Rene El Attal

The impact of fresh frozen plasma vs coagulation factor concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion

INTRODUCTION Clinical observations together with recent research highlighted the role of coagulopathy in acute trauma care and early aggressive treatment has been shown to reduce mortality. METHODS Datasets from severely injured and bleeding patients with established coagulopathy upon emergency room (ER) arrival from two retrospective trauma databases, (i) TR-DGU (Germany) and (ii) Innsbruck Trauma Databank/ITB (Austria), that had received two different strategies of coagulopathy management during initial resuscitation, (i) fresh frozen plasma (FFP) without coagulation factor concentrates, and (ii) coagulation factor concentrates (fibrinogen and/or prothrombin complex concentrates) without FFP, were compared for morbidity, mortality and transfusion requirements using a matched-pair analysis approach. RESULTS There were no major differences in basic characteristics and physiological variables upon ER admission between the two cohorts that were matched. ITB patients had received substantially less packed red blood cell (pRBC) concentrates within the first 6h after admission (median 1.0 (IQR(25-75) 0-3) vs 7.5 (IQR(25-75) 4-12) units; p<0.005) and the first 24h as compared to TR-DGU patients (median 3 (IQR(25-75) 0-5) vs 12.5 (8-20) units; p<0.005). Overall mortality was comparable between both groups whilst the frequency for multi organ failure was significantly lower within the group that had received coagulation factor concentrates exclusively and no FFP during initial resuscitation (n=3 vs n=15; p=0.015). This translated into trends towards reduced days on ventilator whilst on ICU and shorter overall in-hospital length of stays (LOS). CONCLUSION Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions. Prospective and randomised clinical trials with sufficient patient numbers based upon this strategy are advocated.

The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma

BACKGROUND FFP and coagulation factor concentrates are used to correct trauma-induced coagulopathy (TIC). However, data on coagulation profiles investigating effects of therapy are scarce. METHODS This is an analysis of 144 patients with major blunt trauma ((ISS)≥15), who were enrolled in a prospective cohort study investigating characteristics and treatment of TIC. Patients who received fibrinogen concentrate and/or prothrombin complex concentrate alone (CF Group) were compared with those additionally receiving FFP transfusions (FFP Group). RESULTS Sixty-six patients exclusively received CF, while 78 patients additionally received FFP. Overall, patients were comparable regarding age, gender and ISS (CF Group, ISS 37 (29, 50); FFP Group ISS 38 (33, 55), p=0.28). Patients treated with CF alone showed sufficient haemostasis and received significantly fewer units of red blood cells (RBC) and platelets than did those also receiving FFP [(RBC 2(0, 4) U vs. 9 (5, 12) U; platelets 0 (0, 0) U vs. 1 (0, 2) U, p<0.001)]. In addition, fewer patients in the CF Group developed multiorgan failure (MOF) (18.2% vs. 37.2%, p=0.01) or sepsis (16.9% vs. 35.9%, p=0.014) than in the FFP Group. Propensity score-matching (n=28 pairs) used to reduce the impact of treatment selection confirmed that additional FFP administration showed no benefit in restoring haemostasis, but was associated with significantly higher transfusion rates for RBC and platelets. CONCLUSION The use of CF alone effectively corrected coagulopathy in patients with severe blunt trauma and concomitantly decreased exposure to allogeneic transfusion, which may translate into improved outcome.

Management of hemorrhage in severe pelvic injuries.

BACKGROUND Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. METHODS In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. RESULTS Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. CONCLUSION Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients

INTRODUCTION Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures. METHODS Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years. RESULTS ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22-27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe post-traumatic shortening only. CONCLUSION We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (< or = 7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.

