Oliver Hauschild

Open-wedge osteotomy using an internal plate fixator in patients with medial-compartment gonarthritis and varus malalignment: 3-year results with regard to preoperative arthroscopic and radiographic findings.

PURPOSE Our purpose was to evaluate the 3-year clinical results of patients with medial-compartment osteoarthritis of the knee and varus malalignment who underwent open-wedge high tibial osteotomy (HTO) with an internal plate fixator (TomoFix; Synthes, Solothurn, Switzerland). Clinical results are correlated with arthroscopic and radiographic findings at the time of surgery. METHODS This study included 69 patients with a minimum follow-up of 36 months who underwent open-wedge HTO for medial-compartment osteoarthritis of the knee. Knee function was assessed before surgery and at 6, 12, 24, and 36 months after HTO by use of subjective International Knee Documentation Committee and Lysholm scores. Arthroscopic findings before HTO and radiographic assessment of the metaphyseal deformity of the proximal tibia (tibial bone varus angle) were correlated with clinical outcome. RESULTS A significant continuous increase in International Knee Documentation Committee score from 47.25 ± 18.71 points before surgery to 72.72 ± 17.15 points at 36 months after HTO was found (P < .001). Grade of cartilage damage of the medial compartment and partial-thickness defects of the lateral compartment did not significantly influence clinical outcome (P > .05 at all time points). The tibial bone varus angle was correlated significantly with greater improvement and better clinical outcome after HTO (P < .01). The overall complication rate of 8.6% was mostly related to surgical causes; nevertheless, a high proportion of patients reported discomfort related to the implant at some point during the follow-up period (40.6%). CONCLUSIONS Open-wedge osteotomy by use of the TomoFix system leads to reliable 3-year results. Results do not depend on the severity of medial cartilage defects, whereas partial-thickness defects of the lateral compartment seem to be well tolerated. The prognostic relevance of patellofemoral cartilage defects remains unclear. Local irritation of the implant was observed in a significant number of patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Angioembolization for pelvic hemorrhage control: results from the German pelvic injury register.

BACKGROUND Hemorrhage from pelvic vessels is a potentially lethal complication of pelvic fractures. There is ongoing controversy on the ideal treatment strategy for patients with pelvic hemorrhage. The aim of the study was to analyze the role of angiography and subsequent embolization in patients with pelvic fractures and computed tomography scan-proven vascular injuries. METHODS The data from the prospective multicenter German pelvic injury registry were analyzed. Of 5,040 patients with pelvic fractures, 152 patients with associated vascular injuries were identified. Patients undergoing angioembolization (n = 17) were compared with those undergoing conventional measures for hemorrhage control (n = 135) with regard to demographic and physiologic parameters, fracture type distribution, and treatment measures. Outcome measures were mortality, requirement for blood transfusions, complications, and hospital length of stay. RESULTS Embolization and nonembolization groups were comparable with regard to age, sex, Injury Severity Score, Hannover Polytrauma Score, initial hemoglobin levels, blood pressure, fracture distribution, and conventional measures. Blood transfusion requirement was significantly prolonged in the embolization group. This resulted in a higher adult respiratory distress syndrome incidence and a tendency toward increased multiple organ failure rate in this group. There was no significant difference in overall mortality rate when compared with the nonembolization group (17.6% vs. 32.6%, respectively; p = 0.27). None of the patients undergoing embolization died from exsanguination when compared with 20.6% in the nonembolization group (p = 0.038). CONCLUSION Angioembolization alongside with conventional measures is an effective complementary means for hemorrhage control in patients sustaining pelvic fracture-related vascular lesions. It might prove even more effective when performed early enough to avoid prolonged blood transfusion requirement. Further studies without the mentioned limitations of the study are desired. LEVEL OF EVIDENCE Therapeutic study, level IV.

Effects of three-dimensional navigation on intraoperative management and early postoperative outcome after open reduction and internal fixation of displaced acetabular fractures.

