Ralf Rosenberger

Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up.

Objective: To evaluate radiological and functional outcome in patients treated with minimally invasive transiliac plate osteosynthesis for unstable pelvic injuries. Design: Retrospective analysis of a prospective treatment protocol in a consecutive patient series. Setting: Level 1 trauma center. Patients: Between January 1998 and December 2005, 31 patients with type C injuries of the pelvic ring were treated with minimally invasive transiliac plate osteosynthesis. According to the AO classification, 16 patients had a C1-injury, 9 had a C2 fracture, and 6 patients sustained a C3 injury of the pelvic ring. Anterior-posterior, inlet, and outlet radiographs were obtained preoperatively, immediately postoperatively, and during follow-up. Clinical outcome was determined according to the Hannover pelvic outcome score. Intervention: Posterior plate osteosynthesis for type C injuries of the pelvic ring. Main Outcome Measurement: Preoperative and postoperative dislocation of the posterior pelvic ring, loss of reduction, implant failure, implant removal, clinical results of the pelvic injury and general limitations following the trauma. Results: Maximum average dislocation of the posterior pelvic ring was 16.1 mm preoperatively; postoperatively, it was 6.1 mm. A total of 23 patients (74.2%) could be followed up after an average of 20 months (range 7-57 months). Seven patients underwent follow-up treatment at other hospitals closer to their respective residences, whereas 1 patient passed away in the early postoperative phase due to multiorgan failure. Loss of reduction occurred in 2 cases. The clinical outcome regarding the pelvis was very good in 8 cases, good in 9 cases, fair in 4 cases, and poor in 2 cases. Social reintegration according to the Hannover pelvic outcome score was complete in 9 cases, poor in 10 cases, and incomplete in 10 cases. Conclusion: Posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac joint in a unilateral injury, as well as a higher rate of symptomatic hardware.

Computerassistierte minimalinvasive Therapie der Osteochondrosis dissecans tali Computer-Assisted Minimally Invasive Treatment of Osteochondrosis Dissecans of the Talus

