T. Kälicke

Fluorine-18 fluorodeoxyglucose PET in infectious bone diseases: results of histologically confirmed cases.

Abstract.The aim of this study was to evaluate the clinical use of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in acute and chronic osteomyelitis and inflammatory spondylitis. The study population comprised 21 patients suspected of having acute or chronic osteomyelitis or inflammatory spondylitis. Fifteen of these patients subsequently underwent surgery. FDG-PET results were correlated with histopathological findings. The remaining six patients, who underwent conservative therapy, were excluded from any further evaluation due to the lack of histopathological data. The histopathological findings revealed osteomyelitis or inflammatory spondylitis in all 15 patients: seven patients had acute osteomyelitis and eight patients had chronic osteomyelitis or inflammatory spondylitis. FDG-PET yielded 15 true-positive results. The tracer uptake correlated with the histopathological findings in each case. Bone scintigraphy performed in 11 patients yielded ten true-positive results and one false-negative result. Follow-up carried out on two patients revealed normal or clearly reduced tracer uptake, which correlated with a normalisation of clinical data. In early postoperative follow-up it was impossible to differentiate between postsurgical reactive changes and further infection using FDG-PET. It is concluded that acute and chronic osteomyelitis of the peripheral as well as the central skeleton can be detected using FDG-PET. Osteomyelitis can be differentiated from soft tissue infection surrounding the bone. Unlike computed tomography and magnetic resonance imaging, FDG-PET is not affected by metal implants used for fixing fractures. FDG-PET demonstrated promising initial results with respect to treatment monitoring. Nevertheless, in the early postoperative phase FDG-PET seems to be of limited value owing to unspecific tracer uptake.

The undiagnosed Essex-Lopresti injury

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist. Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.

Prinzipien chirurgischer Therapiekonzepte der postoperativen und chronischen Osteomyelitis

ZusammenfassungDie postoperative Infektion des Knochens stellt sowohl in ihrer akuten als auch in der chronischen Verlaufsform eine der schwersten Komplikationen orthopädischer und unfallchirurgischer Operationen dar. Die Therapie beinhaltet nicht nur eine aufwendige bildgebende und mikrobiologische Diagnostik und aufwendige chirurgische Interventionen sondern auch eine intensive physikalische Therapie. Trotz des beträchtlichen Aufwands gelingt es nicht immer die Chronifizierung der Entzündung zu verhindern respektive eine definitive Infektsanierung zu gewährleisten. Zusätzlich sind die chronischen Knocheninfekte nahezu immer mit weiteren funktionellen Einschränkungen, wie limitierte Gelenkbeweglichkeit, neurologische Defizite und Schmerzen verbunden. Bei akuten postoperativen Infekten ist deshalb ein konsequentes chirurgisches Vorgehen besonders wichtig, um die Chronifizierung zu verhindern. Die Prinzipien bestehen in der Dekontamination durch Nekrosektomie und Spülung. Isolierte epifasziale Revisionen eines Operationsgebietes sind ebenso unzureichend, wie eine fehlende schichtübergreifende Wundrandexzision.Bei den chronischen Infekten muss zur definitiven Sanierung ein radikales Knochen- und Weichteildébridement erfolgen. Die Wiederherstellung des Weichteilmantels erfolgt entweder durch lokalen oder freien Gewebetransfer. Muskel(haut)lappenplastiken werden bevorzugt, da die Keimresistenz durch die „Luxusperfusion“ größer ist als bei fasziokutanen Transplantaten. Die knöcherne Rekonstruktion erfolgt durch Spongiosaplastik (partielle Defekte), Segmenttransport (Kontinuitätsdefekte) oder freie, gefäßgestielte Knochen(muskel)transplantation (große partielle Defekte).Die in der Regel für die Patienten sehr aufwendigen Rekonstruktionsmaßnahmen, müssen vor Therapiebeginn im Detail besprochen werden. Übersteigt das notwendige Resektionsausmaß die Rekonstruktionsmöglichkeiten, müssen die Therapiealternativen Wiederherstellung der Funktion bei persistierender Entzündung, symptomatische infektberuhigende Therapie und Amputation mit dem Patienten besprochen werden. Da jedes Therapiekonzept aus mehreren unverzichtbaren Pfeilern besteht, ist eine enge und gute Kommunikation und Kooperation zwischen Chirurgen, plastischen Chirurgen, Radiologen und Mikrobiologen eine Grundvoraussetzung.AbstractInfection of the bone is one of the most serious complications in the field of orthopedic and trauma orthopedic surgery. Sufficient treatment protocols not only contain complex surgical procedures but also sophisticated diagnostic tools, proper use of antibiotics, and intensive physical therapy right from the beginning. Even in light of these advanced treatment protocols, which have great impact on both patients and health care systems, persisting infection and residual functional deficits of the extremities are not rare. In cases of early (acute) infection, the main objective is to avoid chronification by diligent surgical interventions. The surgical principle is the meticulous debridement and lavage of the situs. Revision of only the epifascial layers is as inadequate as the simple reopening of the wound without excision of the whole wound including all tissue layers. In cases of chronic soft tissue and bone infection, radical debridement of all infected and scar tissue is also the basic requirement of treatment. Reconstruction of the soft tissue envelope is done by local or free flap surgery. Because of they are better resistant to infection, musculo(cutaneous)flaps are preferred. Bony reconstruction is done by autologous cancellous bone grafting (partial defects), segment transport (full thickness defects), or freely transplanted vascularized bone grafts (large partial defects).Both soft tissue and osseous reconstruction take a relatively long period of time requiring several operations and periods of hospitalization. These have to be discussed and explained to the patients extensively. If the required amount of resection and the capability of reconstruction do not coincide, the surgeon and the patient have to decide whether restoration of function without definitive infection care, symptomatic infection therapy, or amputation is the most proper treatment option according to the patient’s everyday needs and lifestyle. Because each treatment protocol is a composition of orthopedic trauma surgeons, plastic surgeons, radiologists, microbiologists, and physical therapists, reliable cooperation and communication is essential.

