Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors

PURPOSE

To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors.

METHODS

Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant.

RESULTS

Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions.

CONCLUSION

sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment

INTRODUCTION

This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS).

MATERIALS AND METHODS

Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described.

RESULTS

A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization.

DISCUSSION

Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

Effect of changing the acquisition trajectory of the 3D C-arm (CBCT) on image quality in spine surgery: experimental study using an artificial bone model

BACKGROUND

Intraoperative 3D imaging using cone-beam CT (CBCT) provides improved assessment of implant position and reduction in spine surgery, is used for navigated surgical techniques, and therefore leads to improved quality of care. However, in some cases the image quality is not sufficient to correctly assess pedicle screw position and reduction, especially due to metal artifacts. The aim of this study was to investigate whether changing the acquisition trajectory of the CBCT in relation to the pedicle screw position during dorsal instrumentation of the spine can reduce metal artifacts and consequently improve image quality as well as clinical assessability on the artificial bone model.

METHODS

An artificial bone model was instrumented with pedicle screws in the thoracic and lumbar spine region (Th10 to L5). Then, the acquisition trajectory of the CBCT (Cios Spin, Siemens, Germany) to the pedicle screws was systematically changed in 5° steps in angulation (- 30° to + 30°) and swivel (- 30° to + 30°). Subsequently, radiological evaluation was performed by three blinded, qualified raters on image quality using 9 questions (including anatomical structures, implant position, appearance of artifacts) with a score (1-5 points). For statistical evaluation, the image quality of the different acquisition trajectories was compared to the standard acquisition trajectory and checked for significant differences.

RESULTS

The angulated acquisition trajectory increased the score for subjective image quality (p < 0.001) as well as the clinical assessability of pedicle screw position (p < 0.001) highly significant with particularly strong effects on subjective image quality in the vertebral pedicle region (d = 1.06). Swivel of the acquisition trajectory significantly improved all queried domains of subjective image quality (p < 0.001) as well as clinical assessability of pedicle screw position (p < 0.001). The data show that maximizing the angulation or swivel angle toward 30° provides the best tested subjective image quality. Angulation and swivel of the acquisition trajectory result in a clinically relevant improvement in image quality in intraoperative 3D imaging (CBCT) during dorsal instrumentation of the spine.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery

BACKGROUND

Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures.

METHODS

Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed.

RESULTS

A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications.

CONCLUSION

Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

Radiation exposure for pedicle screw placement with three different navigation system and imaging combinations in a sawbone model

BACKGROUND

Studies have shown that pedicle screw placement using navigation can potentially reduce radiation exposure of surgical personnel compared to conventional methods. Spinal navigation is based on an interaction of a navigation software and 3D imaging. The 3D image data can be acquired using different imaging modalities such as iCT and CBCT. These imaging modalities vary regarding acquisition technique and field of view. The current literature varies greatly in study design, in form of dose registration, as well as navigation systems and imaging modalities analyzed. Therefore, the aim of this study was a standardized comparison of three navigation and imaging system combinations in an experimental setting in an artificial spine model.

METHODS

In this experimental study dorsal instrumentation of the thoracolumbar spine was performed using three imaging/navigation system combinations. The system combinations applied were the iCT/Curve, cCBCT/Pulse and oCBCT/StealthStation. Referencing scans were obtained with each imaging modality and served as basis for the respective navigation system. In each group 10 artificial spine models received bilateral dorsal instrumentation from T11-S1. 2 referencing and control scans were acquired with the CBCTs, since their field of view could only depict up to five vertebrae in one scan. The field of view of the iCT enabled the depiction of T11-S1 in one scan. After instrumentation the region of interest was scanned again for evaluation of the screw position, therefore only one referencing and one control scan were obtained. Two dose meters were installed in a spine bed ventral of L1 and S1. The dose measurements in each location and in total were analyzed for each system combination. Time demand regarding screw placement was also assessed for all system combinations.

RESULTS

The mean radiation dose in the iCT group measured 1,6 ± 1,1 mGy. In the cCBCT group the mean was 3,6 ± 0,3 mGy and in the oCBCT group 10,3 ± 5,7 mGy were measured. The analysis of variance (ANOVA) showed a significant (p < 0.0001) difference between the three groups. The multiple comparisions by the Kruskall-Wallis test showed no significant difference for the comparison of iCT and cCBCT (p1 = 0,13). Significant differences were found for the direct comparison of iCT and oCBCT (p2 < 0,0001), as well as cCBCT and oCBCT (p3 = 0,02). Statistical analysis showed that significantly (iCT vs. oCBCT p = 0,0434; cCBCT vs. oCBCT p = 0,0083) less time was needed for oCBCT based navigated pedicle screw placement compared to the other system combinations (iCT vs. cCBCT p = 0,871).