ZusammenfassungOperationszielRevaskularisation der Nekrosezone im Talus und Anregung der Knochenneubildung bei Schonung des talaren Knorpelüberzugs durch computerassistierte minimalinvasive Anbohrung oder retrograde Spongiosaunterfütterung des osteochondrotischen Herdes.IndikationenOsteochondrosis dissecans tali Stadium I–III nach Berndt & Harty.KontraindikationenOsteochondrosis dissecans tali Stadium IV nach Berndt & Harty.Allgemeine Kontraindikationen wie z. B. schlechte Haut- und Weichteilverhältnisse oder schlechter Allgemeinzustand.OperationstechnikPräoperativ: Anpassung einer abnehmbaren Schale für das obere Sprunggelenk (OSG-Fixationsschale), anschließend Computertomographie des Sprunggelenks mit angelegter OSG-Fixationsschale. Planung der Lage des zentralen Bohrstifts im Talus mit einem Navigationssystem im Labor. Einstellung und Arretierung der Zielvorrichtung.Intraoperativ: Anlage der sterilisierten OSG-Fixationsschale. Retrograde Platzierung des 2,4-mm-Kirschner-Drahts über die arretierte Zielvorrichtung. Bildwandlerkontrolle der Lage des Kirschner-Drahts.Arthroskopie des OSG; je nach Befund werden weitere Parallelbohrungen gesetzt oder eine retrograde Spongiosaplastik mit Spongiosaentnahme aus dem Kalkaneus durchgeführt.WeiterbehandlungBei retrograder Anbohrung/Parallelbohrung: 1 Woche Teilbelastung mit 30 kg.Bei retrograder Spongiosaplastik: 4 Wochen Teilbelastung mit 15 kg, dann 2 weitere Wochen Teilbelastung mit 30 kg.Physiotherapie.ErgebnisseVon Dezember 1999 bis Januar 2005 wurde bei 41 Patienten eine computerassistierte Behandlung der Osteochondrosis dissecans tali zur retrograden Anbohrung oder retrograden Spongiosaplastik gewählt. Bei 39 der 41 Patienten wurde die osteochondrale Läsion—wie im postoperativen Magnetresonanztomogramm (MRT) verifiziert—erreicht, d. h., der Bohrkanal führte in die Läsion. In zwei Fällen lag intraoperativ ein nicht behebbarer Materialfehler vor, so dass die vorgestellte Methode an 39 Patienten angewendet werden konnte. Für die ersten 15 Patienten, die eine retrograde Anbohrung/Parallelbohrung mit begleitender Sprunggelenkarthroskopie erhielten und keine retrograde Spongiosaplastik, werden die 1-Jahres-Ergebnisse anhand der MRT-Verlaufskontrolle (Bohrkanallage, Vitalitätsbeurteilung des osteochondrotischen Areals) und eines klinischen Scorings präsentiert. Die vier Frauen und elf Männer waren durchschnittlich 34,1 Jahre alt (14–55 Jahre). Im radiologischen Vergleich zwischen den prä- und postoperativen Stadien der Osteochondrosis dissecans ließ sich bei 46,7% der Patienten eine Verbesserung des Stadiums nach Berndt & Harty nachweisen. Bei 40,0% zeigte sich im MRT postoperativ das gleiche Osteochondrosis-dissecans-Stadium, und bei 13,3% verschlechterte es sich um einen Grad.In der klinischen Nachuntersuchung betrug der AOFAS-Score im Mittel 88,9 Punkte.AbstractObjectiveRevascularization of areas of necrosis in the talus and stimulation of bone regeneration whilst protecting the talar hyaline cartilage using computer-assisted minimally invasive drilling or retrograde cancellous bone relining of the osteochondrotic zone.IndicationsOsteochondrosis dissecans of the talus, Berndt & Harty stages I–III.ContraindicationsOsteochondrosis dissecans of the talus, Berndt & Harty stage IV.General contraindications such as poor skin and soft-tissue conditions or poor general condition.Surgical TechniqueBefore the operation: fitting a removable cast for the ankle (ankle fixation cast), then computed tomography of the ankle with the ankle fixation cast fitted. Planning the site of the central Kirschner wire in the talus using a navigation system in the laboratory. Adjusting and locking the aiming device.Intraoperative procedures: fitting the sterilized ankle fixation cast. Retrograde placement of the 2.4-mm Kirschner wire through the locked aiming device. Check on the position of the Kirschner wire using an image intensifier.Arthroscopy of the ankle; further parallel holes may then be drilled depending on the findings or retrograde cancellous bone grafting may be performed by harvesting cancellous bone from the calcaneus.Postoperative ManagementFor retrograde drilling/parallel drilling: 1 week of partial weight bearing at 30 kg.For retrograde cancellous bone grafting: 4 weeks of partial weight bearing at 15 kg, then 2 more weeks of partial weight bearing at 30 kg.Physiotherapy.ResultsFrom December 1999 to January 2005, 41 patients with osteochondrosis dissecans of the talus were selected for computer-assisted treatment by retrograde drilling or retrograde cancellous bone grafting. In 39 of the 41 patients, the osteochondral lesion—as verified by postoperative magnetic resonance imaging (MRI)—was accessed, i.e., the drilled hole led to the lesion. In two cases, irreparable flaws in the materials were discovered intraoperatively, so that the above method was only performed on 39 patients. The 1-year results for the first 15 patients treated with retrograde drilling/parallel drilling and concomitant ankle arthroscopy without retrograde cancellous bone graft are presented here based on the follow-up MRI (position of drill hole, assessment of vitality of the area of osteochondritis) and a clinical score. The four women and eleven men were, on average, 34.1 years old (14–55 years). In the radiologic comparison of the pre- and postoperative stages of the osteochondritis dissecans, 46.7% of patients showed an improvement in the Berndt & Harty stage. 40.0% showed the same osteochondrosis dissecans stage in the postoperative MRI, and in 13.3% it deteriorated by one grade.In the clinical follow-up examination, the AOFAS Score averaged 88.9 points.

Revision anterior cruciate ligament reconstruction: an update

With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.

