H. Tscherne

Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study

A cadaver arterial injection study was performed to analyse the vascular supply to the femur and to study the effects of two surgical plating techniques on femoral vascularity. A 16-hole LC-DCP was applied on the intact femora of five fresh human cadavers. On one side, the plate was inserted using a conventional lateral plate osteosynthesis (CLPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPO) technique. After plating, blue silicone dye was injected through the common femoral artery. Cadaveric dissection was then performed to identify the femoral perforating arteries (PAs) and the nutrient artery (NA) of the femur. The pattern of periosteal filling and medullary perfusion of the injected dye was analysed and the topography of the PAs and NA was determined. CLPO placed the PAs and NA of the femur at risk. MIPO maintained the integrity of the PAs and NA and was associated with superior periosteal and medullary perfusion. The results of this study indicate that MIPO is superior to the CLPO in maintaining arterial femoral vascularity and perfusion.

Epidemiology of pelvic ring injuries

3260 patients with pelvic and acetabular fractures were assessed using a standardized documentation form by collating the data on 1905 patients treated at the Department of Traumatology of the Hannover Medical School together with those patients treated between 1991 and 1993 in the German Multicentre Study Group (Pelvis) of the German Trauma Society and the German Section of the AO International. 2551 patients had pelvic ring injuries. 61.7% of the patients were multiply injured. 12.2% were suffering a complex pelvic trauma defined as a pelvic injury with concomitant soft tissue injury. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury). There were concomitant acetabular fractures in 15.7%. The most frequent single lesions affecting the pelvic girdle were fractures of the ischiopubic bones (transpubic instability), injuries involving the sacroiliac joint (transiliosacral instability), and sacral fractures (transsacral instability). The overall rate of operative stabilizations was 21.6%. Type B injuries were stabilized in 28.9% and type C injuries in 46.7%. The overall mortality rate was 13.4%, depending significantly on the associated extrapelvic trauma. In complex pelvic injuries, the mortality rate was 31.1% whereas for pelvic fractures without concomitant soft tissue injury the rate was only 10.8%.

Use of an injectable calcium phosphate bone cement in the treatment of tibial plateau fractures: a prospective study of twenty-six cases with twenty-month mean follow-up.

Objective To evaluate the potential benefit of a new injectable mineral bone cement (Norian SRS, Cupertino, CA, USA) for the treatment of tibial plateau fractures OTA types 41.B2–B3 and C3. Design Prospective study with established protocol. Setting University hospital; university teaching hospital. Patients Twenty-six patients gave informed consent to participate in this study and were available for follow-up examinations. All patients had sustained intraarticular tibial plateau fracture types OTA B2–B3 and C3. All cases were followed with a mean follow-up time of 19.7 months (6 to 36 months, median eighteen months). Intervention Twenty-five cases were treated with open reduction, osteosynthesis with screws or plate, and injection of Norian SRS in the subchondral bone defect. One case had closed reduction, screw osteosynthesis, and percutaneous cement injection. Main Outcome Measurements Radiographs in two planes were evaluated prospectively at six, twelve, and twenty-six weeks postoperatively and at last follow-up using Rasmussens radiologic score. Clinical parameters were measured at the same time intervals using Lysholms and Tegners knee scores. Results Two cases required early wound revisions because of sterile drainage. Two cases developed partial loss of reduction of the fracture between four and eight weeks after surgery, requiring revision surgery in one case (total complication rate 15.3 percent). No other patients had complications, and all other fractures healed without any displacement. The high mechanical strength of the cement allowed early weight bearing after a mean postoperative period of 4.5 weeks (1 to 6 weeks). Conclusions An injectable mineral bone cement with high initial mechanical strength was used to fill bone defects in unstable tibial plateau fractures with good success. This material offers new perspectives in the treatment of tibial plateau fractures.