CONCLUSION

Under standardized conditions oCBCT navigation demanded twice as much radiation as the cCBCT for the same number of scans, while the radiation exposure measured for the iCT and cCBCT for one scan was comparable. Yet, time effort was significantly less for oCBCT based navigation. However, for transferability into clinical practice additional studies should follow evaluating parameters regarding feasibility and clinical outcome under standardized conditions.

[Computer-assisted procedures in orthopedics and trauma surgery-Where do we stand?]

Computer-assisted procedures are becoming increasingly more relevant in orthopedics and trauma surgery. The data situation on these systems has improved in recent years but still has a low level of evidence. In particular, data on short-term or medium-term results on the use of these procedures are currently available. These could show that improved precision and reproducibility of the surgical procedures can be achieved by the use of computer-assisted procedures. Nevertheless, there is still no recommendation in the current guidelines for routine use.

Post-operative Use of Cervical Orthoses for Subaxial Cervical Spine Injuries - a Survey-based Analysis at German Spine Care Centres

INTRODUCTION

There are no evidence-based recommendations for the post-operative treatment and application of soft or rigid cervical collars after operative treatment of injuries of the subaxial cervical spine. Cervical collars can restrict peak range of motion and serve as a reminder to the patient. However, they can also cause pressure ulcers. The aim of this online-based survey among German spine centres was to gain an overview of post-operative treatment and the application of soft or rigid cervical collars after surgical treatment of injuries of the subaxial cervical spine.

MATERIALS AND METHODS

An online-based survey was conducted among 59 spine centres certified by the German Spine Society. It comprised seven items and the option of adding remarks in the form of open-ended responses.

RESULTS

The return rate was 63% (37 out of 59). Of the 37 analysed spine centres, 51% routinely apply a cervical collar post-operatively, 27% apply a soft and 16% a rigid cervical collar, 8% sequentially apply first a rigid and later a soft cervical collar. Less than half of the spine centres (43%) routinely use no cervical collar. Rigid collars are applied for more than 6 weeks and soft collars up to 6 weeks at some spine centres. Standardised post-operative treatment plans are common. The selection of the post-operative treatment plan depends primarily on the type of injury and method of operation and partly on patient age and bone quality. The satisfaction of German spine centres with the current handling of post-operative treatment of subaxial cervical spine injuries is high.

DISCUSSION

The post-operative treatment of injuries of the subaxial cervical spine at German spine centres is heterogeneous, and the evidence on advantages and disadvantages of the post-operative application of cervical collars is insufficient. Planning and implementation of randomised controlled clinical trials in subaxial cervical spine injuries is challenging.

Is the postoperative pedicle screw position after dorsal instrumentation with or without intraoperative cone beam CT imaging worse in patients with obesity than in normal-weight patients?

Background

Intraoperative cone beam CT (CBCT) imaging in dorsal instrumentation facilitates pedicle screw positioning. However, in patients with obesity, the benefit may be reduced due to artifacts that affect image quality. The purpose of this study was to evaluate whether intraoperative CBCT leads to an improved postoperative screw position compared to conventional fluoroscopy independent of body weight.

Methods

A total of 71 patients (18 patients with a BMI > 30 kg/m², 53 patients with a BMI < 30 kg/m²) who underwent dorsal instrumentation with intraoperative CBCT imaging were included in study groups one (SG1) and two (SG2). Two control groups (CG1 and CG2) were randomly sampled to include 22 patients with a BMI > 30 kg/m² and 60 patients with a BMI < 30 kg/m² who underwent dorsal instrumentation without intraoperative CBCT imaging. The pedicle screw position in postoperative computed tomography was assessed using the Gertzbein–Robbins classification.

Results

In SG1 (BMI > 30 kg/m²), a total of 107 (83.6%) pedicle screws showed no relevant perforation (type A + B), and 21 (16.4%) pedicle screws showed relevant perforation (type C − E). In SG2 (BMI < 30 kg/m²), 328 (90.9%) screws were classified as type A + B, and 33 (9.1%) screws were classified as type C − E. In CG1 (BMI > 30 kg/m²), 102 (76.1%) pedicle screws showed no relevant perforation (type A + B), and 32 (23.9%) pedicle screws showed relevant perforation (type C − E). In CG2 (BMI < 30 kg/m²), 279 (76.9%) screws were classified as type A + B, and 84 (23.1%) screws were classified as type C − E. There were significant differences between the values of SG1 and SG2 (p = 0.03) and between the values of SG2 and CG2 (p < 0.0001).