Computerassistierte minimalinvasive Therapie der Osteochondrosis dissecans tali

ZusammenfassungOperationszielRevaskularisation der Nekrosezone im Talus und Anregung der Knochenneubildung bei Schonung des talaren Knorpelüberzugs durch computerassistierte minimalinvasive Anbohrung oder retrograde Spongiosaunterfütterung des osteochondrotischen Herdes.IndikationenOsteochondrosis dissecans tali Stadium I–III nach Berndt & Harty.KontraindikationenOsteochondrosis dissecans tali Stadium IV nach Berndt & Harty.Allgemeine Kontraindikationen wie z. B. schlechte Haut- und Weichteilverhältnisse oder schlechter Allgemeinzustand.OperationstechnikPräoperativ: Anpassung einer abnehmbaren Schale für das obere Sprunggelenk (OSG-Fixationsschale), anschließend Computertomographie des Sprunggelenks mit angelegter OSG-Fixationsschale. Planung der Lage des zentralen Bohrstifts im Talus mit einem Navigationssystem im Labor. Einstellung und Arretierung der Zielvorrichtung.Intraoperativ: Anlage der sterilisierten OSG-Fixationsschale. Retrograde Platzierung des 2,4-mm-Kirschner-Drahts über die arretierte Zielvorrichtung. Bildwandlerkontrolle der Lage des Kirschner-Drahts.Arthroskopie des OSG; je nach Befund werden weitere Parallelbohrungen gesetzt oder eine retrograde Spongiosaplastik mit Spongiosaentnahme aus dem Kalkaneus durchgeführt.WeiterbehandlungBei retrograder Anbohrung/Parallelbohrung: 1 Woche Teilbelastung mit 30 kg.Bei retrograder Spongiosaplastik: 4 Wochen Teilbelastung mit 15 kg, dann 2 weitere Wochen Teilbelastung mit 30 kg.Physiotherapie.ErgebnisseVon Dezember 1999 bis Januar 2005 wurde bei 41 Patienten eine computerassistierte Behandlung der Osteochondrosis dissecans tali zur retrograden Anbohrung oder retrograden Spongiosaplastik gewählt. Bei 39 der 41 Patienten wurde die osteochondrale Läsion—wie im postoperativen Magnetresonanztomogramm (MRT) verifiziert—erreicht, d. h., der Bohrkanal führte in die Läsion. In zwei Fällen lag intraoperativ ein nicht behebbarer Materialfehler vor, so dass die vorgestellte Methode an 39 Patienten angewendet werden konnte. Für die ersten 15 Patienten, die eine retrograde Anbohrung/Parallelbohrung mit begleitender Sprunggelenkarthroskopie erhielten und keine retrograde Spongiosaplastik, werden die 1-Jahres-Ergebnisse anhand der MRT-Verlaufskontrolle (Bohrkanallage, Vitalitätsbeurteilung des osteochondrotischen Areals) und eines klinischen Scorings präsentiert. Die vier Frauen und elf Männer waren durchschnittlich 34,1 Jahre alt (14–55 Jahre). Im radiologischen Vergleich zwischen den prä- und postoperativen Stadien der Osteochondrosis dissecans ließ sich bei 46,7% der Patienten eine Verbesserung des Stadiums nach Berndt & Harty nachweisen. Bei 40,0% zeigte sich im MRT postoperativ das gleiche Osteochondrosis-dissecans-Stadium, und bei 13,3% verschlechterte es sich um einen Grad.In der klinischen Nachuntersuchung