Outcome after pelvic ring injuries

Open reduction and internal fixation of unstable pelvic ring fractures provides the best stability of fixation as well as the best late clinical results. Whereas several studies have supported this both in biomechanical studies and clinical trials, there is still controversy about the long-term outcome of these injuries. A series of 58 patients who had received surgical stabilization of Tile B- and C-type fractures between 1985 and 1990 were followed up for an average of 28 months. The follow-up included a detailed clinical and radiological examination, an evaluation of the patients general social status and a detailed neurological and urological screening. The data were summarized in a new scoring system rating radiological, clinical and social results independently. Patients suffering B-type fractures showed 79% good and excellent results. Despite the fact that after C-type fractures 50% healed anatomically and 30% healed with a 5 mm or less residual posterior displacement, only 27% of the patients were rated good or excellent. Further studies must be conducted for closer evaluation of risk factors influencing the results after anatomical reconstruction of the pelvic ring.

Fractures of the thoracolumbar spine Late results and consequences of dorsal instrumentation

SummaryBetween January 1989 and July 1992, 76 patients with thoracolumbar fractures were operatively treated at the Department of Trauma Surgery, Hannover Medical School. After a mean of more than 3 years, 56 of 62 patients (90 %) still alive who had their implants removed were examined. According to the ASIF classification 33 patients sustained type A fractures, 13 type B and 10 type C. Three patients with incomplete paraplegia returned to normal; in one case of complete paraplegia no change occurred. In 40 cases the dorsal instrumentation was combined with transpedicular cancellous bone grafting. The mean operative time totaled 3 h. In this series, two complications (3.6 %) were observed: one iatrogenic vertebral arch fracture without consequences and one deep infection. Compared to the preoperative status, our follow-up examinations demonstrated permanent physical and social sequelae: the percentage of individuals able to do physical labor was reduced by half (22 to 11 patients) whereas the share of unemployed or retired patients doubled (4 to 8 patients). At the time of follow-up examination only 21 of 42 patients continued in sports. The assessment of complaints and functional outcome with the ”Hannover Spinal Trauma Score” reflected a significant difference (P < 0.001) between the status before injury (96.6/100 points) and at the time of follow-up (71.4/100 points).The radiographic assessment in the lateral plane (Cobb technique) demonstrated a significant (P < 0.001) mean restoration from an initial angle of –15.6 ° (kyphosis) to + 0.4 ° (lordosis). Serial postoperative radiographic follow-up showed progressive loss of correction; at follow-up examination we found a mean of 10.1 ° (P < 0.001). Compared to the preoperative deformity a mean improvement of 6.1 ° to an average of –9.7 ° at follow-up examination was noted. The addition of transpedicular cancellous bone grafting did not decrease the loss of correction. CT scans after implant removal were performed in 9 cases: only 3 of 9 patients showed evidence of intervertebral fusion. No correlation could be found between ASIF classification and radiographic outcome. However, the preoperative wedge angle of the vertebral body correlated significantly with the postoperative loss of reduction. Due to disappointing results after dorsal stabilization with transpedicular cancellous bone grafting we recommend a combined procedure with dorsal stabilization and ventral fusion in cases of complete or incomplete burst injury of the vertebral body.ZusammenfassungVon Januar 1989 bis Juli 1992 wurden an der Unfallchirurgischen Klinik der Medizinischen Hochschule Hannover 76 Patienten mit Frakturen der thorakolumbalen Wirbelsäule operiert. Von 62 überlebenden Patienten nach Implantatentfernung konnten nach mehr als 3 Jahren 56 (90 %) nachuntersucht werden. Es handelte sich um 33 A-, 13 B- und 10 C-Verletzungen; 3mal lag ein inkomplettes Querschnittsyndrom vor, das sich vollständig zurückbildete; eine komplette Querschnittläsion besserte sich nicht. Neben einer Instrumentierung mit Fixateur interne wurde in 40 Fällen zusätzlich eine transpedikuläre interkorporelle Spondylodese durchgeführt. Die mittlere Operationszeit betrug 3 h. Es wurden 2 Komplikationen (3,6 %) beobachtet: Ein intraoperativer Wirbelbogenbruch ohne Konsequenz und ein revisionspflichtiger Infekt.Die Spätergebnisse dokumentieren signifikante körperliche und soziale Dauerfolgen im Vergleich zum präoperativen Zustand: Während sich der Anteil der körperlich Arbeitenden halbierte (von 22 auf 11 Patienten), verdoppelte sich die Anzahl der Arbeitslosen und Berenteten (von 4 auf 8 Patienten). Sportliche Aktivitäten übten von ursprünglich 42 Patienten zum Zeitpunkt der Nachuntersuchung nur noch 21 aus. Der als Bewertungsmaßstab vorgestellte „Hannover-Wirbelsäulenscore“ zeigt im Vergleich zum präoperativen Zustand (96,9 von 100 Punkten) eine signifikant geringere Punktzahl (p < 0,001) bei der Nachuntersuchung als Ausdruck bleibender Beschwerden oder Funktionsbeeinträchtigungen (71,4 von 100 Punkten).Röntgenologisch ließ sich mit dem Grund-Deckplatten-Winkel (GDW) eine durchschnittliche Korrektur der initialen Fehlstellung von –15,6 ° Kyphose auf + 0,4 ° Lordose nachweisen (p < 0,001). Bei jeder folgenden Untersuchung fand sich jedoch ein signifikanter Korrekturverlust, der zum Zeitpunkt der Nachuntersuchung im Mittel bei 10,1 ° lag (p < 0,001). Der absolute Wert betrug –9,7 ° und lag damit nur um 6,1 ° besser als der Ausgangsbefund. Einen positiven Effekt der transpedikulären Spongiosaplastik auf den Korrekturverlust konnten wir nicht nachweisen. CT-Untersuchungen nach Implantatentfernung zeigten lediglich bei 3 von 9 Patienten mit transpedikulärer Spongiosaplastik eine knöcherne Durchbauung.Eine Korrelation zwischen dem Frakturtyp nach der AO-Klassifikation und dem radiologischen Spätergebnis konnte nicht nachgewiesen werden; es bestand jedoch ein statistisch signifikanter Zusammenhang zwischen der Schwere der Verletzung der vorderen Säule und dem postoperativen Korrekturverlust.Wegen der enttäuschenden Ergebnisse nach transpedikulärer Spongiosaplastik und dorsaler Instrumentierung empfehlen wir bei Verletzung der vorderen Säule im Sinne eines inkompletten oder kompletten Berstungsbruchs ein kombiniertes dorsoventrales Vorgehen.

