C. W. Müller

Therapieempfehlungen zur Versorgung von Verletzungen der Brust- und Lendenwirbelsäule

ZusammenfassungIn dieser Arbeit werden Empfehlungen zur Versorgung von Frakturen der Brust- (BWS) und der Lendenwirbelsäule (LWS) gegeben. Die Empfehlungen beruhen auf der Erfahrung der beteiligten Wirbelsäulenchirurgen der Arbeitsgemeinschaft „Wirbelsäule“ der Deutschen Gesellschaft für Unfallchirurgie unter Berücksichtigung der aktuellen Literatur. Grundlagen der Diagnostik, der konservativen und operativen Therapie werden dargestellt. Die Frakturen werden Anhand von morphologischen Kriterien, wie der Zerstörung des Wirbelkörpers, der Fragmentdislokation, der Einengung des Spinalkanals, der Achsabweichungen und der Abweichung vom individuellen sagittalen Profil beurteilt. Die Abweichung von dem individuellen sagittalen Profil wird anhand der Änderung des monosegmentalen oder bisegmentalen Grund-Deckplatten-Winkels bestimmt. Es werden die Therapieoptionen für den knochengesunden Patienten aufgezeigt.AbstractThis paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the “Deutsche Gesellschaft für Unfallchirurgie” and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

Recommendations for the treatment of thoracolumbar and lumbar spine injuries

ZusammenfassungIn dieser Arbeit werden Empfehlungen zur Versorgung von Frakturen der Brust- (BWS) und der Lendenwirbelsäule (LWS) gegeben. Die Empfehlungen beruhen auf der Erfahrung der beteiligten Wirbelsäulenchirurgen der Arbeitsgemeinschaft „Wirbelsäule“ der Deutschen Gesellschaft für Unfallchirurgie unter Berücksichtigung der aktuellen Literatur. Grundlagen der Diagnostik, der konservativen und operativen Therapie werden dargestellt. Die Frakturen werden Anhand von morphologischen Kriterien, wie der Zerstörung des Wirbelkörpers, der Fragmentdislokation, der Einengung des Spinalkanals, der Achsabweichungen und der Abweichung vom individuellen sagittalen Profil beurteilt. Die Abweichung von dem individuellen sagittalen Profil wird anhand der Änderung des monosegmentalen oder bisegmentalen Grund-Deckplatten-Winkels bestimmt. Es werden die Therapieoptionen für den knochengesunden Patienten aufgezeigt.AbstractThis paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the “Deutsche Gesellschaft für Unfallchirurgie” and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

Ist eine routinemäßige Implantatentfernung nach unfallchirurgischen Eingriffen sinnvoll

We present a literature review about implant removal after operative extremity and spine fracture treatment. The indication for implant removal procedures has become less frequent in recent years, but is still more common in Europe than for example in North America. The time required to perform a implant removal can easily exceed the planned amount. Implant removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the implant should be made with great care. Therefore good communication with the patient and thorough information about risks and benefits are essential.

Is routine implant removal after trauma surgery sensible

We present a literature review about implant removal after operative extremity and spine fracture treatment. The indication for implant removal procedures has become less frequent in recent years, but is still more common in Europe than for example in North America. The time required to perform a implant removal can easily exceed the planned amount. Implant removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the implant should be made with great care. Therefore good communication with the patient and thorough information about risks and benefits are essential.

Classification of Osteoporotic Thoracolumbar Spine Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Study Design: Expert opinion. Objectives: Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed. Methods: The working group “Osteoporotic Fractures” of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature. Results: The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63). Conclusions: The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.

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.

Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Study Design: Abstract consensus paper with systematic literature review. Objective: The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. Methods: The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. Results: As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. Conclusion: Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

[Limb salvage or amputation after severe trauma to the lower extremities : Evidence from the LEAP Study].