Biomechanical Comparison of 2 Anterior Cruciate Ligament Graft Preparation Techniques for Tibial Fixation Adjustable-Length Loop Cortical Button or Interference Screw

Background: Cortical button fixation at the femoral side and interference screws within the tibial bone tunnel are widely used for anterior cruciate ligament graft fixation. Using a bone socket instead of a full tunnel allows cortical button fixation on the tibial side as well. If adjustable-length loop cortical button devices are used for femoral and tibial fixation, the tendon graft has to be secured with sutures in a closed tendon loop. The increased distance of fixation points and potential slippage of the tendon strands at the securing sutures might lead to greater risk of postoperative graft elongation when compared with conventional graft preparation with tibial interference screw fixation. Hypothesis: Compared with an anterior cruciate ligament graft with tibial adjustable-length loop cortical button fixation, a graft with tibial interference screw fixation will show less graft elongation during cyclic loading and lower ultimate failure loads. Study Design: Controlled laboratory study. Methods: Grafts with tibial adjustable-length loop cortical button fixation and grafts with tibial interference screw fixation were biomechanically tested in calf tibiae (n = 10 per group). Femoral fixation was equivalent for both groups, using an adjustable-length loop cortical button. Specimens underwent cyclic loading followed by a load-to-failure test. Results: Grafts with screw fixation showed significantly less initial elongation (cycles 1-5: 1.46 ± 0.26 mm), secondary elongation (cycles 6-1000: 1.87 ± 0.67 mm), and total elongation (cycles 1-1000: 3.33 ± 0.83 mm) in comparison with grafts with button fixation (2.47 ± 0.26, 3.56 ± 0.39, and 6.03 ± 0.61 mm, respectively) (P < .001). While pull-out stiffness was significantly higher for grafts with screw fixation (309.5 ± 33.2 vs 185.6 ± 16.4 N/mm) (P < .001), grafts with button fixation were able to withstand significantly higher ultimate failure loads (908 ± 74 vs 693 ± 119 N) (P < .001). Conclusion: Grafts with tibial adjustable-length loop cortical button fixation resulted in higher graft elongation during cyclic loading and showed higher ultimate failure loads in comparison with conventional graft preparation with tibial interference screw fixation at time zero. Clinical Relevance: The results of this biomechanical study suggest that grafts with tibial interference screw fixation provide better knee stability at time zero because of reduced graft elongation and greater stiffness in comparison with grafts with tibial adjustable-length loop cortical button fixation.

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.

