Maximilian Hartel

Unstable Bicondylar Tibial Plateau Fractures : A Clinical Investigation

Objective: To evaluate fracture patterns in bicondylar tibial plateau fractures and their impact on treatment strategy. Design: Prospective data analysis with documentation of initial injury and treatment strategy, computed tomography scans, conventional x-rays, long-term evaluation of radiographs, and functional assessments. Setting: Level 1 regional trauma center. Patients: Prospective data acquisition of 14 consecutive patients (10 male and 4 female) with a bicondylar tibial plateau fracture (AO Type C). Intervention: Application of a stepwise reconstruction strategy of the tibial plateau starting with the reposition and fixation of the posteromedial split fragment using a 3.5 buttress plate, followed by reposition and grafting of the lateral compartment and lateral fixation with a 3.5 plate in 90 degree to the medial fixation device. Main Outcome Measurements: All patients were evaluated with full-length standing film, standardized x-rays, Lysholm score for functional assessment, and patients self-appraisal. Results: Most of the complex bicondylar fractures follow a regular pattern in that the medial compartment is split in a mediolateral direction with a posteromedial main fragment, combined with various amounts of multifragmental lateral compartment depression. The technique introduced allows for accurate and stable reduction and fixation of this fracture type. The final Lysholm knee score showed an average of 83.5 points (range: 64.5-92). Conclusions: Complex bicondylar tibial plateau fractures follow a regular pattern, which is not represented in existing 2-dimensional fracture classifications. A 2-incision technique starting with the reduction of the posteromedial edge results in accurate fracture reduction with low complication rates and excellent knee function.

An intraoperatively moulded PMMA prostheses like spacer for two-stage revision of infected total knee arthroplasty

We report a series of 16 consecutive total knee arthroplasty (TKA) revision procedures for deep infection, treated with a newly developed intraoperatively moulded PMMA cement-prostheses-like spacer (CPLS). The standard treatment consisted of a two-stage protocol with initial explantation of the infected components combined with radical debridement, followed by implantation of a temporary cement spacer and final reimplantation of a new TKA. A sterilizeable Teflon tapered aluminium mould was developed for production of a custom made CPLS during the intervention. Stable implantation of the CPLS was achieved with a second cementation, allowing for correct alignment and ligament balancing. The spacer remained 3.5 months on average until reimplantation of a TKA occurred. At time of reimplantation, patients had an average KSS score of 84.44 points with an average flexion capacity of 102°. There was no recurrent infection during the study period of minimum 2 years. With this new technique, a low friction articulation with good stability, high comfort and a better range of motion compared to handcrafted spacers was achieved. The use of this spacer is a time sparing, cheap and convenient option in 2-stage TKA revision.

The mean anatomical shape of the tibial plateau at the knee arthroplasty resection level: an investigation using MRI.

Clinical assessments after Total Knee Arthroplasty (TKA) show persisting pain after implantation in over 20% of patients. Impingement of soft tissue around the knee, due to imprecise geometry of the tibial implant, can be one reason for persisting ailment. Two hundred and thirty seven MRI scans were evaluated using an active contour detection algorithm (snake) to obtain a high-resolution mean anatomical shape of the tibial plateau. Differences between female and male, older and younger (<or=40/>40) and left and right averaged shapes were determined. The shapes obtained were asymmetric throughout. Absolute differences between the subgroups fell short of inter-individual variations represented by calculated one-sigma confidence intervals. Our results indicate that a differentiation in TKA tibial plateau design by gender, age, or side is of minor relevance.

Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures

INTRODUCTION Patients with a fracture in the anterior pelvic ring often simultaneously demonstrate pain in the posterior pelvic ring. The aim of the present prospective study was to assess the sensitivity of CT, MRI and clinical examination in the detection of fractures in the posterior pelvic ring in patients with fractures of the anterior pelvic ring diagnosed in conventional radiographs. METHODS Sixty patients with radiographic signs of an anterior pelvic ring injury were included in this prospective analysis. Following a focused clinical examination of the posterior pelvis, all patients underwent both a CT and then a MRI scan of their pelvis. Two board certified radiologists evaluated the CT and MRI scans independently. To estimate the presence of osteoporosis the Hounsfield units of the vertebral body of L5 were measured in each case. RESULTS Fifty-three women and seven men, with a mean age of 74.7+/-15.6 years were included into the study. A fracture of the posterior pelvic ring was found in fourty-eight patients (80%) patients using MRI. Fractures of the posterior pelvic ring would have been missed in eight cases (17%), if only CT had been used. Eighty-five percent of the patients with a posterior fracture had an osteoporosis. The majority of the cases suffered from a low energy trauma. Thirty-eight patients (83%) with positive clinical signs at the posterior pelvic ring actually had a fracture of the posterior pelvic ring in the MRI. The clinical examination proved to be equally effective to CT in detecting posterior pelvic ring fractures. CONCLUSION The significance of both, clinical examination and CT was confirmed in the detection of fractures in the posterior pelvic ring. MRI examination of the pelvis however, was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. Using MRI may be beneficial in select cases, especially when reduced bone density is suspected.

Determination of Femoral Neck Angle and Torsion Angle Utilizing a Novel Three-Dimensional Modeling and Analytical Technology Based on CT Datasets.

Introduction Exact knowledge of femoral neck inclination and torsion angles is important in recognizing, understanding and treating pathologic conditions in the hip joint. However, published results vary widely between different studies, which indicates that there are persistent difficulties in carrying out exact measurements. Methods A three dimensional modeling and analytical technology was used for the analysis of 1070 CT datasets of skeletally mature femurs. Individual femoral neck angles and torsion angles were precisely computed, in order to establish whether gender, age, body mass index and ethnicity influence femoral neck angles and torsion angles. Results The median femoral neck angle was 122.2° (range 100.1–146.2°, IQR 117.9–125.6°). There are significant gender (female 123.0° vs. male 121.5°; p = 0.007) and ethnic (Asian 123.2° vs. Caucasian 121.9°; p = 0.0009) differences. The median femoral torsion angle was 14.2° (-23.6–48.7°, IQR 7.4–20.4°). There are significant gender differences (female 16.4° vs. male 12.1°; p = 0.0001). Femoral retroversion was found in 7.8% of the subjects. Conclusion Precise femoral neck and torsion angles were obtained in over one thousand cases. Systematic deviations in measurement due to human error were eliminated by using automated high accuracy morphometric analysis. Small but significant gender and ethnic differences were found in femoral neck and torsion angles.

The influence of tibial morphology on the design of an anatomical tibial baseplate for TKA

BACKGROUND Finding the right balance between tibial coverage and minimal implant overhang is an important factor in TKA. Another significant cause of failure is component malrotation. METHODS An average master shape of the proximal tibia at TKA resection level was calculated using fine slice computed tomographies of 117 cadaveric knees. To find out whether alternate implant contours would be necessary depending on the patients body size, we established five subgroups to compare. CAD-Analysis was performed to simulate the overhang produced after ±4°/±7°/±10° rotation. RESULTS A master shape for the tibial resection cut (with a 5° posterior slope, 7 mm under lateral joint line) could be determined. Neither left vs. right knee joint, nor male vs. female nor the size subdivision appears to alter the calculated master shape significantly. The optimized shape allowing for ±4° of rotational freedom was found to be the best variant. CONCLUSIONS Valid methods have been obtained to design a two-dimensional average shape of the tibial plateau. The modifications described in this study might come in useful, when designing future implant designs. CLINICAL RELEVANCE An optimized fit at the tibial plateau and lower rates of component malrotation may result in better outcomes after TKA.

