Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable?

BACKGROUND CONTEXT

Many institutions' retrospective studies investigated the effect of the timing of surgery on outcomes of polytraumatized patients with severe lesions of the thoracic spine and mainly found a better outcome for patients who were operated on less than 72 hours posttrauma.

PURPOSE

We conducted a prospective study in a Level I trauma center to validate the retrospective data and to investigate other variables, in addition to the timing of surgery that may influence patient outcomes.

STUDY DESIGN

Prospective observational clinical study.

PATIENT SAMPLE

Within this prospective study at a Level I trauma center, we enrolled 38 multiple injured patients with unstable fractures of vertebral column from Level Th1 to L1. Further inclusion criteria consisted of an injury severity score of 16 or more and an intensive care unit (ICU) stay of more than 7 days. The age of included patients was limited from 16 or more to 75 or less years.

OUTCOME MEASURES

Hospital stay, stay on ICU, and mortality.

METHODS

Twenty-two patients were operated on less than or equal to 72 hours posttrauma, and 16 received late surgery greater than or equal to 72 hours posttrauma.

RESULTS

Patients who received early surgery had a significantly higher mortality rate (p<.01) than those who received late surgery. Sixty-seven percent of our patients who had an initial hemoglobin (Hb) less than 10 mg/dL died. Seventy-five percent of those patients who had an Hb less than 10 mg/dL and received a thoracic drain died.

CONCLUSIONS

Although some reports indicate advantages for early surgery for thoracic spine trauma in the polytraumatized patient, careful patient selection should be used. Based on the results of this prospective study, early surgery for thoracic spine trauma in patients with concomitant severe thoracic trauma and low initial Hb levels may pose a risk for poor clinical outcomes.

[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]

BACKGROUND

Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia.

PATIENTS AND METHODS

In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention.

RESULTS

A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group.

CONCLUSION

A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

[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.

Additional external hinged fixator after open repositioning and internal fixation of acute elbow instability in non-compliant patients

This is a retrospective analysis of the clinical and radiological outcome in 11 patients with complex acute posttraumatic elbow instability after dislocation. These patients had also been treated with a hinged external fixator after open reduction, capsular and ligamentous reconstruction and internal fixation, because of an expected diminished compliance, to avoid a secondary dislocation of the internal fixation. Concentric stability and a sufficient range of motion of the elbow joint were achieved in all cases. Non-compliant patients were classified by the surgeon as not compliant or not able or not willing to cooperate post-operatively for various reasons, such as alcoholism, drug abuse, mental disability, cerebral trauma or senile dementia. Non-compliant patients had undergone open reduction and internal fixation of an acute posttraumatic unstable elbow. The addition of a hinged external fixator allows early intensive mobilization, and can protect and improve the clinical outcome after these complex elbow injuries. This evaluation remains, of course, largely subjective and decision making is not easy because in most cases, the patient was not known before surgery. Thus, the only patient exclusion criteria in this study was surgeon classification as “compliant”.

Myths and facts of spondylodiscitis: an analysis of 183 cases

The authors conducted a retrospective study on 183 cases of spondylodiscitis, treated conservatively (44%) or surgically (56%) between November 1991 and June 2006. The male/female ratio was 99/84, and the mean age 62.6 years. The mean follow-up period was 12 years (range 4-19). Interesting from a clinical viewpoint: temperature, white blood cell count, and CRP were sometimes normal, while pain varied from slight to unbearable. The commonest risk factor was diabetes mellitus, and the most frequent pathogen was Staphylococcus aureus. Methicillin resistant Staphylococcus aureus (MRSA) was found in 6 patients, and 3 or 50% of these died, in sharp contrast with the overall mortality rate of 8.7%. A neurological deficit was seen in 43.7% of the patients; complete recovery occurred in 71% of the patients with a Frankel D stage, but in only 15.4 to 222% of those with a stage A, B or C.

Rare complication after VAC-therapy in the treatment of deep sore ulcers in a paraplegic patient

The VAC-therapy is a safe, easy, and effective therapy for the management of chronic wounds. Known advantages of the VAC technique are the quicker wound healing by stimulating the blood flow, the formation of granulation tissue, angiogenesis, and cell proliferation. The use of negative pressure treatment can decrease the number of dressing changes and length of hospital stay. However, some related complications after and during VAC therapy have been described. We here describe a rare complication during the treatment of severe os ischium sore with VAC therapy, which has not been reported in the literature yet. We report about a 43-year-old paraplegic patient, referred to our clinic from a regional hospital where he had been admitted 2 months earlier, presenting with a necrotizing fasciitis after VAC therapy during the treatment of fourth grade os ischium sore. After operative debridement and long-term antibiotics with Ciprofloxacin soft tissue closure was performed using a myocutaneous tensor fascia lata flap. Temporary stabilization was achieved by a triangle external fixateur attached to the right femur and the pelvis. After 1 week the tapping point of the muscle flap could be covered with local skin mesh-graft from the right calf as a donor site. The patient was mobilized in a wheelchair and was discharged home 3 months after admission. The VAC technique is a safe, easy, and effective means in chronic wound care management. However, the described rare complication should be kept in mind. The clinical management of VAC therapy requires a distinct indication and close clinical monitoring by experienced medical professionals. The use of VAC therapy in fourth grade sores may have deleterious consequences for the patient.

[Paraplegia after isolated rupture of the spinal cord - a rare injury]

INTRODUCTION

Complex vertebral fractures can lead to injury of the spinal cord with resulting paraplegia. High-speed accidents are common causes, especially in younger patients. Malignant or inflammatory processes play an important role in the elderly. Less common reasons for a spinal cord injury are congenital malformations. We here report about a 17-year-old patient who suffered from paraplegia after an isolated rupture of the spinal cord without an injury of the vertebral bodies, intervertebral disc or ligamentous structures. This type of injury has not been reported in the literature before.