betrug der AOFAS-Score im Mittel 88,9 Punkte.AbstractObjectiveRevascularization of areas of necrosis in the talus and stimulation of bone regeneration whilst protecting the talar hyaline cartilage using computer-assisted minimally invasive drilling or retrograde cancellous bone relining of the osteochondrotic zone.IndicationsOsteochondrosis dissecans of the talus, Berndt & Harty stages I–III.ContraindicationsOsteochondrosis dissecans of the talus, Berndt & Harty stage IV.General contraindications such as poor skin and soft-tissue conditions or poor general condition.Surgical TechniqueBefore the operation: fitting a removable cast for the ankle (ankle fixation cast), then computed tomography of the ankle with the ankle fixation cast fitted. Planning the site of the central Kirschner wire in the talus using a navigation system in the laboratory. Adjusting and locking the aiming device.Intraoperative procedures: fitting the sterilized ankle fixation cast. Retrograde placement of the 2.4-mm Kirschner wire through the locked aiming device. Check on the position of the Kirschner wire using an image intensifier.Arthroscopy of the ankle; further parallel holes may then be drilled depending on the findings or retrograde cancellous bone grafting may be performed by harvesting cancellous bone from the calcaneus.Postoperative ManagementFor retrograde drilling/parallel drilling: 1 week of partial weight bearing at 30 kg.For retrograde cancellous bone grafting: 4 weeks of partial weight bearing at 15 kg, then 2 more weeks of partial weight bearing at 30 kg.Physiotherapy.ResultsFrom December 1999 to January 2005, 41 patients with osteochondrosis dissecans of the talus were selected for computer-assisted treatment by retrograde drilling or retrograde cancellous bone grafting. In 39 of the 41 patients, the osteochondral lesion—as verified by postoperative magnetic resonance imaging (MRI)—was accessed, i.e., the drilled hole led to the lesion. In two cases, irreparable flaws in the materials were discovered intraoperatively, so that the above method was only performed on 39 patients. The 1-year results for the first 15 patients treated with retrograde drilling/parallel drilling and concomitant ankle arthroscopy without retrograde cancellous bone graft are presented here based on the follow-up MRI (position of drill hole, assessment of vitality of the area of osteochondritis) and a clinical score. The four women and eleven men were, on average, 34.1 years old (14–55 years). In the radiologic comparison of the pre- and postoperative stages of the osteochondritis dissecans, 46.7% of patients showed an improvement in the Berndt & Harty stage. 40.0% showed the same osteochondrosis dissecans stage in the postoperative MRI, and in 13.3% it deteriorated by one grade.In the clinical follow-up examination, the AOFAS Score averaged 88.9 points.