Foudroyant Course of an Extensive Clostridium septicum Gas Gangrene in a Diabetic Patient with Occult Carcinoma of the Colon

Background. Spontaneous gas gangrene is a rare disease in which Clostridium septicum frequently can be detected. After an incubation period of 5–48 hours, a very painful swelling is accompanied by a rapidly spreading toxic-infectious clinical picture ultimately leading to septic shock and multiple organ failure. We present a case of a completely documented rare infectious disease with triage findings including initial vital signs, initial medical findings, and the emergency lab., radiological, intraoperative, histopathological, microbiological, and postmortem results. After initial diagnosis of the underlying disease, the patient has been immediately transferred to the operating theatre. The laboratory findings reflect the devastating effect of toxin α which is a toxin typically produced by C. septicum. The patient presented both an anaemia and a manifest coagulopathy as well as an onset of multiple organ failure. Despite the aggressive medical and surgical measures that have been taken, this patient could not be saved. Discussion. The case presented vividly emphasises the difficulty to identify these cases early enough to save a patient. This documentation may help health care providers to identify this life threatening disease as early as possible in future cases.

Optimising care in a Swiss University Emergency Department by implementing a multicentre trauma register (TARN): report on evaluation, costs and benefits of trauma registries

Background Diagnostic and therapeutic approaches to trauma patients are, depending on experience, equipment and different therapeutic doctrines, subject to wide variations. The ability to compare trauma centres using a standardised trauma register helps to reveal unresolved systemic issues and simplifies the quality management in an Emergency Department (ED). Methods This study describes the selection, implementation and initial evaluation process of an international trauma register in a level 1 ED in a university hospital. Furthermore, first preliminary results and a literature review on the benefits are presented. Results The UK-based Trauma and Research Network (TARN) was found to be the most suitable register for a level 1 Swiss trauma centre. In contrast to the majority of the mortality-oriented registry systems, the database is capable of predicting the probability of survival for the referenced patients. Staff and technical adaptations were arranged and regular and reliable data acquisition and entry was ensured within 6 weeks. The University Hospital Bern has performed well from the very beginning and ranks within the top ten hospitals. Conclusions With TARN, an appropriate trauma register has been chosen. First preliminary results have been obtained, and it was concluded that there was a good match between TARNs patient cohort and the Bernese. On the basis of the data entered into the register, the hospital authorities can now plan and perform improvements on the individual aspects of trauma care. Due to an objective comparability, weak points can be identified, lessons can be learned and further improvement can be achieved.

Primary prosthetic replacement in per- and intertrochanteric fractures.

AbstractPurpose Hip arthroplasty is rarely indicated in the treatment of per- and intertrochanteric femur fractures. Although the majority of fractures are amenable to closed- or open reduction and internal fixation (CRIF/ORIF), in some patients the complexity of the fracture or other patient-related factors may cause the orthopaedic surgeon to consider arthroplasty as the treatment of choice. Decision-making is challenging, and a reliable score has not yet been established.ResultsReviewing literature, several predictors of inferior outcome after CRIF/ORIF in per- and intertrochanteric fractures such as age, gender, poor bone quality, hip osteoarthritis, operation time and postoperative weight-bearing restrictions have been identified. Based on the literature review, a novel Hamburg Per- and Intertrochanteric Fracture Score (HPIFS) is proposed to support decision-making for per- and intertrochanteric fracture treatment.ConclusionsCRIF/ORIF remain the workhorses in per- and intertrochanteric fracture management. Arthroplasty offers an advantageous treatment option for a well-defined patient and fracture collective. The HPIFS might support the decision-making process.

Partial tetraplegic syndrome as a complication of a mobilizing/manipulating procedure of the cervical spine in a man with Forestier's disease: a case report

IntroductionEven if performed by qualified physical therapists, spinal manipulation and mobilization can cause adverse events. This holds true particularly for the cervical spine. In light of the substantial risks, the benefits of cervical spine manipulation may be outweighed by the possibility of further injury.Case presentationWe present the case of a 56-year-old Caucasian man with Forestiers disease who went to see a physiotherapist to relieve his aching neck while on a holiday trip. Following the procedure, he was transferred to a local hospital with a partial tetraplegic syndrome due to a cervical 6/7 luxation fracture. Reportedly, the physiotherapist took neither a detailed history, nor adequate diagnostic measures.ConclusionsThis case highlights the potentially dangerous complications associated with cervical spine mobilization/manipulation. If guidelines concerning cervical spine mobilization and manipulation practices had been followed, this adverse event could have been avoided.