PATIENT AND METHOD

We report about a 17-year-old patient, referred to our hospital, presenting with lumbal paraplegia after a high-speed accident 8 days prior to admission. After initial stabilisation of the polytraumatised patient, he was referred to our hospital for further treatment.

RESULTS AND CONCLUSION

The radiological examination showed a bilateral acetabular fracture, a right anterior pelvic ring fracture and shaft fractures of the left humerus and right femur. Furthermore, the spinal cord at thoracic level 10/11 was ruptured. Interestingly, there was no injury of the vertebral bodies, intervertebral disc or ligamentous structures. A tethered cord as a possible anatomic variation could be excluded in this case by MRI. However, anatomic variations could be the reason for this injury and should be kept in mind.

[Arthrodesis of the infected ankle joint: results with the Ilizarov external fixator]

BACKGROUND

The treatment of severe bacterial infections of the ankle joint is difficult and complex. In the case of a chronic infection with destruction of the ankle joint, a tibiotalar arthrodesis with external fixation is the treatment of choice. In this study the results of ankle arthrodesis due to bacterial infection using the Ilizarov external fixator are presented.

PATIENTS AND METHODS

Between 2001 and 2004 37 patients (10 female, 27 male, mean age 58 years) were treated with a tibiotalar arthrodesis using the Ilizarov fixator. All patients had a confirmed infection in the course of their disease. Active infection was present in 20 patients at the time of the operation. Most secondary ankle arthritides (81 %) were caused post-traumatically after various internal fixation procedures. Previous ankle arthrodeses were tried in 14 cases (12 cases with internal fixation, two cases with external monolateral fixation). Patients were treated with a four-ring Ilizarov frame (in two cases with a five-ring frame) and stainless steel wires. All patients could be included at a mean follow-up of 46 (12-49) months. A modified AOFAS score was used for the functional outcome.

RESULTS

The operation took 141 minutes at an average ranging from 90 to 252 minutes. The inpatient treatment lasted between 10 and 63 days (mean 26 days). The time spent in the fixator was 116.7 (69-245) days. All patients were mobilised under full weight bearing with the external fixator. Surgical revision was necessary in 13 patients: four patients needed wound revisions due to ongoing infection, six patients needed wire exchange due to deep infection in three cases and wire breakage in three cases, one patient needed additional wires because of an initially instable frame configuration and two patients needed secondary skin grafting. Bony consolidation was achieved in 32 patients (86.5 %). With a re-arthrodesis performed in four patients using the Ilizarov fixator, the overall fusion rate was 94.6 %. Infection was persistent in two cases with one solid ankle fusion and one ankle pseudarthrosis. At the time of follow-up 35 patients were able to walk under full weight loading with orthopaedic shoe modifications, four patients needed support of a cane and three patients wore an ankle-foot orthesis. The two patients with persistent pseudarthrosis were mobilised in a lower-leg orthesis after declining another surgical revision. The positioning of the hindfoot showed in seven cases an equinus of 10°, in one case a varus of 10° and in two cases a valgus positioning of 10°. A plantigrade foot positioning or with minimal degrees of deviation could be achieved in all other cases. The modified AOFAS score at the time of the follow-up examination ranged from 19 to 86 with an average score of 67.9 points. All patients except three were satisfied or rather satisfied with the treatment procedure and its results.

CONCLUSION

The Ilizarov external fixator is a safe method for ankle fusion in cases of infection. The advances are a possible application at acute infection and immediate mobilisation at full weight bearing. However, it remains a time-consuming and stressful procedure for the patient.

[Operative treatment of pediatric open fractures of the lower limb using the Taylor spatial frame fixator]

The operative management of open fractures of the lower limb requires a consistent treatment to avoid soft tissue complications. Acute angular shortening of the fracture enabling primary soft tissue closure is still an uncommon operative technique because of difficulties in correcting the secondary deformity. The case of a pediatric open fracture of the lower limb (Gustilo type IIIa) is described, which was treated with acute angular shortening followed by gradual correction using the Taylor spatial frame (TSF).

[Arm wrestling injuries--report on 11 cases with different injuries]

INTRODUCTION

Arm wrestling may cause severe injuries. Various injuries after arm wrestling have been reported in the literature, whereas the most common injury is the humeral shaft fracture. In this context we report on eleven cases with different injuries during arm wrestling.

MATERIAL AND METHODS

All patients were analyzed using a standardized questionnaire. The effect of drugs, pre-existing conditions and injuries as well as sport activities were examined. Furthermore we report about a 24 year old patient who sustained a radial shaft fracture which has not been reported in the literature yet.

RESULTS

8 patients suffered from a fracture. The humerus was the most affected bone in 7 cases. 3 patients had a muscle strain, whereas in all 3 cases the patients were regularly sportive active and warmed-up be for the injury. Ten patients were reintegrated into the previous job after an average time period of 6 weeks. One patient was out of work.

CONCLUSIONS

Regular sport activity and the muscle strength are important factors for the injury intensity. Further studies are necessary to confirm this theory.

[The risk of nerve lesions in hip alloarthroplasty]

AIM

Repeated luxations, periprosthetic fractures, infections, and nerve palsies are the most frequent complications of hip alloarthroplasty. Paresis acquired during elective implantation entails considerable restrictions in the quality of life. The risk of sustaining a nerve injury depends upon the initial clinical situation, cases of planned leg lengthening in patients with hip dysplasia and high luxations being particularly at risk.