Stabilisierung des dorsalen Beckenrings mit eingeschobener Platte

ZusammenfassungOperationszielMinimalinvasive Stabilisierung des dorsalen Beckenrings bei Typ-C-Verletzungen.IndikationenInstabile Typ-C-Verletzungen des Beckenrings, ein- oder beidseitig.−Transsymphysär-transsakrale Instabilität.−Transpubisch-transsakrale Instabilität.−Transsymphysär-transsakroiliakale Instabilität.−Transpubisch-transsakroiliakale Instabilität.KontraindikationenFrakturen im kindlichen Alter.Trümmerfrakturen des Os ilium.Patienten mit schlechten Haut- und Weichteilverhältnissen und lokalen Infekten.Sakrumfrakturen mit neurologischem Defizit stellen keine Kontraindikation dar, da diese unter Distraktion dekomprimiert und in Neutralstellung verplattet werden.OperationstechnikÜber zwei kurze, senkrechte Hautschnitte nutförmige Osteotomie der Spina iliaca posterior superior beidseits. Tunnelierung der Rückenmuskulatur bis zur Gegenseite. Längenbestimmung einer 4,5-mm-Beckenrekonstruktionsplatte. Biegen der Platte über dem lateralen vierten Loch um etwa 70°. Einschieben der Platte und Anbiegen des freien Plattenendes. Besetzen der Plattenlöcher mit Spongiosaschrauben. Refixation der osteotomierten Knochenfragmente über der Platte mit Kleinfragment-Spongiosaschauben.Ergebnisse34 Patienten mit einem Durchschnittsalter von 42,6 Jahren wurden im Zeitraum von 1998 bis 2005 mit der beschriebenen Methode behandelt, 18 waren polytraumatisiert. Bei 28 Patienten wurde auch der ventrale Beckenring operativ stabilisiert, in elf Fällen als erster Eingriff im Zuge eines zweizeitigen Vorgehens. 25 Patienten konnten nach durchschnittlich 17 Monaten klinisch und radiologisch nachuntersucht werden.In der nativradiologischen Kontrolle nach 1 Jahr zeigte sich bei 16 Patienten ein sehr gutes Ergebnis (maximale Dislokation im dorsalen Beckenring < 5 mm) und bei acht Patienten ein gutes Ergebnis (Dislokation 5–10 mm). In zwei Fällen kam es im 1. postoperativen Jahr zu einem Korrekturverlust eines unmittelbar postoperativ sehr guten Repositionsergebnisses (Dislokation < 5 mm), wobei einmal die Dislokation im Ausheilungsbild < 10 mm betrug, in einem weiteren Fall 19 mm.Ein Patient stellte sich 11 Wochen postoperativ mit einem Spätinfekt vor, der nach Implantatentfernung und Wunddébridement ausheilte. Bei zwei weiteren Patienten mussten in Lokalanästhesie jeweils in der 10. postoperativen Woche prominente Schraubenköpfe nach Refixation der osteotomierten Spinae iliacae posteriores superiores entfernt werden. Auch bei diesen beiden Patienten war der weitere Verlauf unauffällig. Bei einem Patienten wurden die Implantate bereits im 5. postoperativen Monat bei reizlosen Weichteilen entfernt, da er angab, in der Tiefe Wärme- und Kältesensationen zu verspüren. Die Platten wurden in weiteren sechs Fällen nach Ausheilung der Fraktur/Instabilität nach durchschnittlich 9–12 Monaten entfernt, in den anderen Fällen wurden sie belassen.AbstractObjectiveMinimally invasive stabilization of the posterior pelvic ring in type C injuries.IndicationsUnstable type C injuries of the pelvic ring, uni- or bilateral.−Transsymphyseal-transsacral instability.−Transpubic-transsacral instability.−Transsymphyseal-transsacroiliac instability.−Transpubic-transsacroiliac instability.ContraindicationsFractures in childhood.Comminuted fractures of the ilium.Patients with skin and soft tissues in a poor condition and/or local infection.Sacral fractures with a neurologic deficit are not a contraindication because they can be decompressed by distraction and stabilized in a neutral position by plate fixation.Surgical TechniqueNut-shaped osteotomy of the posterior superior iliac spine bilaterally through two short, vertical skin incisions. Tunneling through the muscles of the back to the opposite side. Length measurement for a 4.5-mm pelvic reconstruction plate. The plate is bent by about 70° over the fourth lateral hole. Slide-insertion of the plate and bending of the free plate end for close fit. Cancellous bone screws are inserted into the plate holes. Refixation of the osteotomized bone fragments over the plate with small-fragment, cancellous bone screws.Results34 patients with an average age of 42.6 years were treated according to the described method from 1998 to 2005; 18 were polytraumatized. The anterior pelvic ring was also stabilized by surgery in 28 patients for eleven of whom it was the first intervention in a two-stage procedure. 25 papercutients were available for clinical and radiologic follow-up at 17 months, on average.The plain radiographs after 1 year showed a very good outcome in 16 patients (maximal displacement of the posterior pelvic ring < 5 mm) and a good outcome in eight patients (displacement of 5–10 mm). In two patients there was loss of reduction in the 1st postoperative year despite a very good reduction result immediately postoperatively (dislocation < 5 mm), whereby the dislocation for one patient was < 10 mm on the final radiograph and 19 mm for the other.One patient presented with a late infection 11 weeks postoperatively that healed after implant removal and wound debridement. In two other patients, prominent screw heads, which were used for refixation of the osteotomized posterior superior iliac spine, had to be removed under local anesthesia in the 10th postoperative week. The further course for these two patients was uneventful. In one patient the implants were retrieved in the 5th postoperative month because the patient complained of internal hot and cold sensations although the soft tissue was not irritated. The plates were removed in six other cases after the fracture/instability had healed, i. e., after 9–12 months, on average; in all other cases the implants were left in situ.