Conclusion

CBCT imaging in dorsal instrumentation can lead to an improved pedicle screw position among both patients with obesity and normal-weight patients. However, patients with obesity showed significantly worse pedicle screw positions postoperatively after dorsal instrumentation with intraoperative CBCT imaging than normal-weight patients.

Detection of fibular rotational changes in cone beam CT: experimental study in a specimen model

Background

In syndesmotic injuries, incorrect reduction leads to early arthrosis of the ankle joint. Being able to analyze the reduction result is therefore crucial for obtaining an anatomical reduction. Several studies that assess fibular rotation in the incisura have already been published. The aim of the study was to validate measurement methods that use cone beam computed tomography imaging to detect rotational malpositions of the fibula in a standardized specimen model.

Methods

An artificial Maisonneuve injury was created on 16 pairs of fresh-frozen lower legs. Using a stable instrument, rotational malpositions of 5, 10, and 15° internal and external rotation were generated. For each malposition of the fibula, a cone beam computed tomography scan was performed. Subsequently, the malpositions were measured and statistically evaluated with t-tests using two measuring methods: angle (γ) at 10 mm proximal to the tibial joint line and the angle (δ) at 6 mm distal to the talar joint line.

Results

Rotational malpositions of ≥ 10° could be reliably displayed in the 3D images using the measuring method with angle δ. For angle γ significant results could only be displayed for an external rotation malposition of 15°.

Conclusions

Clinically relevant rotational malpositions of the fibula in comparison with an uninjured contralateral side can be reliably detected using intraoperative 3D imaging with a C-arm cone beam computed tomography. This may allow surgeons to achieve better reduction of fibular malpositions in the incisura tibiofibularis.

Comparison of three imaging and navigation systems regarding accuracy of pedicle screw placement in a sawbone model

3D-navigated pedicle screw placement is increasingly performed as the accuracy has been shown to be considerably higher compared to fluoroscopy-guidance. While different imaging and navigation devices can be used, there are few studies comparing these under similar conditions. Thus, the objective of this study was to compare the accuracy of two combinations most used in the literature for spinal navigation and a recently approved combination of imaging device and navigation system. With each combination of imaging system and navigation interface, 160 navigated screws were placed percutaneously in spine levels T11-S1 in ten artificial spine models. 470 screws were included in the final evaluation. Two blinded observers classified screw placement according to the Gertzbein Robbins grading system. Grades A and B were considered acceptable and Grades C-E unacceptable. Weighted kappa was used to calculate reliability between the observers. Mean accuracy was 94.9% (149/157) for iCT/Curve, 97.5% (154/158) for C-arm CBCT/Pulse and 89.0% for CBCT/StealthStation (138/155). The differences between the different combinations were not statistically significant except for the comparison of C-arm CBCT/Pulse and CBCT/StealthStation (p = 0.003). Relevant perforations of the medial pedicle wall were only seen in the CBCT group. Weighted interrater reliability was found to be 0.896 for iCT, 0.424 for C-arm CBCT and 0.709 for CBCT. Under quasi-identical conditions, higher screw accuracy was achieved with the combinations iCT/Curve and C-arm CBCT/Pulse compared with CBCT/StealthStation. However, the exact reasons for the difference in accuracy remain unclear. Weighted interrater reliability for Gertzbein Robbins grading was moderate for C-arm CBCT, substantial for CBCT and almost perfect for iCT.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel

OBJECTIVES

The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel.

METHODS

A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful.

CONCLUSIONS

Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model

Background

Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar.

Methods

Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed.

Results

The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°.

Conclusions

In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

First experiences with intraoperative CT in navigated sacroiliac (SI) instrumentation: An analysis of 25 cases and comparison with conventional intraoperative 2D and 3D imaging

BACKGROUND

Intraoperative imaging is regularly used for intraoperative reduction control and evaluation of the implant position in trauma surgery. 2D imaging is limited, especially in complex anatomical regions such as the pelvis. The introduction of mobile 3D C-arms (CBCT: cone-beam computed tomography) has significantly improved intraoperative assessment. Nevertheless, there are still limitations regarding the field of view and metal artifacts. The purpose of this study was to evaluate the potential of intraoperative computed tomography (iCT) in surgical treatment of sacroiliac (SI) injuries.