METHOD

A Medline search was conducted using the query "nerve palsies during hip prosthesis implantation", yielding 126 publications, of which 18 were used to predict the risk of nerve palsies in cases with simultaneous leg lengthening during total hip arthroplasties according to different preconditions.

RESULTS

The risk for an acquired nerve lesion during hip alloarthroplasty in arthritis was 0.5 %. In cases of hip dysplasia (with no or moderate leg lengthening during the procedure), the risk was increased to 2.3 %. An even higher risk of 3.5 % was found in cases of revision surgery. According to the literature, the risk of nerve palsies in cases of continuous leg lengthening before THA is raised to 5.9 % with a linear correlation between the amount of leg lengthening and rate of nerve palsies.

CONCLUSION

Neural lesions during single-stage leg lengthening of less than 3 cm in hip alloarthroplasty are uncommon. More extensive lengthening can be achieved with continuous procedures, which should be conducted under clinical monitoring of the peripheral nerves to avert possible nerve injury.

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.

[Solitary fibrous tumor of the pelvis: a rare extrathoracic manifestation]

Solitary fibrous tumors (SFT) are rare spindle cell neoplasms. To date only very few cases of pelvic SFT have been reported in the literature. SFT are characterized by unique microscopic and immunohistochemical findings. Complete local resection is the treatment of choice. Recurrence and metastasis may be related to infrequent malignant histological features, but histology is not always a reliable predictor for prognosis. Therefore long-term follow-up is necessary.We report about a male patient with a malignant pelvic SFT. After complete resection the tumor recurred after a short period of 6 months posterior to the original location in the pelvis. The differential diagnoses and the therapy options are discussed with a review of the present literature.

[Early-onset infection after hemiarthroplasty of the hip: an algorithm for surgical therapy]

BACKGROUND

In a retrospective study, we compared the results of different surgical therapies in 30 patients who had an early-onset infection after implantation of a hip hemiarthroplasty.

MATERIAL AND METHODS

Patients were divided into two groups: In group 1 (n=16, deep infection), we changed the polyethylene inlay as well as the femoral head. In group 2 (n=14, deep infection), an acetabular component was also implanted.

RESULTS

In group 1, successful treatment was achieved in 37.5% of patients 6 months after the last operation, compared with 71.4% in group 2 (p=0.019). All patients were supported with antibiotics. In group 1, three patients died from septic multiorgan failure. Two patients in group 1 and one patient in group 2 received a Girdlestone operation.

CONCLUSIONS

These results suggest that aggressive surgical treatment with soft tissue revision, lavage, and implantation of an acetabular component in combination with antibiotics is a useful technique for treating early-onset infection.

Elevated systemic interleukin-18 in multiple injured patients is not related to clinical outcome

Interleukin-18 (IL-18) is a pleiotropic proinflammatory cytokine with the ability to induce interferon-gamma production in T-helper cells type 1 and natural killer cells. To investigate the role of IL-18 after severe trauma we measured plasma levels of IL-18 in 229 multiple injured patients [mean age of 39 +/- 16 (range 11-81) years, injury severity score (ISS) of 31 +/- 10 (range 16-66) points; 55 women and 174 men] and correlated these with demographics, clinical course, and routine laboratory parameters. IL-18 plasma levels were significantly increased in polytraumatized patients compared to healthy donors (p < 0.001). Survivors presented significantly (p < 0.05) higher IL-18 plasma median values (n = 193, median 98 pg/mL) compared to nonsurvivors (n = 36, median 63 pg/mL). Patients >60 years old (n = 35) had significantly lower plasma levels of IL-18 (median 45 pg/mL) compared to younger ones (n = 194, median 92 pg/mL). In the subgroup of nonsurvivors (n = 12) elderly patients had the lowest plasma levels of IL-18 (median 45 pg/mL). Patients with an ISS >25 had significant higher IL-18 plasma levels compared to the group with an ISS <or=25 (p < 0.001). Our data demonstrate elevated plasma levels of IL-18 after severe trauma.

[Tuberculous rice body synovitis of the shoulder joint]

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

[Posttraumatic tracheal stenosis after complex fracture of the upper cervical spine: a rare complication]

Combined injuries of the upper cervical spine are rare and can lead to life-threatening positional changes of the respiratory tract. Hence, it is very important to recognize tracheal and soft tissue injuries and to treat these adequately. We report on the clinical course and outcome of a case with a delayed high-grade tracheal stenosis after cervical spine injury, which could only be treated by emergency tracheotomy and partial transverse trachea resection.The 25-year-old female suffered a complex dislocated upper cervical spine fracture with a Jefferson fracture, an odontoid fracture and a dislocated C6/7 luxation fracture after a motor vehicle accident. Immediately after trauma inspiratory stridor was reported. Postoperatively, the tracheal stenosis increased and the histological examination of tissue collected during emergency bronchoscopy showed granulation tissue.Even if fractures of cervical spine injuries are treated successfully, soft tissue and tracheal injuries cannot be precluded. Therefore, it is most important that such patients are followed-up closely to classify the problem and to determine the ideal time for surgical treatment of tracheal injuries and stenoses.

Systemic inflammatory mediators in post-traumatic complex regional pain syndrome (CRPS I) - longitudinal investigations and differences to control groups

OBJECTIVES

The Complex Regional Pain Syndrome I (CRPS I) is a disease that might affect an extremity after trauma or operation. The pathogenesis remains yet unclear. It has clinical signs of severe local inflammation as a result of an exaggerated inflammatory response but neurogenic dysregulation also contributes to it. Some studies investigated the role inflammatory mediators and cytokines; however, few longitudinal studies exist and control groups except healthy controls were not investigated yet.

