Sven Shafizadeh

Image-guided spine surgery: state of the art and future directions.

Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon (‘human factor’) and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.

Computer Assisted Percutaneous Placement of Augmented Iliosacral Screws : A Reasonable Alternative to Sacroplasty

Study Design. A technical report of fluoroscopy guided placement of augmented iliosacral screws in osteoporotic insufficiency fractures of the sacrum. Objective. To describe a combined approach of navigated iliosacral screw placement and screw augmentation as an option for osteosynthesis of sacral insufficiency fractures in the elderly. Summary of Background Data. The incidence of sacral insufficiency fractures is increasing. Outcome of conservative treatment is inconsistent. Recently sacroplasty is propagated as an interventional therapy but the long-term outcome is still unknown. Evidence from finite element models suggests that stabilization of the sacrum achieved by sacroplasty is insufficient to restore the weight bearing capacity of the sacrum permanently. Methods. We suggest a minimally invasive fluoroscopically navigated iliosacral screw osteosynthesis with cement augmentation of the screws for treatment of insufficiency fractures of the sacrum. Results. The procedure, especially fluoroscopic visualization and navigation of the osteoporotic sacrum is technically feasible. A total radiograph time of 7,4 minutes, including image acquisition for navigation and fluoroscopic control of cement injection, is acceptable and can be expected to be significantly reduced with repeated applications of the procedure. The patient presented in the report was discharged to rehabilitation soon after the operation. An assistive device (delta wheel) is only needed for longer walking distances. Pain was reduced drastically immediately after surgery. Conclusion. In general, fractures are treated by reduction and fixation to restore the biomechanical function of the injured bone. These principles should be applied to elderly patients with osteoporotic fractures as well. The technique reported here is adapted to the special demands of the elderly patient, i.e., minimally invasive, support of the weakened bone by cement augmentation, bone protective screw positioning and safety due to navigation support.

Epidemiology of extremity injuries in multiple trauma patients

BACKGROUND Previous studies have suggested that distinct extremity injuries are associated with worse outcome following major trauma. The aim of the present study was to determine epidemiological data of extremity injuries in multiple trauma patients with respect to prevalence, injury pattern, specific mechanisms of injury and their impact on mortality. METHODS The Trauma Register of the German Society for Trauma Surgery anonymously documents data on critically injured patients since 1993. Trauma cases documented between 2002 and 2009, older than 16 years of age and with an ISS ≥ 16 were divided into those with AIS ≥ 2 and those without a significant extremity injury. The groups were compared with respect to injury pattern, treatment characteristics and mortality. RESULTS More than half of the 24,885 patients (58.6%) had a significant extremity injury. On average patients with relevant extremity injuries sustained on average 2.1 fractures per case and 4.9% even sustained five or more extremity injuries. Fractures of the femur (16.5%), the tibia (12.6%) and the clavicle (10.4%) were the most common fractures. Patients without significant extremity injury had a significantly lower Glasgow Coma Scale at scene, a more severe brain injury and a higher 30-day- and in-hospital-mortality. In contrast, patients with significant extremity injuries had a higher rate of severe chest trauma, a higher rate of red cell blood transfusion as well a massive blood transfusion, more operative procedures and a longer ICU and in-hospital length of stay. CONCLUSIONS Multiple injured patients with and without significant extremity injuries can be regarded as two different populations with respect to early posttraumatic course and survival. Those without extremity injury had more severe head injuries and a higher mortality. However, significant extremity injury was associated with worse outcomes including a higher number of operative procedures, a higher rate of blood transfusion and a longer hospital length of stay.

Precision of Tunnel Positioning in Navigated Anterior Cruciate Ligament Reconstruction

PURPOSE The aim of this study was to validate the precision of navigated tunnel positioning using a fluoroscopy-based computer-assisted technique. METHODS Ten human cadaveric knees were operated on under operating room conditions. After resection of the anterior cruciate ligament, referenced fluoroscopic images were acquired to plan the tunnel positions according to established radiologic measurement methods. Afterward, femoral and tibial K-wires were placed by use of navigated drill guides without arthroscopic control. Deviations between the planned and actually drilled tunnel positions at the joint level were analyzed by use of both navigated and radiologic assessment methods. RESULTS Navigated analysis between planned and actually drilled tunnel position showed mean deviations of 0.4 mm (range, 0 to 1 mm; SD, 0.52 mm) at the femur and 0.5 mm (range, 0 to 1 mm; SD, 0.5 mm) at the tibia. The radiologic analysis showed mean deviations for the femoral tunnel of 0.83 mm for the depth (range, 0 to 1.46 mm; SD, 0.46 mm) and 0.54 mm for the height (range, 0 to 1.08 mm; SD, 0.41 mm). At the tibia, deviation of 0.74 mm (range, 0 to 1.2 mm; SD, 0.46 mm) was found. CONCLUSIONS The fluoroscopy-based navigation system used in this study allows for precise tunnel positioning with deviations of 1 mm or less. CLINICAL RELEVANCE This technique provides accurate tunnel placement in anterior cruciate ligament surgery.