Tibiamarknagelung mit dem Expert Tibia Nagel

ZusammenfassungOperationszielÜbungsstabile Osteosynthese von Unterschenkelfrakturen mit Wiederherstellung der Achsenverhältnisse, Länge und Rotation der Tibia. Zuverlässige Knochenbruchheilung bei offenen und geschlossenen Frakturen nach frühfunktioneller Übungsbehandlung mit Erhalt der Gelenkbeweglichkeit.IndikationenGeschlossene und offene isolierte Tibia- und Unterschenkelschaftfrakturen (AO 42).Extraartikuläre Frakturen der proximalen oder distalen Tibia (AO 41 A2/A3; AO 43 A1/A2/A3).Segmentfrakturen der Tibia. Intraartikuläre Frakturen der proximalen oder distalen Tibia (AO 41 C1/C2; AO 43 C1/C2) in Verbindung mit weiteren Implantaten.Stabilisierung bei und nach Segmenttransport/Kallusdistraktion an der Tibia.KontraindikationenPatienten in inoperablem Allgemeinzustand.Kniebeugefähigkeit von weniger als 90°.Weichteilinfekt im Bereich des prätibialen Nageleintritts.Markraumphlegmone der Tibia.Komplexe Frakturen der proximalen und/oder distalen Gelenkfläche mit Impression.OperationstechnikWenn möglich, geschlossene Reposition der Tibiafraktur, evtl. mit Einsatz von Repositionshilfen über Stichinzisionen oder in offener Technik. Lagerung auf einem röntgendurchlässigen Tisch; alternativ kann – je nach persönlicher Präferenz – auch auf dem Extensionstisch oder mit Hilfe eines Rahmens aus Carbonstangen gelagert werden. Eröffnen der proximalen Tibia in Verlängerung des Markraums. Einbringen des Expert Tibia Nagels® in kanülierter oder Freihandtechnik mit oder ohne Aufbohren des Markraums in Abhängigkeit von Fraktur und Weichteilkondition. Kontrolle der Längsachse, Länge und Rotation der Extremität. Distale Verriegelung mit dem röntgendurchlässigen Winkelgetriebe. Gegebenenfalls Beseitigung einer Frakturdiastase durch Rückschlagen des Nagels und proximale Verriegelung über den Zielbügel.WeiterbehandlungSofortige Bewegungsübungen des Knie- und oberen Sprunggelenks.Je nach Frakturtyp Mobilisation unter Teilbelastung des Beins mit 20 kg bis zur schmerzabhängigen Vollbelastung an Unterarmgehstützen.Nach 6 Wochen radiologische Verlaufskontrolle und schrittweise Belastungssteigerung.ErgebnisseIn eine prospektive, internationale multizentrische Studie wurden zwischen Juli 2004 und Mai 2005 insgesamt 181 Patienten mit 186 Frakturen eingeschlossen. 57 dieser Frakturen (30,7%) waren offen, davon 15 Grad I, 32 Grad II und zehn Grad III. Meist handelte es sich um Tibiaschaftfrakturen (36%). Nach 1 Jahr konnten noch 146 (81%) dieser Patienten klinisch und radiologisch nachuntersucht werden. Die Rate an Pseudarthrosen für die gesamte Gruppe lag zu diesem Zeitpunkt bei 12,2% (offene Frakturen 18,2%, geschlossene Frakturen 9,7%). Revisionsoperationen einschließlich Dynamisierungen waren bei 18,8% der Patienten vorgenommen worden. Ohne Berücksichtigung der geplanten Dynamisierungen waren in nur 5,4% Reoperationen notwendig. Eine Fehlstellung in Varus-, Valgusoder Antekurvationsrichtung von mehr als 5° in mindestens einer Ebene auf postoperativen radiologischen Langaufnahmen lag bei 4,3% der Schaftfrakturen, 1,5% der distalen Frakturen und 13,6% der proximalen Frakturen vor. Bolzenbrüche fanden sich bei 3,2% der Patienten.AbstractObjectiveRestoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare. Early functional aftercare to maintain joint mobility. Good bony healing in closed and open fractures.IndicationsAll closed and open fractures of the tibia and complete lower leg fractures (AO 42).Certain extraarticular fractures of the proximal and distal tibia (AO 41 A2/A3; AO 43 A1/A2/A3).Segmental fractures of the tibia. Certain intraarticular fractures of the tibia with use of additional implants (AO 41 C1/C2; AO 43 C1/C2).Stabilization during and after segmental bone transport or callus distraction of the tibia.ContraindicationsPatients in poor general condition (e.g., bedridden).Flexion of the knee of less than 90°.Infection in the nail’s insertion area. Infection of the tibial cavity.Complex articular fractures of the proximal or distal tibia with joint depression.Surgical TechniqueClosed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., screws). Positioning of the patient may be performed on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the Expert Tibia Nail® with or without reaming of the medullary canal depending on the fracture type and soft-tissue condition. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device.Postoperative ManagementImmediate mobilization of ankle joint and knee joint. Depending on the type of fracture, mobilization with 20 kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray control 6 weeks postoperatively and increased weight bearing depending on the fracture status.ResultsIn a prospective, international multicentric study, 181 patients with 186 fractures were included between July 2004 and May 2005. 57 of these fractures (30.7%) initially were graded open, 15 of them grade I, 32 grade II, and ten grade III. Most of the fractures (36%) were shaft fractures. After 1 year, 146 patients (81%) could be evaluated clinically and radiologically. The overall pseudarthrosis rate was 12.2% (18.2% for open and 9.7% for closed fractures). The risk for secondary operations or revisions (including dynamization of the nail) was 18.8%. Without consideration of dynamization procedures, revisions were necessary in only 5.4% of all patients. The risk for varus, valgus or antecurvation malalignment of more than 5° in any plane on radiologic long leg views was 4.3% for shaft fractures, 1.5% for distal fractures, and 13.6% for proximal fractures. The implant-specific risk for bolt breakage was 3.2%.OBJECTIVE Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare. Early functional aftercare to maintain joint mobility. Good bony healing in closed and open fractures. INDICATIONS All closed and open fractures of the tibia and complete lower leg fractures (AO 42). Certain extraarticular fractures of the proximal and distal tibia (AO 41 A2/A3; AO 43 A1/A2/A3). Segmental fractures of the tibia. Certain intraarticular fractures of the tibia with use of additional implants (AO 41 C1/C2; AO 43 C1/C2). Stabilization during and after segmental bone transport or callus distraction of the tibia. CONTRAINDICATIONS Patients in poor general condition (e.g., bedridden). Flexion of the knee of less than 90 degrees . Infection in the nails insertion area. Infection of the tibial cavity. Complex articular fractures of the proximal or distal tibia with joint depression. SURGICAL TECHNIQUE Closed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., screws). Positioning of the patient may be performed on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the Expert Tibia Nail((R)) with or without reaming of the medullary canal depending on the fracture type and soft-tissue condition. 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 joint and knee joint. Depending on the type of fracture, mobilization with 20 kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray control 6 weeks postoperatively and increased weight bearing depending on the fracture status. RESULTS In a prospective, international multicentric study, 181 patients with 186 fractures were included between July 2004 and May 2005. 57 of these fractures (30.7%) initially were graded open, 15 of them grade I, 32 grade II, and ten grade III. Most of the fractures (36%) were shaft fractures. After 1 year, 146 patients (81%) could be evaluated clinically and radiologically. The overall pseudarthrosis rate was 12.2% (18.2% for open and 9.7% for closed fractures). The risk for secondary operations or revisions (including dynamization of the nail) was 18.8%. Without consideration of dynamization procedures, revisions were necessary in only 5.4% of all patients. The risk for varus, valgus or antecurvation malalignment of more than 5 degrees in any plane on radiologic long leg views was 4.3% for shaft fractures, 1.5% for distal fractures, and 13.6% for proximal fractures. The implant-specific risk for bolt breakage was 3.2%.