METHODS

To get further insights into the role of systemic inflammatory mediators in CRPS I, we investigated a variety of pro-, anti-, or neuro-inflammatory mediators such as C-Reactive Protein (CRP), White Blood Cell Count (WBC), Interleukins 4, 6, 8, 10, 11, 12 (p70), Interferon gamma, Tumor-Necrosis-Factor alpha (TNF-a) and its soluble Receptors I/II, soluble Selectins (E,L,P), Substance-P (SP), and Calcitonin Gene-Related Peptide (CGRP) at different time points in venous blood from patients with acute (AC) and chronic (CC) CRPS I, patients with forearm fractures (FR), with neuralgia (NE), and from healthy volunteers (C).

RESULTS

No significant changes for serum parameters investigated in CRPS compared to control groups were found except for CC/C (CGRP p = 0.007), FR/C (CGRP p = 0.048) and AC/CC (IL-12 p = 0.02; TNFRI/II p = 0.01; SP p = 0.049). High interindividual variations were observed. No intra- or interindividual correlation of parameters with clinical course (e.g. chronification) or outcome was detectable.

CONCLUSION

Although clinically appearing as inflammation in acute stages, local rather than systemic inflammatory responses seem to be relevant in CRPS. Variable results from different studies might be explained by unpredictable intermittent release of mediators from local inflammatory processes into the blood combined with high interindividual variabilities. A clinically relevant difference to various control groups was not notable in this pilot study. Determination of systemic inflammatory parameters is not yet helpful in diagnostic and follow-up of CRPS I.

[The Taylor Spatial Frame. Correction of posttraumatic deformities of the tibia and hindfoot]

INTRODUCTION

Posttraumatic deformities in the lower limb are mainly multidirectional, with angulation, translation, and rotatory deformities. Acute corrections with internal fixation are often not possible due to the soft tissue damage and the extent of the deformity. The Taylor Spatial Frame (TSF) allows correction in a virtual hinge with 6 axes, thus enabling the correction of multidirectional deformities simultaneously.

METHODS

From February 2003 until December 2006, we applied 31 TSFs to 20 patients with a posttraumatic deformity of the tibia and hindfoot. The mean patient age was 41 years (range 12-73). 9 patients had a nonunion of the tibia with deformity, 6 had a malunion of the lower tibia and ankle, 3 had an angular deformity after ankle fusion, and 2 had malaligned Ilizarov bone segment transports. The mean follow-up time was 25.3 months (range 10-82).

RESULTS

In all 20 patients, full correction of the deformity was achieved. The mean time for correction was 29 days (range 5-82). On average, the frame was worn (time to healing) 164.2 days (80-300) and the mean distraction rate was 1.1 mm/day (0.5-2.0). The Web-based planning was done two times per case for full deformity correction. Complications were 3 pin-site infections, 2 insufficient callus formations and 1 pinhole stress fracture.

CONCLUSIONS

The main advantage of the TSF compared with other external frames is the ability to perform simultaneous correction of angular, axial, translational, and rotatory deformities. This enables a reduced correction time and increased patient comfort.

Treatment of acute and chronic elbow instability with a hinged external fixator after fracture dislocation

This is a retrospective analysis of the clinical and radiological outcome in 24 patients with acute or chronic posttraumatic elbow instability, who were treated with open reduction, internal fixation and a hinged external fixator. The instability was acute after elbow fracture dislocation in 11 cases; the other 13 had chronic posttraumatic instability of the elbow. Concentric stability and a sufficient range of motion of the elbow joint were achieved in all cases. The addition of a hinged external fixator in noncompliant patients, who underwent open reduction and internal fixation of an acute or chronic posttraumatic unstable elbow, allows early intensive mobilisation and can improve the clinical outcome after these complex elbow injuries.

Studies on the biocompatibility and the interaction of silver nanoparticles with human mesenchymal stem cells (hMSCs)

PURPOSE

Silver nanoparticles (Ag-NPs) are widely used in different areas, e.g., in the food, electronic, or clothing industry due to well-known slow-release antiseptic activities. Despite the widespread use of nanosilver, there is a serious lack of information concerning the biological activities of nanosilver on human tissue cells.

MATERIALS AND METHODS

In this study, the influence of spherical Ag-NPs (diameter about 100 nm) on the biological functions (proliferation, cytokine release, and chemotaxis) of human mesenchymal stem cells (hMSCs) was analyzed.

RESULTS

The results showed a concentration-dependent activation of hMSCs at nanosilver levels of 2.5 microg mL(-1), and cytotoxic cell reactions occurred at Ag-NPs concentrations above 5 microg mL(-1). Cell proliferation and the chemotaxis of hMSC both decreased with increasing Ag-NPs concentrations. Different effects on the cytokine release from hMSCs were observed in the presence of Ag-NPs and Ag(+) ions. The release of IL-8 was significantly increased at high but noncytotoxic concentrations of Ag-NPs (2.5 microg mL(-1)). In contrast, the levels of IL-6 and VEGF were concomitantly decreased compared to the control group. The synthesis of IL-11 was not affected at different Ag-NP concentrations. The agglomeration tendency of Ag-NPs in different biological media increased with a high electrolyte content, e.g., in RPMI. However, complexation with fetal calf serum in the cell culture media stabilized the Ag-NPs against agglomeration.

CONCLUSION

In summary, the results showed that Ag-NPs exert cytotoxic effects on hMSCs at high concentrations but also induce cell activation (as analyzed by the release of IL-8) at high but nontoxic concentrations of nanosilver.