Isolated subtalar dislocation.

BACKGROUND Little attention has been devoted to subtalar dislocations without an associated bone injury in the literature to date. The aim of this study was to assess the functional and subjective results of a cohort of patients with this injury. METHODS A total of ninety-seven patients with a subtalar dislocation were treated at two major university trauma centers from January 1994 to March 2007. Computed tomographic scans indicated a subtalar dislocation without associated bone injury in twenty-three of these patients. Clinical and radiographic examinations were performed on all twenty-three patients at an average of 58.3 months after the completion of treatment. The postoperative clinical examination was supplemented by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and the degree of arthritis was assessed radiographically. RESULTS The average score on the AOFAS ankle-hindfoot scale score was 82.3 points. Twenty-one patients achieved a good result, and two patients had a satisfactory result. The range of motion of the subtalar joint was an average of 41.3 degrees. No difference between the results of the medial and lateral subtalar dislocations was observed. Only six patients had minor radiographic changes. CONCLUSIONS The intermediate-term results for a subtalar dislocation without an associated osseous injury are good, and the direction of the dislocation does not appear to make a difference with regard to clinical or radiographic outcome.

Influence of a standardized closed soft tissue trauma on resistance to local infection. An experimental study in rats.

Purpose: The etiology of local posttraumatic infection in the locomotor system depends on the amount, virulence and pathogenicity of the inoculated microorganisms and the local/systemic host damage due to the type and extent of the accident or iatrogenic trauma. The relative effect of these factors remains unclear. In particular, it is still unclear today whether—in presence of microorganisms—soft tissue damage and its pathophysiological consequences lead to infection after soft tissue trauma, or whether the bacterial contamination is the primarily cause for posttraumatic infection. The aim of the project was to gain information on the consequences of a soft tissue injury in terms of resistance to local infection. Since clinical populations are too heterogeneous, the problem was investigated in a standardized, reduced (no surgery or implants) experimental in vivo model.

Traumatic manubriosternal dislocation

Manubriosternal dislocation is an extremely rare occurrence, especially as the result of an indirect compression injury. Manubriosternal dislocations are divided into two types: In a Type I dislocation, the body of the sternum is displaced in a dorsal direction; in Type II dislocation, the body is displaced to the ventral side of the manubrium. A manubriosternal dislocation may be caused by direct or indirect trauma. Direct injury is generally a collision injury occurring in the context of a road accident. Resulting may be in either a Type I or Type II dislocation. Indirect trauma always leads to a Type II dislocation due to a flexion-compression mechanism in the region of the spine. Rheumatic arthritis and obvious kyphosis are predisposing factors in manubriosternal dislocation due to the indirect compression injury. Non-operative treatments after reduction, e.g. correction tape or plaster bandage, symptomatic pain treatment, application of ice, and several weeks without sports, are associated with a not inconsiderable rate of subluxations or reluxations, especially due to insufficient patient compliance. These disorders can lead to chronic pain, periarticular calcification with ankylosis, and progressive deformity. It has not been possible to establish an optimal, standardized operative procedure so far because of the small number of cases. We have achieved very good, postoperative long-term outcomes after plate osteosynthesis of manubriosternal dislocations in two patients.