Medial Patellofemoral Ligament Reconstruction: A New Technique for Graft Fixation at the Patella Without Implants

Patellofemoral instability is a complex disorder that is often accompanied by insufficiency or tearing of the medial patellofemoral ligament. Over the past few years, several techniques using free tendon grafts for medial patellofemoral ligament reconstruction have become popular because of their reproducible effect and good outcome. Whereas most surgeons prefer femoral fixation of the graft using an interference screw, the possibilities of patellar fixation are numerous. All of the different techniques have their own advantages and pitfalls. We describe a technique in which we drill 2 blind-ending tunnels (1 cm) at the medial aspect of the patella, where the doubled graft (not the free ends) is pulled in and fixed. By using a special technique for shuttling the sutures, there is no need for an additional skin incision and no need for implants, allowing very secure graft fixation without a relevant risk of fracture.

Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patients physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.ZusammenfassungEs ist aus klinischen Untersuchungen bekannt, dass ein standardisiertes Schockraummanagement die Behandlungsergebnisse von Schwerverletzten verbessert. „Advanced Trauma Live Support“ (ATLS®) stellt ein Ausbildungskonzept dar, das ein standardisiertes Schockraummanagement lehrt. Ziele sind die schnelle und genaue Einschätzung des Zustands des Traumapatienten, aus der sich eine prioritätenorientierte Behandlung ableitet. Über allem stehen die Gedanken, Sekundärschäden zu vermeiden, die Zeit nicht aus den Augen zu verlieren und eine gleichbleibende Qualität der Versorgung zu sichern.Eine „Standard Operating Procedure“ (SOP) regelt den genauen Behandlungsablauf der Schwerverletztenversorgung und legt die Aufgabenverantwortung der verschiedenen an der Schwerverletztenversorgung teilnehmenden Fachbereiche fest. Eine SOP berücksichtigt darüber hinaus die Grundlagen der Organisationsstruktur der Schwerverletztenversorgung, die erforderlichen räumlichen/apparativen und personellen Anforderungen sowie medizinische Grundlagen der Schwerverletztenversorgung, die Ausbildung und ein Fehlermanagement, um eine Verbesserung der Prozess- und Ergebnisqualität erzielen zu können.Unabhängig von der Versorgungsstufe einer Klinik verbessern SOP und Ausbildungsprogramme die Prozess- und Ergebnisqualität der Behandlung Schwerverletzter. SOP und Ausbildungsprogramme müssen an den Bedürfnissen der Traumaphysiologie und den strukturellen Gegebenheiten orientiert sein. ATLS® stellt keine SOP dar, eignet sich aber als Konzept, standardisierte Behandlungsabläufe für die Schwerverletztenversorgung entsprechend einer SOP zu entwickeln.AbstractThere is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS® is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient’s physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management.SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS® does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Schockraummanagement von Schwerverletzten

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patients physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.ZusammenfassungEs ist aus klinischen Untersuchungen bekannt, dass ein standardisiertes Schockraummanagement die Behandlungsergebnisse von Schwerverletzten verbessert. „Advanced Trauma Live Support“ (ATLS®) stellt ein Ausbildungskonzept dar, das ein standardisiertes Schockraummanagement lehrt. Ziele sind die schnelle und genaue Einschätzung des Zustands des Traumapatienten, aus der sich eine prioritätenorientierte Behandlung ableitet. Über allem stehen die Gedanken, Sekundärschäden zu vermeiden, die Zeit nicht aus den Augen zu verlieren und eine gleichbleibende Qualität der Versorgung zu sichern.Eine „Standard Operating Procedure“ (SOP) regelt den genauen Behandlungsablauf der Schwerverletztenversorgung und legt die Aufgabenverantwortung der verschiedenen an der Schwerverletztenversorgung teilnehmenden Fachbereiche fest. Eine SOP berücksichtigt darüber hinaus die Grundlagen der Organisationsstruktur der Schwerverletztenversorgung, die erforderlichen räumlichen/apparativen und personellen Anforderungen sowie medizinische Grundlagen der Schwerverletztenversorgung, die Ausbildung und ein Fehlermanagement, um eine Verbesserung der Prozess- und Ergebnisqualität erzielen zu können.Unabhängig von der Versorgungsstufe einer Klinik verbessern SOP und Ausbildungsprogramme die Prozess- und Ergebnisqualität der Behandlung Schwerverletzter. SOP und Ausbildungsprogramme müssen an den Bedürfnissen der Traumaphysiologie und den strukturellen Gegebenheiten orientiert sein. ATLS® stellt keine SOP dar, eignet sich aber als Konzept, standardisierte Behandlungsabläufe für die Schwerverletztenversorgung entsprechend einer SOP zu entwickeln.AbstractThere is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS® is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient’s physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management.SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS® does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Recurrent anterior shoulder dislocation due to a partial-thickness articular surface supraspinatus tendon tear without capsulolabral lesion