Rare anterior shoulder dislocation in a toddler

Traumatic anterior shoulder dislocation in toddlers and pediatric patients is a very rare injury pattern. The treatment and the recurrence rate are mostly extrapolated from adult and adolescent data. A 2-year-old toddler is presented with a first-time traumatic shoulder dislocation caused by a pull on the abducted arm. The treatment included a gentle closed reduction performing the Milch maneuver and a short-sling immobilization. The 2.5-year-follow-up demonstrated a stable shoulder with free range of motion while still having a Hill-Sachs-lesion. Shoulder dislocation in toddlers maybe addressed less aggressively after closed reduction than in adults due to an unknown recurrence rate.

Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?

INTRODUCTION

Immobilization in external rotation after a first-time traumatic anterior shoulder dislocation has been shown to improve the position of the labroligamentous lesion relative to the glenoid rim. The purpose of the present study was to evaluate the effect of the external rotation position of the shoulder on different types of labroligamentous lesions in patients with first-time traumatic anterior shoulder dislocation by using MRI.

PATIENTS AND METHODS

We performed a standardized MRI in internal and external rotation of the shoulder after initial reduction in 34 patients with a first-time traumatic anterior shoulder dislocation. Labroligamentous lesions were classified as Bankart, Perthes, or nonclassifiable. Four distinct grades were used to classify the amount of plastic deformation of the anterior labroligamentous structures. The position of the labrum was defined relative to the tip of the glenoid rim by measuring the dislocation and separation.

RESULTS

In all patients, dislocation and separation of the labrum relative to the rim of the glenoid were significantly improved in shoulders in the external rotation position compared to those in the internal rotation position. We observed 15 Bankart, 15 Perthes, and 4 non-classifiable lesions. No HAGL or GLAD lesions were found. Fourteen patients showed a plastic deformation grade I, 16 showed grade II, 3 showed grade III, and 1 showed grade IV. In regression analysis, the odds ratio was 1.100 for the type of lesion and 1.660 for the grade of plastic deformation. Perthes lesions (with an intact anterior scapular periosteum) and grade I plastic deformations showed the best labral reduction on the external rotation MRI.

CONCLUSION

Placing the shoulder in external rotation after a first-time traumatic shoulder dislocation, significantly improves the position of the labroligamentous lesion on the glenoid rim. Perthes lesions that showed a low grade of plastic deformation displayed better reduction in external rotation and then compared to Bankart or other lesions that showed a high grade of plastic deformation. In conclusion, immobilization of the shoulder after a first-time traumatic shoulder dislocation is most effective in patients with Perthes lesions that show low grade plastic deformation.

Ultrasound-induced modifications of cytoskeletal components in osteoblast-like SAOS-2 cells

In clinical and experimental studies an acceleration of fracture healing and increased callus formation induced by low-intensity pulsed ultrasound (LIPUS) has been demonstrated. The exact molecular mechanisms of ultrasound treatment are still unclear. In this study ultrasound transmitted cytoskeletal and growth rate changes of SAOS-2 cells were examined. Osteoblast-like cell lines (SAOS-2) were treated using low-intensity pulsed ultrasound. Cytoskeletal changes were analyzed using rhodamine phalloidine for f-actin staining and indirect immunofluorescence techniques with different monoclonal antibodies against several tubulin modifications. To examine changes of cell number after ultrasound treatment cell counts were done. Significant changes in cytoskeleton structure were detected compared to controls, including an enhancement of stress fiber formation combined with a loss of cell migration after ultrasound application. We further observed that sonication altered the proportion of the more stable microtubules to the more labile microtubule subclass. The labile tyrosinated microtubules appeared highly enhanced, whereas the amount of the more stable acetylated microtubules was remarkably diminished. All these observations were quantified by fluorometric measurements. The centrosomal gamma-tubulin was frequently scattered throughout the cell's cytoplasm, giving rise to additional polyglu-positive microtubular asters, which induced multipolar spindles, leading either to aneuploid mini-or giant cells. Moreover, a significant increase of cell number was noticed in the sonicated group. These experiments demonstrate that ultrasound treatment increases cell number and leads to significant changes of the cytoskeletal structure and composition in vitro.

Activation of human leukocytes on tantalum trabecular metal in comparison to commonly used orthopedic metal implant materials

We analyzed leukocyte functions and cytokine response of human leukocytes toward porous tantalum foam biomaterial (Trabecular Metaltrade mark, TM) in comparison to equally sized solid orthopedic metal implant materials (pure titanium, titanium alloy, stainless steel, pure tantalum, and tantalum coated stainless steel). Isolated peripheral blood mononuclear cells (PBMC) and polymorphonuclear neutrophil leukocytes (PMN) were cocultured with equally sized metallic test discs for 24 h. Supernatants were analyzed for cytokine content by enzyme-linked immunosorbent assay. Compared to the other used test materials there was a significant increase in the release of IL (interleukin)-1ra and IL-8 from PMN, and of IL-1ra, IL-6, and TNF-alpha from PBMC in response to the TM material. The cytokine release correlated with surface roughness of the materials. In contrast, the release of IL-2 was not induced showing that mainly myeloid leukocytes were activated. In addition, supernatants of these leukocyte/material interaction (conditioned media, CM) were subjected to whole blood cell function assays (phagocytosis, chemotaxis, bacterial killing). There was a significant increase in the phagocytotic capacity of leukocytes in the presence of TM-conditioned media. The chemotactic response of leukocytes toward TM-conditioned media was significantly higher compared to CM obtained from other test materials. Furthermore, the bactericidal capacity of whole blood was enhanced in the presence of TM-conditioned media. These results indicate that leukocyte activation at the surface of TM material induces a microenvironment, which may enhance local host defense mechanisms.