Closed reduction/percutaneous fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of reduction.

OBJECTIVE To evaluate arthroscopic versus fluoroscopic reduction and percutaneous fixation of lateral tibial plateau fractures of AO/OTA Types 41.B1 to 41.B3. DESIGN Prospective study. SETTING University hospital. PATIENTS AND INTERVENTION One hundred sixty-eight patients underwent operative treatment for a tibial plateau fracture from 1988 to 1995. Thirty-three of these patients had monocondylar fractures of the lateral plateau that were treated by percutaneous reduction and fixation techniques. In the first ten cases, arthroscopic control of reduction was used. The following twenty-three consecutive cases were treated by reduction and fixation solely under fluoroscopic control. The arthroscopy group was followed for a mean of fifty-two months and the fluoroscopy group for thirty-eight months. RESULTS Nine of ten cases of the arthroscopy group had an excellent or good result in Rasmussens knee score at follow-up. One patient with an unreduced anterolateral depression zone despite arthroscopic surgery required a total knee prosthesis after eighteen months. Sixteen cases in the fluoroscopy group met the follow-up criteria. Fifteen were graded good or excellent in Rasmussens clinical score; sixteen were excellent or good in the radiological score. One patient claimed chronic medial joint line pain after a lateral split fracture and had arthroscopy revealing chondral degeneration on the medial side but had no pathological findings in the lateral compartment. No secondary meniscus or ligament surgery was performed in the follow-up period. CONCLUSIONS Percutaneous treatment of fractures of the tibial plateau can be performed using arthroscopy as well as image intensification to control reduction of the joint surface. We were not able to demonstrate any significant benefit from arthroscopy compared with fluoroscopic reduction. Reduction under image intensification is technically easier in our practice, especially in serial fractures and multiply injured patients. We reserve arthroscopy for cases with significant ligament injuries and for children with fractures of the median eminence.

Rehabilitation and reintegration of multiply injured patients: an outcome study with special reference to multiple lower limb fractures

In this study a group of 104 multiply injured patients (mean ISS = 34) was examined for physical status and social reintegration. Essentially it was noted that 76 per cent of all patients were able to return back to work, although this appears to be age dependent. Open fractures of the leg seem to be the dominating prognostic factor for reintegration resulting in a disability rate of between 20 and 50 per cent. Disability of more than 80 per cent was only due to major head injury. Apparently reintegration is linked to the pattern of injury and is less related to the overall injury severity. We conclude that trauma care is economically cost effective but also needs further standardization and subsequent outcome analysis.