METHODS

Twenty-five cases with injuries of the posterior pelvic ring involving the SI region that were surgically treated with navigated SI screws using the mobile iCT Airo (Brainlab, Munich, Germany) were analysed. Subsequently, the data were compared with historical control groups (CBCT with and without navigation; 2D fluoroscopy only).

RESULTS

The average score for subjective image quality achieved using the Likert scale is significantly higher for the iCT (4.48 ± 0.65) than for the CBCT (3.04 ± 0.69) with p = 0.00. The average duration of surgery using iCT was 189.32 ± 88.64 min, which was not significantly different from the control groups (p = 0.14 - 0.70). The average fluoroscopy time using iCT was 81.96 ± 97.34 s, which was significantly shorter than in all of the control groups (p = 0.00 - 0.03). The rate for postoperatively detected complications after using iCT was 0% (n = 0). Compared with the 2D-only control group (25%; n = 1), there is a significant difference (p = 0.01). The remaining two control groups showed no significant differences (p = 0.09 - 0.19).

CONCLUSIONS

The iCT provides excellent image quality that allows reliable assessment of fracture reduction and implant placement even in complex anatomical regions. The radiation exposure for the medical staff is reduced by decreasing the fluoroscopy time without significantly prolonging the surgical time. Overall, the possibility of intraoperative correction improves clinical outcome and patient treatment in the long term.

Analysis of diagnostics, therapy and outcome of patients with traumatic atlanto-occipital dislocation

BACKGROUND CONTEXT

Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased.

PURRPOSE

The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD.

STUDY DESIGN

Monocentric retrospective cohort study.

PATIENT SAMPLE

A total of 12 patients were included in this study.

OUTCOME MEASURES

The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed.

METHODS

All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination.

RESULTS

The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits.

CONCLUSIONS

The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD.

Long-term outcome and survival rate of monopolar radial head replacement

BACKGROUND

The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae.

METHODS

Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared.

RESULTS

At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs.

CONCLUSIONS

Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.

Cervical Spine Immobilization in Patients With a Geriatric Facial Structure: The Influence of a Geriatric Mandible Structure on the Immobilization Quality Using a Cervical Collar

Introduction:

Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure.

Materials and Methods:

This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group (n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group (n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system.

Results:

A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was (p = 0.0286) significantly more reduced in the adult facial structure group. No (p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°).

Conclusion:

Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine

PURPOSE

For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons.

METHODS

A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed.

RESULTS

A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case).

CONCLUSION

The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Risk Factors for Revision Surgery Following Radial Head Arthroplasty without Cement for Unreconstructible Radial Head Fractures: Minimum 3-Year Follow-up

BACKGROUND

Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors.

METHODS

A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA.

RESULTS

The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery.

CONCLUSIONS

Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fracture reduction and screw position after 3D-navigated and conventional fluoroscopy-assisted percutaneous management of acetabular fractures: a retrospective comparative study

BACKGROUND

Navigational techniques in orthopaedic trauma surgery have developed over the last years leaving the question of really improving quality of treatment. Especially in marginal surgical indications, their benefit has to be evident. The aim of this study was to compare reduction and screw position following 3D-navigated and conventional percutaneous screw fixation of acetabular fractures. The study hypothesis postulated that better fracture reduction and better screw position are obtained with 3D navigation.

MATERIALS AND METHODS

Preoperative and postoperative CT scans of 37 acetabular fractures treated by percutaneous screw fixation (24 3D-navigated, 13 conventional) were evaluated. Differences in pre- and postoperative fracture gaps and steps were compared in all reconstructions as well as the screw position relative to the joint and the fracture.

RESULTS

The differences in fracture gaps and fracture steps with and without 3D navigation were not significantly different. Distance of the screw from the joint line, angle difference between screw and ideal angle relative to the fracture line, length of the possible corridor used and position of the screw thread did not show any significant differences.

CONCLUSION

Comparison of 3D-navigated and conventional percutaneous surgery of acetabular fractures on the basis of pre- and postoperative CTs revealed no significant differences in terms of fracture reduction and screw position.