Epidemiology of traumatic spine fractures

OBJECTIVES

To illustrate the correlations and effects of age, gender and cause of accident on the type of vertebral fracture and fracture distribution, as well as on the likelihood to sustain an associated injury or neurological deficit.

DESIGN

Retrospective analysis of 562 patients with a traumatic fracture of the spine. Each patient was analysed by reviewing the medical records, the initial radiographs and CT-scans.

SETTING

Level 1 trauma centre from 01/1996 to 12/2000.

RESULTS

The most common cause of accident was a high-energy fall (39%), followed by traffic accidents (26.5%). While fall related fractures were evenly distributed over the whole spine, traffic accidents induced significantly more fractures of the cervical and thoracic spine. Sixty-five percent of all cervical spine fractures and 80% of the multisegmental injuries were accompanied by an associated injury. The highest incidence of associated injuries was observed in patients with multilevel fractures (96.5%). Patients with a concomitant injury were more likely to sustain a spinal cord lesion. Sixty-three (11.2%) patients exhibited a complete motor and sensory deficit, 76 (13.5%) an incomplete and 423 (75.3%) no neurological deficit. The highest number of complete motor and sensory neurological deficits was found in cervical spine fractures (19.7%). The majority of patients, 308 (54.8%), sustained a compression fracture, 95 (16.9%) a distraction fracture, and 104 (18.5%) patients experienced a rotational fracture.

CONCLUSIONS

This study demonstrates correlations between the cause of accident, the type of spinal fracture and the fracture distribution. Using the AO classification, the likelihood to sustain either associated and/or spinal cord injuries, is predictable.

[The Taylor spatial frame fixator. Soft-tissue distraction for post-traumatic varus deformities of the hindfoot]

Despite adequate primary treatment many ankle fractures result in post-traumatic deformities and arthrosis. Revision mostly requires a multidirectional correction whereas internal fixation procedures are often not applicable due to soft tissue damage and the extent of deformity. The Taylor spatial frame enables simultaneous correction of multidirectional deformities through a virtual hinge using the same ideas of distraction osteogenesis as the Ilizarov fixator. The presented case demonstrates minimally invasive correction of a complex deformity of the ankle with the Taylor spatial frame fixator. Orthogonal alignment was achieved and a stabilizing tibiotalar arthrodesis was performed achieving a good functional and pain-free result.

Transsacral colon fistula: late complication after resection, irradiation and free flap transfer of sacral chondrosarcoma

Background

Primary sacral tumors are rare and experience related to accompanying effects of these tumors is therefore limited to observations on a small number of patients.

Case presentation

In this case report we present a patient with a history of primary sacral chondrosarcoma, an infection of an implanted spinal stabilization device and discuss the challenges that resulted from a colonic fistula associated with large, life threatening abscesses as late complications of radiotherapy.

Conclusion

In patients with sacral tumors enterocutaneous fistulas after free musculotaneous free flaps transfer are rare and can occur in the setting of surgical damage followed by radiotherapy or advanced disease. They are associated with prolonged morbidity and high mortality. Identification of high-risk patients and management of fistulas at an early stage may delay the need for subsequent therapy and decrease morbidity.

[Operative management and fracture care of the lower leg with the Ilizarov fixator in morbidly obese patients: literature review and results]

Given the rising prevalence of obesity, surgeons and hospitals must become more familiar with the treatment and operative management of obese patients. Several additional pre- and postoperative considerations must be involved such as appropriate assessment of comorbidities and requirements for special equipment. There are still very few data regarding morbidly obese patients with BMIs >50 kg/m(2). After a general literature review of operative management of obese patients, we report on fracture care of the lower limb in such patients with custom-made Ilizarov ring fixators. We found them suited to bear enormous weight-loading but that associated comborbidities can limit successful fracture care.

Systemic IL-17 after severe injuries

IL-17 is a cytokine produced by a newly identified T-cell subpopulation (THl7/THIL-17). It is a central mediator in inflammatory processes that connects T-cell stimulation with neutrophil mobilization. The role of IL-17 in the immune dysfunction after polytrauma is still not clarified. In a retrospective study, the systemic concentration of IL-17 and IL-6 of 71 polytraumatized patients were analyzed daily by enzyme-linked immunosorbent assay. The patients' collective consist of 55 men and 16 women (43 +/- 16 years; injury severity score, 33 +/- 13). In only 6% of the patients, an increase in systemic IL-17 was detected. In most patients (94%), no systemic IL-17 was detectable or the IL-17 concentrations in plasma were in the range of the healthy donor group. To identify a possible role of systemic IL-17 in the posttraumatic phase, the patients were divided into two groups. Group A (47 men, 15 women) consists of patients with IL-17 concentrations in the range of normal healthy donors. Group B (8 men, 1 woman) consists of patients with elevated (>45 pg ml(-1) on at least 3 consecutive days) systemic IL-17 concentrations. Three patients in group B showed highly increased systemic IL-17 concentrations (median, >200 pg mL(-1)). These patients were male and showed all blunt chest and abdominal trauma with lung contusion and pneumohemothorax. However, there was no conformity in other injury patterns, injury severity score, age, outcome, intensive care period, or clinical complications. After a period of 4 years, we were able to obtain a new blood sample from one patient with high IL-17 level. The systemic IL-17 value of this former patient was now less than the detection limit. However, stimulation of peripheral blood mononuclear cells from thlise patient revealed elevated numbers of cells with the capacity to produce IL-17 as determined by enzyme-linked immuno spot assay and flow cytometry compared with peripheral blood mononuclear cells obtained from current polytrauma patients and healthy donors. In conclusion, IL-17 is not suitable as a pathophysiological or predictive marker after polytrauma. Whether highly increased systemic IL-17 concentrations detected in single patients are due to individually increased numbers of TH17 cells as we have demonstrated with one rerecruited patient has to be further analyzed.