BACKGROUND This study was conducted to evaluate whether intraoperative procedure and/or early postoperative results after open reduction and internal fixation (ORIF) of displaced acetabulum fractures are influenced by the use of a three-dimensional (3D) image intensifier in combination with a navigation system. METHODS From January 2004 until December 2008, all patients with acetabular fractures were followed prospectively. From January 2004 until October 2006, all operations were performed under fluoroscopic control using a conventional two-dimensional image intensifier. Since October 2006, we regularly operate acetabular fractures with the intraoperative use of a navigation system and a 3D image intensifier. Pre- and postoperative computed tomography scans of the affected hip were obtained in all patients as were standard anterior-posterior radiographs and ala- and obturator views. All data collection was performed according to the guidelines of the “German Pelvic fracture study group.” RESULTS In total, 68 patients with acetabular fractures were included in the study. A conventional image intensifier was used in 37 patients (group A) and a 3D image-based navigation was used in the remaining 31 patients (group B). In the navigated group, seven patients were assessed incapable of partial weight bearing. These patients underwent computer-assisted percutaneous screwing of their acetabular fracture. Using a navigation system in combination with a 3D image intensifier for ORIF of displaced acetabular fractures led to a significant increase in skin-to-skin time. Postoperative radiolographic analysis revealed an improvement in the quality of fracture reduction in the 3D navigation group. Navigation in combination with the 3D images of the ISO-C 3D limited the need for extended approaches. In addition, the complication rate in the navigated group was significantly lower. CONCLUSION We support the use of navigation systems and a 3D image intensifier as helpful tools during ORIF of displaced acetabular fractures. LEVEL OF EVIDENCE Therapeutic study, level III.

Identification of Risk Factors for Neurological Deficits in Patients With Pelvic Fractures

This multicenter register study was performed to define injury and fracture constellations that are at risk to develop pelvic associated neural lesions. Data of 3607 patients treated from 2004 to 2009 for pelvic fractures were evaluated for neurological deficits depending on Tile classification, pelvic injury configuration, and treatment.In 223 patients (6.5%), neurological lesions were diagnosed on the day of discharge from the hospital. The degree of instability of the pelvic fracture correlated with occurrence of nerve lesions. Rate of neurological dysfunction increased from 1.5% in type A fractures to 14.4% in type C fractures (P<.001). As the most endangered anatomical regions in pelvic fractures, the roots L5 (18.3%) and S1 (15.6%) and isolated peripheral nerves (19.2%) were identified. Patients sustaining complex pelvic trauma (7.85%) suffered from significantly more neurological dysfunctions (33.5%) compared to patients without peripelvic organ or soft tissue injuries (P<.001). Whereas stable type A3 sacral fractures were not associated with a different risk to develop neurological deficits (3.8%), unstable sacral fractures with the need for operative fixation showed an increased rate of accompanying nerve lesions (15.4%; P<.001). Twenty-one (11.5%) operative sacral stabilizations were supplemented with nerve root decompression (mainly S1). Neurological complications in the course of treatment were seen in 69 cases (1.9%).A high degree of instability, complex pelvic trauma, and unstable sacral fractures predispose for additional neurological deficits in patients with pelvic fractures.

Effect of Rotational Component Alignment on Clinical Outcome 5 to 7 Years After TKA With the Columbus Knee System.

The aim of the study was to examine the effects of rotational component alignment on outcome after total knee arthroplasty (TKA) with a minimum follow-up of 5 years. For this study, 96 patients were available for follow-up at a mean of 5.7 years after TKA. Computed tomography scans were available in 55 patients. Outcome (Oxford Knee Score [KSS], Knee Injury and Osteoarthritis Outcome Score [KOOS], 36-item Short Form Health Survey) was correlated with postoperative femoral and tibial component malrotation or femorotibial rotational alignment mismatch. Results showed that femoral or tibial component malrotation or femorotibial mismatch were present in 15.5%, 38.2%, and 29.1% of patients, respectively. Although femoral componoent malrotation was associated with significantly poorer, KSS and KOOS scores, outcome was comparable for patients with or without tibial component malrotation or femorotibial mismatch. In conclusion, both internal and external rotational femoral malalignment exceeding 3° is associated with significantly poorer subjective and objective outcome 5 to 7 years after TKA. Tibial component malrotation and femorotibial mismatch were more common, but did not significantly compromise outcome. [Orthopedics. 2016; 39(3):S50-S55.].