Fracture dislocation of the elbow involving the coronoid process

ZusammenfassungEinleitung. Ellenbogenluxationen gehen in 30–50% mit knöchernen Begleitverletzungen einher.Mitentscheidend für die Stabilität des Ellenbogengelenkes ist hierbei der Processus coronoideus ulnae. Methodik. In einer retrospektiven Studie wurden 39 von 51 Patienten, die im Zeitraum von 1990–1999 in unserer Klinik aufgrund einer Ellenbogenluxation mit Beteiligung des Processus coronoideus operativ versorgt wurden, nach durchschnittlich 45 Monaten untersucht. Ergebnisse. Nach den Kriterien des Scores von Morrey erreichten 3 Patienten ein sehr gutes,19 Patienten ein gutes sowie 14 Patienten ein mäßiges Behandlungsergebnis. In 3 Fällen wurde ein schlechtes Ergebnis erzielt. Schlussfolgerung. Das Endergebnis nach operativer Versorgung von Ellenbogenluxationsfrakturen mit Beteiligung des Processus coronoideus wird maßgeblich vom Ausmaß der knöchernen Begleitverletzungen am Radiusköpfchen und Olekranon bestimmt. Voraussetzung zur Wiedererlangung eines stabilen Gelenkes mit guter Funktion ist die frühzeitige, übungsstabile Refixation oder Rekonstruktion des Processus coronoideus sowie die frühfunktionelle Gelenkmobilisierung.AbstractIntroduction. Elbow dislocations are associated with osseus lesions in 30–50%. Integrity of the coronoid process is essential for stability of the elbow joint. Methods. A retrospective study of 39 patients out of 51 was conducted to evaluate a result of surgical treatment in fracture dislocation of the elbow involving the coronoid process. The patients were followed for an average of 45 months. Results. Operative results were assessed using the Morrey-Score.3 patients presented an excellent, 19 a good, 14 a moderate and 3 a non satisfactory result. Conclusion. Results of operative treatment of fracture dislocation of the elbow are essentially determined by the extent of associated osseus lesions of the radial head and the olecranon.To achieve acceptable functional results early reconstruction and fixation of the coronoid process as well as early mobilisation of the joint is necessary.

Luxationsfrakturen des Ellenbogens mit Beteiligung des Processus coronoideus

ZusammenfassungEinleitung. Ellenbogenluxationen gehen in 30–50% mit knöchernen Begleitverletzungen einher.Mitentscheidend für die Stabilität des Ellenbogengelenkes ist hierbei der Processus coronoideus ulnae. Methodik. In einer retrospektiven Studie wurden 39 von 51 Patienten, die im Zeitraum von 1990–1999 in unserer Klinik aufgrund einer Ellenbogenluxation mit Beteiligung des Processus coronoideus operativ versorgt wurden, nach durchschnittlich 45 Monaten untersucht. Ergebnisse. Nach den Kriterien des Scores von Morrey erreichten 3 Patienten ein sehr gutes,19 Patienten ein gutes sowie 14 Patienten ein mäßiges Behandlungsergebnis. In 3 Fällen wurde ein schlechtes Ergebnis erzielt. Schlussfolgerung. Das Endergebnis nach operativer Versorgung von Ellenbogenluxationsfrakturen mit Beteiligung des Processus coronoideus wird maßgeblich vom Ausmaß der knöchernen Begleitverletzungen am Radiusköpfchen und Olekranon bestimmt. Voraussetzung zur Wiedererlangung eines stabilen Gelenkes mit guter Funktion ist die frühzeitige, übungsstabile Refixation oder Rekonstruktion des Processus coronoideus sowie die frühfunktionelle Gelenkmobilisierung.AbstractIntroduction. Elbow dislocations are associated with osseus lesions in 30–50%. Integrity of the coronoid process is essential for stability of the elbow joint. Methods. A retrospective study of 39 patients out of 51 was conducted to evaluate a result of surgical treatment in fracture dislocation of the elbow involving the coronoid process. The patients were followed for an average of 45 months. Results. Operative results were assessed using the Morrey-Score.3 patients presented an excellent, 19 a good, 14 a moderate and 3 a non satisfactory result. Conclusion. Results of operative treatment of fracture dislocation of the elbow are essentially determined by the extent of associated osseus lesions of the radial head and the olecranon.To achieve acceptable functional results early reconstruction and fixation of the coronoid process as well as early mobilisation of the joint is necessary.

[Spine fractures in patients with ankylosing spondylitis: an analysis of 129 fractures after surgical treatment].

INTRODUCTION The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Wirbelsäulenfraktur bei ankylosierender Spondylitis

INTRODUCTION The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.