[Acute traumatic abdominal wall hernia after blunt abdominal trauma]

Traumatic abdominal wall hernias are rare injuries despite the high incidence of blunt abdominal traumas. The mechanism of this injury includes a sudden increase in intra-abdominal pressure and extensive shear forces applied to the abdominal wall. The typical location is found at anatomic weak areas in the lower abdomen. Often, significant intra-abdominal injuries or injuries of the pelvis and chest are associated. We describe a case of an abdominal contusion trauma leading to a traumatic abdominal wall hernia beside the rectal sheath. In this case, parts of the small bowel penetrated through the ruptured muscle of the abdominal wall up to the subcutis. After appropriate diagnosis, the defect was repaired using a sheet of synthetic mesh to stabilize the abdominal wall. Based on this case, the management of blunt abdominal wall hernias and the literature are discussed.

Hepatic failure after injury - a common pathogenesis with sclerosing cholangitis?

OBJECTIVE

Hepatic failure after trauma occurs in about 5 - 10 % of multiple injured patients. Mortality rate remains high and liver dysfunction might deteriorate to complete liver failure and contribute to multi organ failure (MOF). Pathogenesis is multifactorial and distinct mechanisms are unknown.

METHODS

To get further knowledge about pathogenesis of posttraumatic liver failure we investigated clinical course, inflammatory mediators, ERCP and histologic findings in 7 patients [6 male, 1 female, mean age 45.7 +/- 12.1 years, mean ISS 38.4 +/- 10.8 pts. (range 25-58 pts.)] that evolved hepatic failure after major trauma. Mortality rate was 14 %.

RESULTS

All patients presented with a prolonged shock period after trauma and severe respiratory failure requiring differentiated ventilatory support and prone positioning. Onset of significant bilirubinemia (> 2.0 mg/dl) was day 3 to 16 days (median 11 days) after trauma. Past medical history did not reveal any underlying liver disease in all patients. Pro-and anti-inflammatory parameters like WBC, Procalcitonin, IL-4, IL-10, IL-11, IL-12, and IL-18 remained close to healthy control values. CRP was elevated but did not correlate with Bilirubin. Transaminases (ALT, AST) remained close to normal values but increased during the further course, whereas alkaline phosphatase (aP) and gamma-glutamyl transpeptidase (gGT) were already significantly elevated even before Bilirubin (gammaGT: 394 +/- 317 U/l; controls: < 56 U/l; aP 557 +/- 311 U/l; controls: < 127 U/l). Although no cholestasis was proven in ultrasound and CT investigations, all patients underwent ERCP and liver biopsy. Here, all patients presented uniform signs of multiple strictures of the intrahepatic bile ducts and sclerosing cholangitis.

CONCLUSIONS

Our data provide evidence that sclerosing cholangitis contributes to liver failure after trauma. The pathomorphologic picture can not distinguish between shock liver and sclerosing cholangitis. Ischemia during posttraumatic shock might be an early trigger of hepatic failure, supported by further contributing factors such as catecholamines, parenteral nutrition, and bacterial translocation. As specific therapy for sclerosing cholangitis does not exist yet, prevention of triggers is central to avoid progressive hepatic failure in those patients. Further prospective studies have to prove whether sclerosing cholangitis is commonly involved in the pathogenesis of liver failure after trauma and shock. If so, one might speculate that early therapy with ursodeoxycholic acid might be effective thus reducing incidence and/or severity of hepatic failure in the future.

[Transarticular C1-C2 screw fixation: results of unstable odontoid fractures and pseudarthrosis in the elderly]

BACKGROUND

Transarticular dorsal screw fixation of atlantoaxial instability in the elderly is seldom described in the literature. This study presents the results of this technique in patients aged at least 70 years. A modified method of indirect screw fixation is used in which soft tissue dissection is reduced compared to the classic procedure.

PATIENTS AND METHODS

Between 1998 and 2005 a total of 36 patients with acute or chronic traumatic instability of the atlantoaxial complex were treated surgically. The average age was 80.1 years (70-93 years). Seven patients (19.4%) had associated injuries. The operative technique was standard. The duration of radiological follow-up averaged 23 months (12-57 months) whereas clinical follow-up was for 38 months (12-72 months).

RESULTS

There were no intraoperative complications. Of the total 72 screws inserted, 2 (2.8%) proved to be incorrectly positioned. There were complications not associated with the procedure in 16 patients (44.4%). Nosocomial infections and falls were the most common complications. Two deaths occurred within the first postoperative month. Four more patients died in the follow-up period as a result of diseases not associated with the trauma. Of the 30 surviving patients, 28 (93.3%) were followed up clinically and radiologically. Bony dorsal fusion was documented in every patient followed up. Further operation on the cervical spine was not required in any patient.

CONCLUSION

The presented technique of transarticular C1-C2 screw fixation is associated with reliable fusion rates and good functional results. The procedure can be recommended for atlantoaxial instability in the elderly.