Stereotactic CT-guided Percutaneous Stabilization of Posterior Pelvic Ring Fractures: A Preclinical Cadaver Study

PURPOSE To determine the accuracy of frameless stereotactic computed tomographic (CT)-guided wire placement for percutaneous fixation of posterior pelvic ring fractures in human cadavers. MATERIALS AND METHODS Four intact human cadavers were fixated in a double-vacuum immobilization system. A 2.5-mm helical CT dataset was obtained and transferred to the three-dimensional (3D) navigation system. In every specimen, two paths on each side (total number, 16) were defined on multiplanar reconstructions of the 3D CT datasets, simulating fixation of the iliosacral joint. An aiming device was adjusted according to the plan, and a 2.5-mm pin was advanced through the aiming device to the precalculated target point. To determine the accuracy of pin placement, a control CT scan was co-registered to the planning CT scan (with the planned trajectories). The distance between the planned and achieved positions of the pins (3D accuracy) was calculated in millimeters. RESULTS The mean 3D accuracy was 1.84 mm +/- 0.9 (standard deviation) at the bone entrance point and 2.5 mm +/- 1.2 at the target, as determined with image fusion between the planning CT scan and the control CT scan with the pins in place. CONCLUSIONS The described technique enables accurate placement of pins in the pelvis and may be useful for percutaneous orthopedic procedures.

Biochemical, biomechanical and histological properties of osteoarthritic porcine knee cartilage: implications for osteochondral transplantation

IntroductionCartilage lesions of the knee joint are frequently observed during arthroscopy and when surgical intervention is required, osteochondral autograft procedures are an established method of treatment. Frequently lesions are located on the medial femoral condyle (MFC), and typical donor locations for osteochondral grafts include the medial and lateral patellar groove. This technique provides good results, even when the quality of cartilage transplanted from an osteoarthritic joint is doubtful. This study characterizes biological, biomechanical and histological properties of cartilage explants from the patellar groove harvested from osteoarthritic joints.Materials and methodsCylindrical cartilage explants were harvested from the arthritic areas of the MFC as well as normal appearing regions of the medial and lateral patellar groove from porcine joints revealing various grades of osteoarthritis. Matrix synthesis rates were determined, and explants were investigated by mechanical testing and histology.ResultsArticular cartilage obtained from the typical donor areas of the medial and lateral patellar groove provided constant enhanced material properties, matrix synthesis rates and histological appearance compared to samples from the arthritic lesions of the MFC, even in joints with end-stage osteoarthritis of the MFC. No significant difference was found between patellar groove cartilage samples harvested from joints with different stages of osteoarthritis.ConclusionOur findings demonstrate that healthy appearing cartilage from the patellar groove does not undergo significant alterations in material properties due to the arthritic milieu present in osteoarthritic joints. Accordingly these locations provide a source of functional tissue for transplant procedures even in joints with end-stage osteoarthritis.

Stabilization of the posterior pelvic ring with a slide-insertion plate.