Optimal duration of primary surgery with regards to a “Borderline”-Situation in polytrauma patients

SummaryPrimary stabilization of major fractures in polytrauma patients is known to represent an important principle of treatment and has been shown to reduce the incidence of posttraumatic complications and of organ failure. However, in critically injured patients it has been discussed that extensive primary definitive treatment may also cause adverse effects due to its systemic burden by blood loss, loss of temperature etc. Patients who deteriorated unexpectedly following primary surgery have been named “borderline patients”. In these patients it appears necessary to limit the amount of operative procedures, e. g. by performing temporary fixation of major fractures primarily. The threshold beyond which surgical procedures may cause more harm than good has not been well defined. This holds true especially for the duration of primary surgery. We investigated the clinical outcome in a large number of prospectively documented multiple trauma patients with respect of the duration of primary fracture stabilization. If a primary surgical procedure exceeded 6 hours in multiple trauma patients with an ISS of 25 points, patients demonstrated a significantly elevated ventilation time, an increased mortality, and a higher incidence of death from MOF in comparison with patients that were injured comparably, but were submitted to shorter primary operative procedures.ZusammenfassungDie primäre Frakturstabilisierung stellt eines der wesentlichen Behandlungsprinzipien der Versorgung schwerverletzter Patienten dar und führt zur Reduktion posttraumatischer Komplikationen und Organfunktionsstörungen. Allerdings sind der Durchführung einer chirurgischen primären Definitivversorgung aufgrund der Systembelastung verschiedener Operationsverfahren Grenzen gesetzt. Patienten, welche sich unerwartet nach ausgiebiger Primäroperation verschlechterten, wurden deshalb als Borderline-Patienten bezeichnet. Für diese anhand klinischer Parameter schwer zu erfassenden Patienten erscheint es sinnvoll, das Ausmaß der primär definitiven operativen Versorgung zu begrenzen. Für nicht unmittelbar lebensrettende Sofortoperationen bietet sich ein abgestuftes Vorgehen mit primärer temporärer Frakturstabilisierung durch Fixateur externe und nachfolgender Definitivversorgung an. Die Grenzwerte für ein primär definitives Vorgehen sind bisher ungenau festgelegt, insbesondere im Hinblick auf die Operationsdauer. Die vorliegende Arbeit untersucht die Auswirkungen unterschiedlicher Operationsdauern bei vergleichbarer Verletzungsschwere und -verteilung in einem prospektiv multizentrisch dokumentierten Patientenkollektiv. Eine Operationsdauer von mehr als 6 h bei Patienten mit einer mittleren Verletzungsschwere von 25 Punkten nach „injury severity score“ war mit einer signifikanten Verlängerung der Beatmungsdauer, einer erhöhten Sterblichkeit und einer erhöhten Inzidenz eines Versterbens am Multiorganversagen vergesellschaftet.