In vivo microvascular response of murine cutaneous muscle to ibuprofen-releasing polyurethane foam

In view of their pain-relieving effect, the non steroidal anti-inflammatory drugs are more and more used as a pain-reducing component in modern wound dressings. To analyse the effect on new blood vessel growth, implants from Biatain Ibu, a polyurethane foam containing ibuprofen, were inserted into the dorsal skinfold chamber of BALB/c mice. Implants from ibuprofen-free polyurethane foam Biatain served as controls (n = 10 per group). Blood vessel growth and the functional vessel density (FVD) as a parameter for microvascularization of implant's border zone were assessed by intravital fluorescence microscopy (IVFM). IVFM was performed on days 3, 7 and 12 after implantation. Direct comparison showed no significant differences in FVD (mm/mm(2)) for the border zone of the ibuprofen-releasing implants versus controls on day 3 (185.49 +/- 4.75 versus 197.17 +/- 5.21) and day 7 (229.60 +/- 8.53 versus 247.99 +/- 5.39). However, the IVFM showed a significant increased FVD for ibuprofen-releasing implants (301.30 +/- 8.44 versus 279.24 +/- 5.78) on day 12 (P < 0.05). Also, a significant increase of FVD was detected for the ibuprofen-releasing implants throughout the implantation time of 12 days. This study shows that local release of small-dose ibuprofen from a polyurethane dressing does not decrease new blood vessel growth during the implantation time of 12 days. In the end, the microvascularization of implant's border zones in both groups was found comparatively undisturbed.

[Reduction of glenoid rim fractures after primary shoulder dislocation in external rotation]

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

[Spinal fractures in multiply injured patients: an analysis of the German Trauma Society's Trauma Register]

OBJECTIVE

Spinal trauma is frequently found in multiply injured patients. To gain more insight into the epidemiology and the clinical course of this entity, we analyzed the relevant data held in the German Trauma Registry (German Trauma Society, DGU). The Registry provides prospective, standardized and anonymous documentation on severely injured patients at different predetermined time points from the site of the accident until they are discharged from hospital.

METHODS

Out of 8,057 patients whose details are recorded in the German Trauma Registry, 772 (approximately 10%) with severe spine trauma (AIS>/=3) patients were identified. Far more men (72%) than women (28%) had such spinal injuries. The mean age of the patients with severe spine injury was 37+/-17 years; their mean Injury Severity Score (ISS) was 29+/-15 (range 9-75) points.

RESULTS

The age group 15-54 years was the largest (80%). Motor vehicle accidents (MVA) were the most frequent cause of severe spine trauma (49%), followed by falls from a great height (20%). About half of all severe spine injuries were not suspected in the prehospital setting. Symptoms of incomplete paraplegia were found in 20% of the patients and symptoms of complete paraplegia, in 27%. Patients with injuries to the thoracic spine more often had a lengthy average stay in the intensive care unit, because they were accompanied by thoracic trauma significantly more often than were injuries to the other spinal segments (96% vs 37%). Patients who underwent spinal surgery at an early stage (70% operated on <72 h after their injuries were sustained) showed a tendency to shorter periods ventilatory support and did not remain in the intensive care unit or indeed in the hospital as long as the other patients. Seventy-eight percent of the patients had survived for 90 days after sustaining their injuries.

CONCLUSION

Almost 10% of all documented cases of patients with severe injuries in the German Trauma Registry had severe spinal injuries. These injuries were frequently not recognized or their extent underestimated in the preclinical setting. About 70% underwent spine stabilization within 72 h after being injured. These results support previous findings suggesting that early stabilization of vertebral fractures might be beneficial in multiply injured patients.

Combined ipsilateral fractures of talus and calcaneus

INTRODUCTION

The purpose of this study was to evaluate the frequency of combined ipsilateral talar and calcaneal fractures, the fracture pattern in combination and the clinical outcome of the combined operative treatment.

MATERIALS AND METHODS

Out of 950 patients with calcaneal fractures and 190 patients with talar fractures treated operatively between 1984 and 2003, 11 patients (1% of calcaneal and 6% of talar fractures) were identified with combined ipsilateral talar and calcaneal fractures. Closed reduction and external fixation was performed in one patient with a crush foot injury, and ORIF in all other patients and fractures. All patients underwent clinical and radiological evaluation after a minimum followup period of one year using the AOFAS-Hindfoot Score.

RESULTS

Seven patients had central talar body and 4 patients talar neck fractures. Nine calcaneal fractures were extraarticular sustentaculum, as well as processus anterior fractures, and two were intraarticular fractures. Average followup was 6 (range, 1 to 12.5; median, 4.5) years. There were no perioperative complications related to ORIF. AOFAS-Hindfoot-Score averaged 78.6 (range, 50 to 100). The followup x-rays showed post-traumatic arthritis in the ankle joint in 3 patients and in the subtalar joint in five. AVN with peudarthorsis was present in one patient with an intraarticular calcaneal fracture. Patients with intraarticular calcaneal fractures presented with the worst functional results (AOFAS-Score, 50 and 64), none of these patients required a secondary ankle or subtalar fusion. All other patients had good and excellent functional outcome.

CONCLUSION

Combined ipsilateral talar and calcaneal fractures are rare injuries. Extraarticular calcaneal fractures are more common in this injury pattern, while there was no preference for either talar neck or talar body fractures. Operative treatment with anatomic open reduction and internal fixation may result in favorable clinical outcome. Combined surgical approaches to the hindfoot did not result in increased morbidity.

[Lateral tibial head fracture and avulsion fracture of the tibial tuberosity: a rare combination of injuries]

The rare combination of a lateral tibial head fracture and an avulsion fracture of the tibial tuberosity requires treatment that differs from the therapy of the single occurrence of each of these injuries. Especially postsurgical treatment is not yet standardized. We report about the history of disease in a patient who had a work-related accident in which he suffered trauma during passive knee flexion in combination with an active extension of the quadriceps femoris muscle. We performed a multimodal osteosynthesis followed by postsurgical treatment which is different from the postoperative treatment for the individual injuries: immobilization of the knee joint with a thigh splint for 6 weeks, isometric physical therapy, and prohibition of movement in the knee for 4 weeks. This therapy appears to be an effective and successful approach for this combination of injuries, where no standardized treatment has been established yet.