ZusammenfassungOperationszielMinimalinvasive Stabilisierung des dorsalen Beckenrings bei Typ-C-Verletzungen.IndikationenInstabile Typ-C-Verletzungen des Beckenrings, ein- oder beidseitig.−Transsymphysär-transsakrale Instabilität.−Transpubisch-transsakrale Instabilität.−Transsymphysär-transsakroiliakale Instabilität.−Transpubisch-transsakroiliakale Instabilität.KontraindikationenFrakturen im kindlichen Alter.Trümmerfrakturen des Os ilium.Patienten mit schlechten Haut- und Weichteilverhältnissen und lokalen Infekten.Sakrumfrakturen mit neurologischem Defizit stellen keine Kontraindikation dar, da diese unter Distraktion dekomprimiert und in Neutralstellung verplattet werden.OperationstechnikÜber zwei kurze, senkrechte Hautschnitte nutförmige Osteotomie der Spina iliaca posterior superior beidseits. Tunnelierung der Rückenmuskulatur bis zur Gegenseite. Längenbestimmung einer 4,5-mm-Beckenrekonstruktionsplatte. Biegen der Platte über dem lateralen vierten Loch um etwa 70°. Einschieben der Platte und Anbiegen des freien Plattenendes. Besetzen der Plattenlöcher mit Spongiosaschrauben. Refixation der osteotomierten Knochenfragmente über der Platte mit Kleinfragment-Spongiosaschauben.Ergebnisse34 Patienten mit einem Durchschnittsalter von 42,6 Jahren wurden im Zeitraum von 1998 bis 2005 mit der beschriebenen Methode behandelt, 18 waren polytraumatisiert. Bei 28 Patienten wurde auch der ventrale Beckenring operativ stabilisiert, in elf Fällen als erster Eingriff im Zuge eines zweizeitigen Vorgehens. 25 Patienten konnten nach durchschnittlich 17 Monaten klinisch und radiologisch nachuntersucht werden.In der nativradiologischen Kontrolle nach 1 Jahr zeigte sich bei 16 Patienten ein sehr gutes Ergebnis (maximale Dislokation im dorsalen Beckenring < 5 mm) und bei acht Patienten ein gutes Ergebnis (Dislokation 5–10 mm). In zwei Fällen kam es im 1. postoperativen Jahr zu einem Korrekturverlust eines unmittelbar postoperativ sehr guten Repositionsergebnisses (Dislokation < 5 mm), wobei einmal die Dislokation im Ausheilungsbild < 10 mm betrug, in einem weiteren Fall 19 mm.Ein Patient stellte sich 11 Wochen postoperativ mit einem Spätinfekt vor, der nach Implantatentfernung und Wunddébridement ausheilte. Bei zwei weiteren Patienten mussten in Lokalanästhesie jeweils in der 10. postoperativen Woche prominente Schraubenköpfe nach Refixation der osteotomierten Spinae iliacae posteriores superiores entfernt werden. Auch bei diesen beiden Patienten war der weitere Verlauf unauffällig. Bei einem Patienten wurden die Implantate bereits im 5. postoperativen Monat bei reizlosen Weichteilen entfernt, da er angab, in der Tiefe Wärme- und Kältesensationen zu verspüren. Die Platten wurden in weiteren sechs Fällen nach Ausheilung der Fraktur/Instabilität nach durchschnittlich 9–12 Monaten entfernt, in den anderen Fällen wurden sie belassen.AbstractObjectiveMinimally invasive stabilization of the posterior pelvic ring in type C injuries.IndicationsUnstable type C injuries of the pelvic ring, uni- or bilateral.−Transsymphyseal-transsacral instability.−Transpubic-transsacral instability.−Transsymphyseal-transsacroiliac instability.−Transpubic-transsacroiliac instability.ContraindicationsFractures in childhood.Comminuted fractures of the ilium.Patients with skin and soft tissues in a poor condition and/or local infection.Sacral fractures with a neurologic deficit are not a contraindication because they can be decompressed by distraction and stabilized in a neutral position by plate fixation.Surgical TechniqueNut-shaped osteotomy of the posterior superior iliac spine bilaterally through two short, vertical skin incisions. Tunneling through the muscles of the back to the opposite side. Length measurement for a 4.5-mm pelvic reconstruction plate. The plate is bent by about 70° over the fourth lateral hole. Slide-insertion of the plate and bending of the free plate end for close fit. Cancellous bone screws are inserted into the plate holes. Refixation of the osteotomized bone fragments over the plate with small-fragment, cancellous bone screws.Results34 patients with an average age of 42.6 years were treated according to the described method from 1998 to 2005; 18 were polytraumatized. The anterior pelvic ring was also stabilized by surgery in 28 patients for eleven of whom it was the first intervention in a two-stage procedure. 25 papercutients were available for clinical and radiologic follow-up at 17 months, on average.The plain radiographs after 1 year showed a very good outcome in 16 patients (maximal displacement of the posterior pelvic ring < 5 mm) and a good outcome in eight patients (displacement of 5–10 mm). In two patients there was loss of reduction in the 1st postoperative year despite a very good reduction result immediately postoperatively (dislocation < 5 mm), whereby the dislocation for one patient was < 10 mm on the final radiograph and 19 mm for the other.One patient presented with a late infection 11 weeks postoperatively that healed after implant removal and wound debridement. In two other patients, prominent screw heads, which were used for refixation of the osteotomized posterior superior iliac spine, had to be removed under local anesthesia in the 10th postoperative week. The further course for these two patients was uneventful. In one patient the implants were retrieved in the 5th postoperative month because the patient complained of internal hot and cold sensations although the soft tissue was not irritated. The plates were removed in six other cases after the fracture/instability had healed, i. e., after 9–12 months, on average; in all other cases the implants were left in situ.

