Strohm Pc

Dual-Energy CT Virtual Noncalcium Technique: Detecting Posttraumatic Bone Marrow Lesions—Feasibility Study

PURPOSE To evaluate traumatized bone marrow with a dual-energy (DE) computed tomographic (CT) virtual noncalcium technique. MATERIALS AND METHODS In this prospective institutional review board-approved study, 21 patients with an acute knee trauma underwent DE CT and magnetic resonance (MR) imaging. A software application was used to virtually subtract calcium from the images. Presence of fractures was noted, and presence of bone bruise was rated on a four-point scale for six femoral and tibial regions by two radiologists. CT numbers were obtained in the same regions. Consensus reading of independently read MR images served as the reference standard. Image ratings and CT numbers were subjected to receiver operating characteristic curve analysis. RESULTS After exclusion of 16 regions owing to artifacts, MR imaging revealed 59 bone bruises in the remaining 236 regions (19 of 114 femoral, 40 of 122 tibial). Fractures were present in eight patients. Visual rating revealed areas under the curve of 0.886 and 0.897 in the femur and 0.974 and 0.953 in the tibia for observers 1 and 2, respectively. For CT numbers, the respective areas under the curve were 0.922 and 0.974. If scores of 1 and 2 (strong or mild bone bruise) were counted as positive, sensitivities were 86.4% and 86.4% and specificities were 94.4% and 95.5% for observers 1 and 2, respectively. The kappa statistic demonstrated good to excellent agreement (femur, kappa = 0.78; tibia, kappa = 0.87). CONCLUSION This DE CT virtual noncalcium technique can subtract calcium from cancellous bone, allowing bone marrow assessment and potentially making posttraumatic bone bruises of the knee detectable with CT.

Two-Year Results of Open-Wedge High Tibial Osteotomy With Fixation by Medial Plate Fixator for Medial Compartment Arthritis With Varus Malalignment of the Knee

PURPOSE The purpose of our study was to evaluate the complications, technique-related risks, and the clinical course of patients treated with high tibial osteotomy (HTO) for medial arthritis of the knee with varus malalignment. METHODS Forty-three of 46 consecutive patients (follow-up, 93.5%) treated with HTO using the TomoFix implant (Synthes, Solothurn, Switzerland) were followed-up for 24 months. Radiographic and clinical data were collected preoperatively as well as 6, 12, and 24 months after surgery using standard instruments (Lysholm and subjective International Knee Documentation Committee score). RESULTS Excellent and good results were achieved in 67.5% of patients. Thirty-seven patients (86.0%) reported clinical improvement at 24 months compared to preoperative status. Evaluation of the clinical course following HTO revealed a significant increase in function after 12 (P < .01) and 24 (P < .01), but not at 6 months (P = .336) after surgery. A further increase was found between 12 and 24 months (P = .017); 67.5% of the study population returned to their predisease sports activity level at 24 months after surgery. Except for 1 case of intra-articular fracture, no severe intraoperative complications were found. One case of nonunion that demanded additional surgery was observed. CONCLUSIONS HTO with an open-wedge technique using the TomoFix implant seems to be a safe and efficient procedure. Our data show that postoperative recovery is long, with a majority of patients not reaching a functional end-point by 6 or 12 months. In many patients, further improvement was found after 12 months, which might be related to a removal of the implant. 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.

Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

IntroductionThis systematic review is focused on the in-hospital mortality and neurological outcome of survivors after prehospital resuscitation following trauma. Data were analyzed for adults/pediatric patients and for blunt/penetrating trauma.MethodsA systematic review was performed using the data available in Ovid Medline. 476 articles from 1/1964 - 5/2011 were identified by two independent investigators and 47 studies fulfilled the requirements (admission to hospital after prehospital resuscitation following trauma). Neurological outcome was evaluated using the Glasgow outcome scale.Results34 studies/5391 patients with a potentially mixed population (no information was found in most studies if and how many children were included) and 13 paediatric studies/1243 children (age ≤ 18 years) were investigated. The overall mortality was 92.8% (mixed population: 238 survivors, lethality 96.7%; paediatric group: 237 survivors, lethality 86.4% = p < 0.001).Penetrating trauma was found in 19 studies/1891 patients in the mixed population (69 survivors, lethality: 96.4%) and in 3 pediatric studies/91 children (2 survivors lethality 97.8%).44.3% of the survivors in the mixed population and 38.3% in the group of children had a good neurological recovery. A moderate disability could be evaluated in 13.1% in the mixed population and in 12.8% in children. A severe disability was found in 29.5% of the survivors in the mixed patients and in 38.3% in the group of children. A persistent vegetative state was the neurological status in 9.8% in the mixed population and in 10.6% in children.For each year prior to 2010, the estimated log-odds for survival decreased by 0.022 (95%-CI: [0.038;0.006]). When jointly analyzing the studies on adults and children, the proportion of survivors for children is estimated to be 17.8% (95%-CI: [15.1%;20.8%]). The difference of the paediatric compared to the adult proportion is significant (p < 0.001).ConclusionsChildren have a higher chance of survival after resuscitation of an out-of-hospital traumatic cardiac arrest compared to adults but tend to have a poorer neurological outcome at discharge.

