage. Whether a matrix for the scarred healing tendon will be created in addition to the construction of a support for the primary tendon seam without a foreign body reaction has to be left to further histological clarifications that cannot be implemented in the present casuistry.

[Vastus lateralis flap--an ideal procedure for definitive surgery of infected cavities of the hip]

Between January 1994 and August 1998, 12 patients with 13 chronic infections after resection arthroplasty were treated successfully with vastus lateralis muscleflap. One patient was suffering from chronic infection on both sides. In all cases we found the infected cavity to be the origin of the persistent infection. The average duration of infection was 8.3 months. The patients had undergone an average of 3.8 operations. Up to now there was no recurrent infection, controlled by clinical investigation, ultrasound and laboratory findings in all 13 cases. Follow up investigation occurred 2.5 years (1.5-4.7) after flap transfer. The flap is easy to harvest. He has a very constant pattern of vascular pedicle and a wide arc of rotation. The functional deficits of donor side morbidity are minimal. That vastus lateralis flap seems to be an ideal procedure to stop draining infections due to infected cavities in the hip region.

[Treatment of complex elbow injuries by joint-spanning articulated fixator]

Biomechanical investigations in eight specimen elbow joints to test articulated external fixation showed correct extension-flexion joint position between 0 and 120 degrees. The central axis through the radial and ulnar condyles varies less than 3 degrees in total. X-ray cinematography showed correct articulation in all cases without subluxation. In six patients with persistent subluxation and complex fracture of the proximal ulna external fixation with an additional articulation was placed. All patients began with physiotherapy on the 3rd day after operation, the range of joint motion was 0-30-95 degrees in all cases, after 6 weeks 0-30-110 degrees. Additional articulated external fixation at the elbow joint can be an alternative treatment to long-term transfixation of the elbow in cases of complex injury.

[Surgical treatment of injuries of the thoracolumbar transition. 1: Epidemiology]

The authors report on a prospective multicenter study with regard to the operative treatment of fractures and dislocations of the thoracolumbar spine. 18 traumatologic centers in Germany and Austria, forming the working group "spine" of the German Society of Trauma Surgery, are participating in this continuing study. Between September 1994 and December 1996 682 patients (64% male) with an average age of 39 1/2 (7-83) years were entered. The entry criteria included all patients with acute and operatively treated (within 3 weeks after trauma) fractures and dislocations of the thoracolumbar spine (Th 10-L 2). Part 1 of this publication outlines the protocol and epidemiologic data. The incidence of fractures and dislocations of the thoracolumbar spine and associated injuries were recorded according to a standardized protocol, as well as the different operative methods and complications, duration of hospital stay, rehabilitation and incapacity. The analysis of the clinical social and radiological course was a second focus. The most frequent mechanism of injury was a fall (50%) or traffic accident (22%). Most of the fractures occurred at the L 1 level (49%). All injuries were classified according to the ASIF (AO) classification. 65% sustained an A-type fracture (compression fracture). Associated injuries were observed in 35% and 6% were polytraumatized. Extremities and thorax were most frequently affected. Younger age and traffic accidents lead more often to C-type fracture (fracture dislocation) and polytrauma. An increased number of multisegmental or multilevel lesions were observed in polytraumatized patients. There were 16% with incomplete paraplegia (Frankel/ASIA B-D) and 5% with complete paraplegia (Frankel/ASIA A). The rate of patients with initial neurologic deficits significantly increased with the severity of spinal injury according to the Magerl classification. Until discharge a neurologic improvement (at least 1 Frankel/ASIA grade) was observed in 32% of the partially paralyzed (Frankel/ASIA B-D) and in 12% of the patients with complete paraplegia (Frankel/ASIA A). A neurologic deterioration occurred in 3 patients (0.4%). As a base for further follow-up and late results the individual starting point was determined by collecting relevant data of the patients' history: 277 (40.6%) patients suffered from simultaneous diseases, one half was spine related. At the time of injury 559 (82.0%) patients were employed; 429 (62.9%) doing manual work. 369 (54.1%) patients stated sportive activities before the injury and 561 (82.3%) designated their "back function" as normal. For the time before injury the patients scored an average of 93.4 points in the Hannover Spine Score (0-100 points concerning complaints and function of the back/spine).

[A simple and rapid method for removal of broken unreamed tibial nails]

By using UTN in the treatment of very distal tibia fractures delayed fracture-healing and pseudarthrosis with breakage of the nail are described. The removal of the distal solid part of the nail shows a special difficulty. We report about two cases of broken UTN in 1997. A simple extraction device to remove the distal part of the broken nail is demonstrated.

[Augmented repair as therapy of fresh injury of the posterior cruciate ligament]

The discussion about the therapy of the posterior cruciate ligament persists. Conservative treatment, augmented repair, and reconstruction with autografts are discussed. From 1993 to 1997, 49 patients with posterior cruciate ligament rupture had repair Trevira ligament augmentation of 3 mm. There were 21 isolated and 28 combined ruptures. In 5 cases bony avulsions were refixed by screw or additional hook plate. Investigation of 36 patients, in 15 cases with isolated ligamentous ruptures was made. Osseous avulsion had good results in all cases. Isolated posterior cruciate ligament rupture showed good stability in 7 of 15 cases and instability of 2 + in 8 cases. The medial range Lysholm score was 76.8 (+/- 21.6), the OAK score showed 2 very good and 5 good results, 3 fair and 5 bad results. Using the IKDC score led to 3 very good and 4 good results, 2 fair and 6 bad results. Using subjective criteria, 10 patients described results as very good or good, 2 fair and 3 bad. Posterior cruciate ligament rupture with additional knee injury or fracture of the leg showed bad results in 60 % of cases, and good or fair results in only 40 %. We think augmented repair of fresh injury of the posterior cruciate ligament can be used as an alternative therapy to reconstruction with autograft.