Does the accident patient need to be protected from the emergency doctor

SummaryQuality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance.Regarding the triage, for example, it was noted that 28 % of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7 % of patients two additional mistakes and in 4 % of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment.Preclinical intubation and mechanical ventilation was not performed in 16.5 % although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38 % of patients suffering from severe thoracic trauma (AISThorax≥ 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17 % of all documented patients.According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.ZusammenfassungIn den letzten Jahren wurde zunehmend auch in der präklinischen Versorgung eine Qualitätsanalyse gefordert. Um die Qualität zu definieren und diese im Sinne der Qualitätssicherung kontrollieren, müssen Zielgrößen in Form von Standards festgeschrieben werden. Diese sind bereits unter Mitarbeit verschiedener deutscher Organisationen zusammengestellt worden, welches zu der Einführung eines bundeseinheitliches Notarztprotokolls geführt hat. Eine eigentliche Qualitätskontrolle dieser seit 1992 prospektiv dokumentierten Daten existiert jedoch nicht. Wir führten eine Auswertung aller polytraumatisierter Patientendaten durch, die mit einer definierten Verletzungsschwere primär oder sekundär in unsere Klinik eingeliefert wurden. Die Fehleranalyse beinhaltet wichtige Aspekte der präklinischen Diagnostik und Behandlung (Triage, Indikationsstellung und Ausführung von präklinischen Maßnahmen).Es zeigte sich, daß 28 % der Patienten, die aufgrund der Gesamtverletzungsschwere oder einer schwersten Einzelverletzung unmittelbar an ein Traumazentrum hätten transferriert werden müssen (Triage), primär in ein Krankenhaus der Regelversorgung eingeliefert wurden. Bei 7 % der Patienten ließ sich zwei und bei 4 % mehr als zwei Triagefehler nachweisen. Andererseits gab es Fälle, in denen trotz erkannter nur geringer Verletzungsschwere eine Intubation oder gar das Legen einer Thoraxdrainage erfolgte.Die präklinische Intubation und Beatmung wurde in 16,5 % der Fälle trotz klarer Indikation nicht durchgeführt. Eine Thoraxdrainage wurde trotz schwerem Thoraxtrauma (PTSThorax≥ 12/oder AISThorax≥ 4) und initialer Intubation und Beatmung bei 38 % nicht durchgeführt. Eine suffiziente Infusionstherapie (> 2500 ml effektiver Volumenersatz) war in 17 % der Fälle nicht erfolgt. Andererseits häufen sich Fälle in denen die Verletzungsschwere anscheinend überschätzt wurde und invasive Maßnahmen ergriffen wurden, die nach den vorhandenen Standards nicht indiziert gewesen wären.Diesen Ergebnissen zur Folge ist vorallem die Beurteilung der Verletzungsschwere am Unfallort häufig ein großes Problem, da hier der höchste Anteil vermeidbarer Fehler zu beobachten war. Ebenso wurde die Schwere des Thoraxtraumas vielfach falsch eingeschätzt und entsprechend nicht die erforderlichen Maßnahmen durchgeführt. Dies bedeutet, daß obwohl die Qualifikation des Notarztes nunmehr gesetzlich geregelt ist und Richtlinien für die Ausbildung erarbeitet sind, noch erhebliche Defizite in der Erkennung und Behandlung von Verletzungsfolgen bestehen. Einer Gefährdung des Unfallpatienten durch den Notarzt, der falsche Maßnahmen (im Sinne von zuviel oder zu wenig) ergreift, muß entgegengesteuert werden.

Extracorporeal shock wave therapy for delayed union of long bone fractures – preliminary results of a prospective cohort study

SummaryExtracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.ZusammenfassungDie extrakorporale Stoßwellentherapie (ESWT) wurde in den letzten Jahren als nicht-invasive, risikoarme Behandlungsmöglichkeit in der Therapie von Pseudarthrosen (PA) propagiert. Das Ziel dieser prospektiven klinischen Untersuchung war es, anhand des eigenen Patientenguts die Auswirkungen der ESWT auf den Heilungsverlauf von Pseudarthrosen des Röhrenknochens zu überprüfen. Patienten mit einer Pseudarthrosendauer > 6 Monaten wurden in 2 Sitzungen mit jeweils 2000 Impulsen und 18 kV ESWT behandelt. Eine Nachuntersuchung erfolgte 1, 3 und 6 Monate nach der 2. ESWT; 25 Patienten mit 27 Pseudarthrosen haben den Nachuntersuchungszeitraum von 6 Monaten erreicht. In 11 von 27 PA kam es klinisch und radiologisch zur Ausheilung (41 %). Eine klinische Besserungstendenz trat bei 5 Patienten bereits innerhalb des 1. Monats auf, bei allen Patienten innerhalb der ersten 3 Monate. Eine radiologische Durchbauung zeigte sich in keinem Fall innerhalb des 1. Monats, bei allen jedoch innerhalb der ersten 3 Monate. Somit verzögert sich bei Mißerfolg der ESWT eine Reosteosynthese maximal um 3 Monate. Der Einsatz der ESWT erscheint daher bei einer Pseudarthrosendauer > 6 Monate von Röhrenknochen als adjuvante, nicht-invasive Behandlung gerechtfertigt.