Die proximale Humerusfraktur im hohen Lebensalter

ZusammenfassungDie Behandlung der dislozierten proximalen Humerusmehrfragmentfraktur beim alten Menschen wird weiter kontrovers diskutiert, auch neuere Therapieverfahren wie die winkelstabile Plattenosteosynthese konnten ihre Überlegenheit bisher nicht beweisen. Eine prospektiv durchgeführte Vergleichsstudie bei dislozierten 3- und 4-Part-Frakturen mit Plattenosteosynthese und primärer Prothesenimplantation ist erforderlich.AbstractThe treatment of dislocated proximal humeral fractures in elderly patients is still a subject of controversy. Newer techniques such as fixed angle plate fixation did not show better results despite theoretical advantages. Prospective randomized studies are necessary to evaluate treatment recommendations.

Injury severity and localisations seen in polytraumatised children compared to adults and the relevance for emergency room management

PURPOSE The treatment of paediatric polytrauma patients in the emergency room is not common. The knowledge of specific injuries in consideration of the age-specific characteristics is of particular importance for precise diagnostics and therapy. The goal of this study is the aquisition of the frequency, the localisation and the severity of paediatric polytrauma (age: 0-16 years) in comparison with adults. PATIENTS AND METHODS In the period 7 / 01 to 5 / 04 the localisation and injury severity of 23 paediatric polytrauma patients (age: 2-16 years) were compared retrospectivly with those of 324 adults (age: 17-88 years). In the paediatric group (ISS: 31) the lethality was 17 % and so much higher than that in the grown-up population (ISS: 33) with 10 % at comparable injury severity. The cause of accident and the injury severity of the affected body region were analysed. The severity of the diffferent body regions were classified by the Abbreviated Injury Severity Score (AIS). The results were discussed with regard to the current literature. RESULTS With 65 %, more than every second child suffered from severe head injuries (AIS > 2), whereas only 37 % of the adults were affected in this way. The different types of intracranial bleedings were analysed and compared. Heavy injuries of the thorax (AIS > 2) were the result of an accident in 61 % of the children and in 54 % of the adults. The incidence of children with injuries to the abdomen was 30 % compared to 31 % in the grown-up collective. Lesions of the spleen and liver had a frequency of 13 to 16 %. Injuries of the spine could be only found in 4 % of the children compared to 40 % of the adult group. The frequencies of pelvic injuries were similar at 22 % for children and 28 % for adults. With 13 % for the upper extremities and 17 % for the lower extremities, children were much less injured in these body regions. In the group of adults 43 % had injuries to the upper extremities and 33 % injuries to the lower extremities. CONCLUSIONS Taking the results into account with consdieration of the literature data, the authors recommend that the emergency room management for adults and, especially, the radiolgical diagnostic chain with CT scans should also be applied to polytraumatised children. The main reasons for this are the extremely high incidence of intracranial injuries and the high sensitivity of CT scans also for abdominal trauma and pelvic injuries.Purpose: The treatment of paediatric polytrauma patients in the emergency room is not common. The knowledge of specific injuries in considera- tion of the age-specific characteristics is of par- ticular importance for precise diagnostics and therapy. The goal of this study is the aquisition of the frequency, the localisation and the severi- ty of paediatric polytrauma (age: 0-16years) in comparison with adults. Patients and Methods:In the period 7/01 to 5/04 the localisation and injury severity of 23paediat- ric polytrauma patients (age: 2-16years) were compared retrospectivly with those of 324adults (age: 17-88years). In the paediatric group (ISS: 31) the lethality was 17% and so much higher than that in the grown-up population (ISS: 33) with 10% at comparable injury severity. The cause of accident and the injury severity of the affected body region were analysed. The severity of the diffferent body regions were classified by the Abbreviated Injury Severity Score (AIS). The results were discussed with regard to the current literature. Results: With 65%, more than every second child suffered from severe head injuries (AIS >2), whereas only 37% of the adults were affected in this way. The different types of intracranial blee- dings were analysed and compared. Heavy inju- ries of the thorax (AIS >2) were the result of an accident in 61% of the children and in 54% of the adults. The incidence of children with injuries to the abdomen was 30% compared to 31% in the grown-up collective. Lesions of the spleen and liver had a frequency of 13 to 16%. Injuries of the spine could be only found in 4% of the children compared to 40% of the adult group. The fre- quencies of pelvic injuries were similar at 22% for children and 28% for adults. With 13% for the upper extremities and 17% for the lower extremi- ties, children were much less injured in these