Different patterns of intra-articular lesions are found in patients with chronic posttraumatic anterior shoulder instability. Besides bony lesions like Hill-Sachs lesion or glenoid bone deficiency, these include predominantly soft tissue injuries of the ligament-labrum complex, as well as rotator cuff tears. Full-thickness rotator cuff tears have been found in addition to labrum lesions after traumatic anterior shoulder dislocation. Their contribution to glenohumeral instability has been well documented in clinical and cadaver studies. If possible repair of both the tear and the labrum injury has been recommended. Partial tears of the rotator cuff are mostly located on the articular side, and for these tears the term PASTA (partial articular surface tendon avulsion) lesion was coined. Only few authors have described PASTA lesions as concomitant lesions in patients with shoulder instability. An isolated PASTA lesion without concomitant injury to the ligament-labrum complex in patients with chronic anterior shoulder instability has not been mentioned in the literature. We report about 2 judo athletes with recurrent posttraumatic anterior shoulder instability who had an isolated PASTA lesion involving more than 50% of the footprint without additional labrum injury.

Increased medial and lateral tibial posterior slopes are independent risk factors for graft failure following ACL reconstruction

PurposeTo analyze the contribution of increased lateral (LTPS) and medial tibial slopes (MTPS) as independent risk factors of graft failure following anterior cruciate ligament (ACL) reconstruction.Materials and methodsFifty-seven patients with graft failure after ACL reconstruction who underwent revision surgery between 2009 and 2014 were enrolled and matched to a control group of 69 patients with primary anatomic successful ACL reconstruction. Patients were matched based on age, sex, date of primary surgery and graft type. LTPS and MTPS were measured on MRI in a blinded fashion. Tibial and femoral tunnel positions were determined on CT scans. Independent t test was used to compare the MTPS and LTPS between subgroups. Risks of graft failure associated with an increasing MTPS and LTPS were analyzed using binary logistic analysis.ResultsThe means of LTPS (7.3°) and MTPS (6.7°) in the graft failure group were found to be significantly greater than in the control group (4.6° and 4.1°, respectively; p = < 0.001). Non-anatomic and anatomic tunnel positions were found in 42 cases (73.7%) and 15 cases (26.3%), respectively. There were no significant differences in MTPS or LTPS between patients with anatomic and non-anatomic tunnel positions within the graft failure group. An increase of the MTPS of 1° was associated with an 1.24 times increased likelihood of exhibiting graft failure [95% CI 1.07–1.43] (p = 0.003) and an increase of the LTPS of 1° was associated with an 1.17 times increased likelihood of exhibiting graft failure [95% CI 1.04–1.31] (p = 0.009). The increased risk was most evident in patients with a lateral tibial posterior slope of ≥ 10°.ConclusionsIncreased LTPS and MTPS are independent risk factors for graft failure following ACL reconstruction regardless whether tunnel position is anatomic or non-anatomic. This information may be helpful to clinicians when considering slope correction in selected revision ACL reconstruction procedures.

Differences between traumatic and non-traumatic causes of ACL revision surgery

PurposeThe purpose of this study was to evaluate and classify causes for anterior cruciate ligament (ACL) reconstruction failure. It was hypothesized that specific technical and biological reconstruction aspects would differ when comparing traumatic and non-traumatic ACL reconstruction failures.Materials and methodsOne hundred and forty-seven consecutive patients who experienced ACL reconstruction failure and underwent revision between 2009 and 2014 were analyzed. Based on a systematic failure analysis, including evaluation of technical information on primary ACL reconstruction and radiological assessment of tunnel positions, causes were classified into traumatic and non-traumatic mechanisms of failure; non-traumatic mechanisms were further sub-divided into technical and biologic causes. Spearman’s rank correlation coefficient and chi-squared tests were performed to determine differences between groups based on various factors including graft choice, fixation technique, technique of femoral tunnel positioning, tunnel malpositioning, and time to revision.ResultsNon-traumatic, i.e., technical, and traumatic mechanisms of ACL reconstruction failure were found in 64.5 and 29.1% of patients, respectively. Biological failure was found only in 6.4% of patients. Non-anatomical femoral tunnel positioning was found the most common cause (83.1%) for technical reconstruction failure followed by non-anatomical tibial tunnel positioning (45.1%). There were strong correlations between non-traumatic technical failure and femoral tunnel malpositioning, transtibial femoral tunnel drilling techniques, femoral transfixation techniques as well as earlier graft failure (p < 0.05).ConclusionsTechnical causes, particularly tunnel malpositioning, were significantly correlated with increased incidence of non-traumatic ACL reconstruction failure. Transtibial femoral tunnel positioning techniques and femoral transfixation techniques, showed an increased incidence of non-traumatic, earlier graft failure.