Bernhard Ullrich

Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Study Design: Prospective clinical cohort study (data collection); expert opinion (recommendation development). Objectives: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. Methods: a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification–based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. Results: A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately. Conclusions: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.

Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Study Design: Expert consensus. Objectives: To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. Methods: This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma. Results: Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a “dangerous mechanism of injury.” Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6. Conclusions: These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

Repositionshindernis des hinteren Volkmann-Dreiecks durch Interposition der Sehne des M. flexor digitorum longus@@@Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

Gelenkerhaltende Korrektureingriffe nach distaler Radiusfraktur

ZusammenfassungFrakturen des distalen Radius zählen zu den häufigsten ossären Verletzungen. Bei signifikanten intra- und/oder extraartikulären Fehlstellungen oder Pseudarthrosen nach konservativer bzw. operativer Therapie, die von persistierenden Beschwerden und funktioneller Einschränkung begleitet werden, sollte die Indikation für einen korrigierenden Eingriff geprüft werden. Öffnende Osteotomien mit Defektauffüllung mittels Beckenkammspan oder autologer Spongiosa haben sich gemeinhin bewährt und sind als Standardverfahren etabliert. Wann immer möglich, sollte das Ziel der Korrektur in einer Rekonstruktion möglichst anatomischer Verhältnisse mit Rekonstruktion der radialen Länge, des palmaren Tilt sowie der Ulnarinklination liegen. Hierbei sind das Radiokarpalgelenk und das distale Radioulnargelenk grundsätzlich als funktionelle Einheit zu betrachten. Letztlich besteht eine klare Korrelation zwischen dem klinischen und radiologischen Ergebnis nach erfolgter Korrektur.AbstractFractures of the distal radius are one of the most frequent bony injuries. Corrective surgery should be considered in cases of significant malpositioning of intra-articular or extra-articular fractures as well as malunions after conservative or surgical treatment associated with persistent pain and functional impairment. Open wedge osteotomy combined with an iliac crest graft or autologous cancellous bone is the most widely recommended technique and has become established as the standard method. Whenever possible, an anatomical reduction with reconstruction of the radial length, palmar tilt and ulnar inclination should be performed. In so doing, the radiocarpal and the distal radioulnar joints have to be considered as one functional unit. The functional outcome after corrective osteotomy shows a clear correlation with the radiological result.

Repositionshindernis des hinteren Volkmann-Dreiecks durch Interposition der Sehne des M. flexor digitorum longus

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.