New techniques for bone synthesis on the humerus

ZusammenfassungSchulternahe Oberarmbrüche treten häufig auf. Für die Behandlung besteht nur bei sehr einfachen, undislozierten Brüchen und bei völliger Zerstörung der Kopfkalotte beim alten Menschen weitgehende Einigkeit über das therapeutische Vorgehen. Für die Mehrzahl der 2–4 Part-Frakturen existieren unterschiedlichste und z. T. widersprüchliche Empfehlungen in der Literatur. Die unterschiedlichen Angaben spiegeln den Konflikt der möglichst anatomischen Reposition, der möglichst übungsstabilen Fixation bei möglichst geringer zusätzlicher Schädigung der umgebenden Strukturen durch das zusätzliche Operationstrauma wider. Ob die winkelstabilen Implantate der neuesten Plattengeneration eine Verbesserung im Outcome ergeben, ist im Augenblick Gegenstand klinischer Studien. Für den Schaftbereich scheinen die Indikationen klarer. Die Entwicklungen der neuesten Platten oder intramedullären Implantate bringen eine Verbesserung im chirurgischen Handling, implantatspezifische Komplikationen werden durch Weiterentwicklungen gemindert (z. B. Nageldislokationen). Ob sich hier eine messbare Verbesserung für den Patienten ergibt, bleibt ebenfalls noch abzuwarten.AbstractFractures of the upper arm near the shoulder are common. A consensus on treatment only occurs for simple, un-dislocated fractures and with the complete destruction of the concha in elderly people. For most of the 2–4 component fractures, there exist a variety of, in part contradictory, recommendations in the literature. The most diverse statements mirror the conflict between the best anatomical solution and the practically most stable position with the least possible additional damage of the surrounding structures through surgery. Whether the implants with the most stable angle using the latest generation of plates will lead to an improvement in the results is at present a matter under clinical study. The indications are clearer for the shaft. The development of the latest plates and intramedullary implants provides a surgical improvement, and implant specific complications (e.g., pin movement) will be reduced with further development. Whether there are also advantages for the patient remain to be seen.

Neue Osteosyntheseverfahren am Humerus

ZusammenfassungSchulternahe Oberarmbrüche treten häufig auf. Für die Behandlung besteht nur bei sehr einfachen, undislozierten Brüchen und bei völliger Zerstörung der Kopfkalotte beim alten Menschen weitgehende Einigkeit über das therapeutische Vorgehen. Für die Mehrzahl der 2–4 Part-Frakturen existieren unterschiedlichste und z. T. widersprüchliche Empfehlungen in der Literatur. Die unterschiedlichen Angaben spiegeln den Konflikt der möglichst anatomischen Reposition, der möglichst übungsstabilen Fixation bei möglichst geringer zusätzlicher Schädigung der umgebenden Strukturen durch das zusätzliche Operationstrauma wider. Ob die winkelstabilen Implantate der neuesten Plattengeneration eine Verbesserung im Outcome ergeben, ist im Augenblick Gegenstand klinischer Studien. Für den Schaftbereich scheinen die Indikationen klarer. Die Entwicklungen der neuesten Platten oder intramedullären Implantate bringen eine Verbesserung im chirurgischen Handling, implantatspezifische Komplikationen werden durch Weiterentwicklungen gemindert (z. B. Nageldislokationen). Ob sich hier eine messbare Verbesserung für den Patienten ergibt, bleibt ebenfalls noch abzuwarten.AbstractFractures of the upper arm near the shoulder are common. A consensus on treatment only occurs for simple, un-dislocated fractures and with the complete destruction of the concha in elderly people. For most of the 2–4 component fractures, there exist a variety of, in part contradictory, recommendations in the literature. The most diverse statements mirror the conflict between the best anatomical solution and the practically most stable position with the least possible additional damage of the surrounding structures through surgery. Whether the implants with the most stable angle using the latest generation of plates will lead to an improvement in the results is at present a matter under clinical study. The indications are clearer for the shaft. The development of the latest plates and intramedullary implants provides a surgical improvement, and implant specific complications (e.g., pin movement) will be reduced with further development. Whether there are also advantages for the patient remain to be seen.