ZusammenfassungDie Entscheidung zwischen Erhaltungsversuch und primärer Amputation der schwersttraumatisierten unteren Extremität ist schwierig und folgenreich. In der Lower-Extremity-Assessment-Project(LEAP)-Studie wurden prospektiv Patienten mit schweren, den Erhalt der Extremität bedrohenden Verletzungen ab distal des Femurs mit drittgradig offenen Frakturen, definierten Weichteilschäden und Amputationsverletzungen eingeschlossen und nachuntersucht. Die vorliegende Übersichtsarbeit stellt die Ergebnisse der Studie, die in multiplen Teilaspekten publiziert wurde, unter Berücksichtigung der neueren Literatur dar und leitet Schlussfolgerungen für die klinische Praxis ab. Wichtige Ergebnisse sind: Bisher ist kein Score ausreichend reliabel, den Erfolg eines Extremitätenerhalts vorherzusagen. Das Ausmaß der muskulären Verletzung erscheint für die Funktion bedeutsamer als das der knöchernen Verletzung. Wesentlich für das Ergebnis sind Begleitverletzungen, die im individuellen Therapiekonzept berücksichtigt werden müssen, sowie Vorerkrankungen und andere patientenspezifische Faktoren (Alkohol, Nikotin, Versicherungsstatus, soziale Aspekte). Psychische Beeinträchtigungen sind häufige Folgen dieser Verletzungen und sollten bei der Rehabilitation Beachtung finden.AbstractDeciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.

Gliedmaßenerhalt oder Amputation nach schwerem Trauma der unteren Extremität

ZusammenfassungDie Entscheidung zwischen Erhaltungsversuch und primärer Amputation der schwersttraumatisierten unteren Extremität ist schwierig und folgenreich. In der Lower-Extremity-Assessment-Project(LEAP)-Studie wurden prospektiv Patienten mit schweren, den Erhalt der Extremität bedrohenden Verletzungen ab distal des Femurs mit drittgradig offenen Frakturen, definierten Weichteilschäden und Amputationsverletzungen eingeschlossen und nachuntersucht. Die vorliegende Übersichtsarbeit stellt die Ergebnisse der Studie, die in multiplen Teilaspekten publiziert wurde, unter Berücksichtigung der neueren Literatur dar und leitet Schlussfolgerungen für die klinische Praxis ab. Wichtige Ergebnisse sind: Bisher ist kein Score ausreichend reliabel, den Erfolg eines Extremitätenerhalts vorherzusagen. Das Ausmaß der muskulären Verletzung erscheint für die Funktion bedeutsamer als das der knöchernen Verletzung. Wesentlich für das Ergebnis sind Begleitverletzungen, die im individuellen Therapiekonzept berücksichtigt werden müssen, sowie Vorerkrankungen und andere patientenspezifische Faktoren (Alkohol, Nikotin, Versicherungsstatus, soziale Aspekte). Psychische Beeinträchtigungen sind häufige Folgen dieser Verletzungen und sollten bei der Rehabilitation Beachtung finden.AbstractDeciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.

Gliedmaßenerhalt oder Amputation nach schwerem Trauma der unteren Extremität@@@Limb salvage or amputation after severe trauma to the lower extremities: Evidenz aus der LEAP-Studie@@@Evidence from the LEAP Study

ZusammenfassungDie Entscheidung zwischen Erhaltungsversuch und primärer Amputation der schwersttraumatisierten unteren Extremität ist schwierig und folgenreich. In der Lower-Extremity-Assessment-Project(LEAP)-Studie wurden prospektiv Patienten mit schweren, den Erhalt der Extremität bedrohenden Verletzungen ab distal des Femurs mit drittgradig offenen Frakturen, definierten Weichteilschäden und Amputationsverletzungen eingeschlossen und nachuntersucht. Die vorliegende Übersichtsarbeit stellt die Ergebnisse der Studie, die in multiplen Teilaspekten publiziert wurde, unter Berücksichtigung der neueren Literatur dar und leitet Schlussfolgerungen für die klinische Praxis ab. Wichtige Ergebnisse sind: Bisher ist kein Score ausreichend reliabel, den Erfolg eines Extremitätenerhalts vorherzusagen. Das Ausmaß der muskulären Verletzung erscheint für die Funktion bedeutsamer als das der knöchernen Verletzung. Wesentlich für das Ergebnis sind Begleitverletzungen, die im individuellen Therapiekonzept berücksichtigt werden müssen, sowie Vorerkrankungen und andere patientenspezifische Faktoren (Alkohol, Nikotin, Versicherungsstatus, soziale Aspekte). Psychische Beeinträchtigungen sind häufige Folgen dieser Verletzungen und sollten bei der Rehabilitation Beachtung finden.AbstractDeciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.