Marknagelung distaler Unterschenkelfrakturen am Beispiel des ExpertTM Tibianagels

OBJECTIVE Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare and to maintain joint mobility. Good bony healing in closed and open fractures. INDICATIONS Closed and open fractures of the tibia and complete lower leg fractures distal to the isthmus (AO 42), extraarticular fractures of the distal tibia (AO 43 A1/A2/A3), segmental fractures of the tibia with a fracture in the distal tibia, and certain intraarticular fractures of the distal tibia without impression of the joint line with the use of additional implants (AO 43 C1) CONTRAINDICATIONS Patient in reduced general condition (e.g., bed ridden), flexion of the knee of less than 90°, patients with knee arthroplasty of the affected leg, infection in the area of the nails insertion, infection of the tibial cavity, complex articular fractures of the proximal or distal tibia with joint depression. SURGICAL TECHNIQUE Closed reduction of the fracture preferably on a fracture table or using a distractor or an external fixation frame. If necessary, use pointed reduction clamps or sterile drapery. In some cases, additional implants like percutaneous small fragment screws, poller screws or k-wires are helpful. Open reduction is rarely necessary and must be avoided. Opening of the proximal tibia in line with the medullary canal. Canulated insertion of the Expert(TM) tibia nail (ETN; Synthes GmbH, Oberdorf, Switzerland) with reaming of the medullary canal. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device. POSTOPERATIVE MANAGEMENT Immediate mobilization of ankle and knee joint. Mobilization with 20 kg weight-bearing with crutches. X-ray control 6 weeks postoperatively and increased weight-bearing depending on the fracture status. In cases with simple fractures, good bony contact, or transverse fracture pattern, full weight-bearing at the end of week 6 is targeted. RESULTS Between July 2004 and May 2005, 180 patients were included in a multicenter study. The follow-up rate was 81% after 1 year. Of these, 91 fractures (50.6%) were located in the distal third of the tibia. In this segment, the rate of delayed union was 10.6%. Malalignment of > 5° was observed in 5.4%. A secondary malalignment after initial good reduction was detected in only 1.1% of all cases. The implant-specific risk for screw breakage was 3.2%. One patient sustained a deep infection. If additional fibula plating was performed an 8-fold higher risk for delayed bone healing was observed (95%CI: 2.9-21.2, p< 0.001). If the fracture of the fibula was at the same height as on the tibia, the risk for delayed healing was even 14-fold (95% CI: 3.4-62.5, p< 0.001). Biomechanically plating of the fibula does not increase stability in suprasyndesmal distal tibia-fibular fractures treated with an intramedullary nail. Using the ETN with its optimized locking options, fibula plating is not recommended, thus, avoiding soft tissue problems and potentially delayed bone healing.

The impact of coagulopathy on the outcome of traumatic epidural hematoma

PurposeTo evaluate the impact of trauma-associated coagulation disorders on the neurological outcome in patients with traumatic epidural hematoma undergoing surgical or non-surgical treatment. A retrospective analysis was performed using prospectively collected data in a consecutive patient series from a level 1 trauma center.MethodsEighty-five patients with traumatic epidural hematoma were identified out of 1,633 patients admitted to our emergency room with traumatic head injuries between October 2004 and December 2008. The following prospectively assessed parameters were analyzed: Glasgow Coma Scale, coagulopathy, presence of skull fractures, additional injuries, the Injury Severity Score, hematoma volume and thickness at admission, hematoma volume progression over time and neurologic symptoms. Furthermore, patients were grouped based on whether they had undergone surgical or non-surgical treatment of the epidural hematoma. Clinical outcome was determined according to the Glasgow Outcome Score (GOS) at hospital discharge.ResultsPatients with coagulopathy showed significantly lower GOS values compared to patients with intact blood coagulation. Initial and progressive hematoma volumes did not influence neurological outcome. Patients with multiple injuries did not show a worse outcome compared to those with isolated epidural hematoma. There was no difference in patient’s outcome after surgical or non-surgical treatment.ConclusionsPoor outcome after traumatic epidural hematoma was associated with coagulopathy. Progression of epidural hematoma volume was not associated with coagulopathy or with poor neurological outcome. Prospective studies are needed to confirm these results.