Influence of Arm Positioning on Radiation Dose for Whole Body Computed Tomography in Trauma Patients

BACKGROUND Multislice whole body computed tomography is regarded as the method of choice for primary investigation of hemodynamically stable patients with multiple injuries. However, a disadvantage of this method is the high level of radiation to which the patient is exposed. Various recommendations on how to position the patients arms during whole body computed tomography have been given in the literature, but conclusive data are missing. Therefore, the aim of our study was to investigate the relationship between different arm positions and radiation dose in patients undergoing whole body computed tomography. METHODS In a retrospective analysis of available data derived from former whole body computed tomography screening of patients with multiple injuries, we calculated the effective radiation dose and scanning time for different arm positions (both arms up, both arms at sides, right arm up, and left arm up). Statistical analysis was performed using the independent t test with 95% confidence intervals. Statistical significance was set at 0.05. RESULTS The data evaluated had been recorded for 956 patients during a period of 18 months. Of these patients, 710 were included in the study. In 487 cases (68%), both arms were up; in 82 cases (12%), down by the sides; in 90 cases (13%), the right arm was up; and in 44 cases (6%), the left arm was up. Overall, the radiation dose was statistically significantly higher with both arms at sides (24.69 mSv ± 6.91 mSv) than with both arms up (19.18 mSv ± 4.99 mSv; p < 0.0000001). Statistically significant differences in effective radiation dose were not found for either the right arm up (23.52 mSv ± 5.23 mSv; p = 0.211) or the left arm up (22.53 mSv ± 5.4 mSv; p = 0.076) compared with both arms down at sides. Comparison of scan lengths for the thorax or abdomen did not yield any significant differences between arms down and any other arm position. Analysis of scanning times did not reveal any significant differences for whole body computed tomography with both arms down (07:31 minutes ± 02:53 minutes) compared with both arms up (07:30 minutes ± 02:04 minutes; p = 0.94), right arm up (07:15 minutes ± 01:43 minutes; p = 0.582), or left arm up (07:18 minutes ± 01:24 minutes; p = 0.707). CONCLUSION Based on our retrospective investigation, it can be recommended with reference to whole body computed tomography screening that the arms should be in the arms-up position during thorax or abdomen scanning of a severely injured patient, provided there are no clear clinical indications of shoulder injury. For the patient, this position is associated with a significantly reduced radiation dose without noticeable loss of time.

Reliability of leg alignment using the OrthoPilot system depends on knee position: a cadaveric study

Despite the increase in clinical use of navigation systems in total knee arthroplasty, few studies have focused on the reproducibility of these systems. The aim of the present study was to assess the influence of knee position and observer experience on intra- and inter-observer agreement in limb alignment assessment with the OrthoPilot system. Limb alignment in the coronal plane and extension range of the knee were assessed in four embalmed cadaveric specimens by five independent observers and measurements were repeated four times to determine intra- and inter-observer agreement, expressed as intraclass correlation coefficients (ICCs). Additionally, navigation results were compared against figures from conventional measurement of leg alignment (ground truth). Intra- and inter-observer agreements were excellent for assessing the extension range (ICC, 0.97 and 0.95) and the coronal femuro-tibial axis in knee extension (ICC, 0.92 and 0.88) but were generally worse in knee flexion (ICC, 0.62 and 0.55). There was an increased tendency of intraobserver errors in observers with less clinical experience. Mean correlation with conventional measurements was fair (Spearman’s rho 0.61). The OrthoPilot system showed excellent reproducibility for assessment of extension range and coronal limb alignment. However, assessments of coronal limb alignment in flexion were prone to error and caution should be taken when relying on these measurements.