[Angle-stable fixation of intramedullary nails using the Angular Stable Locking System® (ASLS)].

ZusammenfassungOperationszielHöhere Stabilität von Marknagelosteosynthesen durch winkelstabile Verriegelung zwischen Marknagel und Verriegelungsbolzen. Ein neuartiges Schrauben-Dübel-System (ASLS®, Synthes GmbH Oberdorf, Schweiz) wird dabei in übliche, kanülierte Nägel eingesetzt. Die Entscheidung kann intraoperativ erfolgen.IndikationenErweiterte Marknagelindikationen. Je kleiner und instabiler das zu verriegelnde Fragment ist, desto eher ist die Indikation zur winkelstabilen Verriegelung des proximalen und/oder distalen Fragments angezeigt.Femur-, Tibia- und Humersfrakturen, Marknagelosteosynthese im osteoporotischen Knochen sowie ante- und retrograd eingebrachte Nägel. Besonders bei retrograd eingebrachten Nägeln wird das Wackeln des Nagels im Schaftbereich nachhaltig abgestellt.KontraindikationenKeine.OperationstechnikDurchbohren mit dem ersten Bohrer, welcher die Stärke des Kerndurchmessers des Schraubenschafts hat. Aufbohren der zugewandten Kortikalis auf den Außendurchmesser der Hülse. Dann Aufstecken der Hülse auf die Spitze der Schraube. Die Schrauben-Hülsen-Kombination wird durch das größere zugewandte Loch vorgeschoben bis die mit der Hülse besetzte Schraubenspitze im Loch des Verriegelungsmarknagels sitzt. Vordrehen der Schraube. Das dann im Kerndurchmesser größer werdende Gewinde des Schraubenschafts expandiert die Hülse und führt zum winkelstabilen Formschluss. Die Schraube wird dann bis zum Aufsitzen des Schraubenkopfs auf der zugewandten Kortikalis vorgeschraubt. Das zugewandte erweiterte Loch wird mit dem erweiterten Anteil des Gewindeschafts unter dem Schraubenkopf besetzt. Die 1–3 notwendigen Gewindegänge werden durch die selbstschneidende Nut bei diesem Gewindesprung selbst geschnitten.WeiterbehandlungDurch die winkelstabile Verriegelung kann nach bisheriger Erfahrung das Behandlungsregime nach Nagelung in Richtung frühere und/oder stärkere Teilbelastung oder frühere Vollbelastung erweitert werden. Ansonsten gelten die Richtlinien der Nachbehandlung bei Marknagelung.ErgebnisseDie multizentrische Pilotstudie hat gezeigt, dass die Technik reproduzierbar und einfach ist. Komplikationen bei der Operationstechnik sind nicht aufgetreten. Biomechanische Laborstudien haben ergeben, dass die Stabilität bei axialer und drehender Belastung statisch und dynamisch deutlich höher ist als mit einer konventionellen Verriegelung. Versagenszustände treten später ein.Wie groß die klinischen Vorteile endgültig sind, werden weitere Anwendungen und die Ergebnisse einer derzeit laufenden prospektiv randomisierten Studie zeigen.AbstractObjectiveGreater stability in intramedullary osteosynthesis using angle-stable fixation with intramedullary nails and proximal locking screws. A novel screw-and-sleeve system (ASLS®, Synthes GmbH, Oberdorf, Switzerland) is applied using normal cannulated nails. Decisions can be made intraoperatively.IndicationsThis technology widens the range of indications for intramedullary nailing: The smaller and less stable the fragment requiring fixation, the greater the indication for angular stable fixation of the proximal and/or distal fragment.Femoral, tibial and humeral fractures, intramedullary osteosynthesis in osteoporotic bone and ante- and retrograde nailing. Particularly in the case of retrograde nailing, sustained prevention of nail toggling is achieved.ContraindicationsNone.Surgical techniqueDrill with the first drill bit, which has the same core diameter as the screw shaft. Drill the cortex to the external diameter of the sleeve. Place the sleeve on the tip of the screw. The screw–sleeve combination is then advanced through the larger near hole until the sleeve-covered screw tip sits in the locking hole of the intramedullary fixation nail. Advance the screw. As the screw diameter becomes larger, the sleeve expands resulting in an angular stable locking effect. The screw is then advanced until the head of the screw sits on the exposed surface of the cortex. The hole is filled with the expanded part of the screw shaft beneath the screw head. The necessary 1–3 turns are cut by the self-tapping flute on the screw.Postoperative managementAccording to experience to date, this form of angle-stable fixation enables earlier and/or greater partial mobilization or earlier full mobilization. In all other respects, the guidelines for aftercare in intramedullary nailing apply.ResultsA multi-center pilot study has shown the technique to be reproducible and simple. There have been no complications using this technique to date. Biomechanical laboratory studies have demonstrated that stability with respect to axial and torsional loading is statically and dynamically higher than with conventional nailing. Device failure occurs later.Further applications as well as results of a prospective randomised study currently under way will show how great the clinical advantages ultimately prove to be.OBJECTIVE Greater stability in intramedullary osteosynthesis using angle-stable fixation with intramedullary nails and proximal locking screws. A novel screw-and-sleeve system (ASLS®, Synthes GmbH, Oberdorf, Switzerland) is applied using normal cannulated nails. Decisions can be made intraoperatively. INDICATIONS This technology widens the range of indications for intramedullary nailing: The smaller and less stable the fragment requiring fixation, the greater the indication for angular stable fixation of the proximal and/or distal fragment. Femoral, tibial and humeral fractures, intramedullary osteosynthesis in osteoporotic bone and ante- and retrograde nailing. Particularly in the case of retrograde nailing, sustained prevention of nail toggling is achieved. CONTRAINDICATIONS None. SURGICAL TECHNIQUE Drill with the first drill bit, which has the same core diameter as the screw shaft. Drill the cortex to the external diameter of the sleeve. Place the sleeve on the tip of the screw. The screw-sleeve combination is then advanced through the larger near hole until the sleeve-covered screw tip sits in the locking hole of the intramedullary fixation nail. Advance the screw. As the screw diameter becomes larger, the sleeve expands resulting in an angular stable locking effect. The screw is then advanced until the head of the screw sits on the exposed surface of the cortex. The hole is filled with the expanded part of the screw shaft beneath the screw head. The necessary 1-3 turns are cut by the self-tapping flute on the screw. POSTOPERATIVE MANAGEMENT According to experience to date, this form of angle-stable fixation enables earlier and/or greater partial mobilization or earlier full mobilization. In all other respects, the guidelines for aftercare in intramedullary nailing apply. RESULTS A multi-center pilot study has shown the technique to be reproducible and simple. There have been no complications using this technique to date. Biomechanical laboratory studies have demonstrated that stability with respect to axial and torsional loading is statically and dynamically higher than with conventional nailing. Device failure occurs later. Further applications as well as results of a prospective randomised study currently under way will show how great the clinical advantages ultimately prove to be.