Hybrid Imaging of Peripheral Skeletal Disease by SPECT/High-Resolution Flat-Panel CT

The aim of this study was to determine the impact of high-resolution cone-beam CT with flat-panel detectors on the interpretation of bone SPECT in diseases of the peripheral skeleton. Methods: Forty-one consecutive patients with peripheral skeletal disease were examined with a SPECT/high-resolution CT system providing isotropic voxels of 0.33 × 0.33 × 0.33 mm. High-resolution images were retrospectively analyzed by 2 readers and compared with low-resolution images obtained by filtering the high-resolution images to a lower resolution. Results: SPECT/high-resolution CT demonstrated higher diagnostic confidence scores (1.98 ± 0.27 vs. 1.3 ± 0.45, P < 0.01) and better interobserver agreement (κ = 0.5 vs. 0.2) than SPECT/low-resolution CT. The diagnosis made by SPECT/high-resolution CT was in agreement with the final clinical diagnosis in 95% (reader 1) and 90% (reader 2) of the cases, as compared with 59% (reader 1) and 60% (reader 2) of the cases for SPECT/low-resolution CT (P < 0.01). Conclusion: High-resolution flat-panel CT has the potential to significantly improve SPECT/CT imaging in diseases of the peripheral skeleton.

Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

PURPOSE The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts. MATERIAL AND METHODS In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study. RESULTS Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated. CONCLUSION Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.

Management of ipsilateral femoral neck and shaft fractures

PURPOSE The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts. MATERIAL AND METHODS In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study. RESULTS Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated. CONCLUSION Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.

Tibial cleaning method for cemented total knee arthroplasty: An experimental study

Background: The survival rate of cemented knee prosthesis depends among other factors on optimal cement-bone contact, nevertheless no standard exists for cementing technique of tibial components. The aim of this study was to determine which tibial surface preparation technique leads to the best bone-cement contact. Materials and Methods: Human tibial plateau specimens were cleaned in four different ways before cementing: a) no cleaning, b) manual syringe irrigation, c) fracture brush cleaning, and d) pulsatile jet-lavage. The specimens were cut into transverse sections and the bone cement contact distance was calculated for every 10 mm and the cement penetration depth was measured. Both values were statistically analyzed (ANOVA). Results: The longest bone-cement contact (62 mm) was seen after PJL, the shortest (10.6 mm) after no cleaning at all. The deepest cement penetration (4.1 mm) again was seen after PJL, the least (0.7 mm) after no cleaning. Statistically, PJL yielded the longest bone-cement contact and deepest cement penetration. Conclusion: The results supports the use of pulsatile jet-lavage before cementing tibial components in knee arthroplasty.

Oblique Axis Body Fracture: An Unstable Subtype of Anderson Type III Odontoid Fractures-Apropos of Two Cases.

Purpose. Anderson type III odontoid fractures have traditionally been considered stable and treated conservatively. However, unstable cases with unfavorable results following conservative treatment have been reported. Methods. We present the cases of two patients who sustained minimally displaced Anderson type III fractures with a characteristic fracture pattern that we refer to as “oblique type axis body fracture.” Results. The female patients aged 90 and 72 years, respectively, were both diagnosed with minimally displaced Anderson type III fractures. Both fractures had a characteristic “oblique type” fracture pattern. The first patient was treated conservatively with cervical spine immobilization in a semirigid collar. However, gross displacement was noted at the 6-week follow-up visit. The second patient was therefore treated operatively by C1–C3/4 posterior fusion and the course was uneventful. Conclusions. Oblique type axis body fractures resemble a highly unstable subtype of Anderson type III fractures with the potential of severe secondary deformity following conservative treatment, irrespective of initial grade of displacement. The authors therefore warrant a high index of suspicion for this injury and suggest early operative stabilization.