Comparing the Short-Term Outcome after Polytrauma and Proximal Femur Fracture in Geriatric Patients

Because of demographic change, geriatric patients are becoming a major challenge for traumatology. Multiple trauma patients and patients with proximal femoral fractures are important groups of patients in geriatric traumatology. This retrospective study compares two patient groups with different severities of injuries, and analyzes their patient characteristics and short-term outcomes, focusing on functionality upon discharge. The investigation aims to present the characterizing features of both patient groups, and to identify the potential risk factors for early functionality after trauma. The patient collective comprises two patient groups: a polytrauma group with 91 patients, and a femoral fracture group with 132 patients. Under the control of potential influencing factors, the present study showed no significant influence of belonging to either of the patient groups (multiple trauma or proximal femoral fracture) on the mobility status at discharge. Age, known dementia, pre-clinical intubation, and the lowest Hb value were identified as significant influencing factors. Despite their old age and vulnerability, the majority of geriatric patients survive accidents. Further prospective investigations concerning the maintenance or restoration of functionality after an accident are therefore desirable.

Influence of endplate size and implant positioning of vertebral body replacements on biomechanics and outcome

BACKGROUND

Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes.

METHOD

Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence.

FINDING

Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes.

INTERPRETATION

Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence.

Training to identify red flags in the acute care of trauma: who are the patients at risk for early death despite a relatively good prognosis? An analysis from the TraumaRegister DGU®

Background

In the acute care of trauma, some patients with a low estimated risk of death die suddenly and unexpectedly. In this study, we aim to identify predictors for early death within 24 h following hospital admission in low-risk patients.

Methods

The TraumaRegister DGU® was used to collect records of patients who were primarily treated in a participating hospital between 2004 and 2013 with a RISC II score below 10%.

Results

During the study period, 64,379 patients met the inclusion criteria. The mean RISC II score was 2.0%, and the mean ISS was 16 ± 9. The overall hospital mortality rate was 2.1%, and 0.5% of patients (n = 301) died within the first 24 h. A SPB of ≤ 90 mmHg was associated with an increased risk of death (p < 0.001). An AIS abdomen score of ≥ 3 was associated with increased risk of death within the first 24 h (p < 0.001). A high risk of early death was also seen in patients with an AIS score (thorax) ≥ 3; 51% of those who died died within the first 24 h (p < 0.005). Death in patients over 60 years was more common after 24 h (p < 0.001). Patients with an ASA score of ≥ 3 were more likely to die after the first 24 h (p < 0.001).

Conclusions

Indicators predicting a high risk of early death in patients with a low RISC II score include a SPB ≤ 90 mmHg and severe chest and abdominal trauma. Emergency teams involved in the acute care of trauma patients should be aware of these “red flags” and treat their patients accordingly.

[Options for soft tissue reconstruction in pseudarthrosis]

BACKGROUND

Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan.

METHODS

Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.

Reliability of dynamic fluoroscopy for medial elbow stability in the presence of radial head resection

Background

The aim of this study was to examine whether dynamic fluoroscopy is reliable for assessment of medial elbow stability in the presence of radial head resection and different stages of medial collateral ligament (MCL) dissection in a cadaveric elbow model.

Materials and methods

Six intact elbow specimens were measured for joint angulation while applying valgus stress in four examination conditions (Examiner 1, Examiner 2, 1 Nm, 2 Nm) in four different elbow positions (fully pronated or supinated at 0° of elbow extension and 30° of elbow flexion). The elbow specimens were examined for valgus stress in three stages: (1) intact, (2) after radial head resection, and (3) after subsequent dissection of the complete MCL. Anteroposterior radiographs of the elbow were made at each stage to determine joint angulation. Intraclass correlation coefficients (ICCs) were calculated.

Results

In intact elbows, mean joint angulation ranged from 2.2° ± 2.0 (1 Nm) to 5.2° ± 2.3 (Examiner 1). Radial head resection did not increase joint angulation during valgus stress, regardless of joint position and examination condition (Examiner 1: 5.5°; Examiner 2: 5.0°; 1 Nm: 2.6°, 2 Nm: 3.9°). Additional dissection of the MCL led to significantly higher joint angulation during measurements with the standardized torques (1 Nm: 12.4°; 2 Nm: 23.3°). Very good to excellent ICCs for joint angulation between Examiner 1 and Examiner 2 (0.861 to 0.959) were found.

Conclusion

Dynamic fluoroscopy is a reliable diagnostic tool for determining medial elbow stability in the presence of radial head resection and different stages of MCL dissection.

Diagnostic accuracy of intraoperative CT-imaging in complex articular fractures - a cadaveric study

Anatomic reconstruction of articular fractures is one of the critical factors in later achieving good functional outcome. Intraoperative 3D imaging has been shown to offer better evaluation and therefore can significantly improve the results. The purpose of this study was to assess the difference between intraoperative three-dimensional fluoroscopy (3D) and intraoperative computed tomography (iCT) imaging regarding fracture reduction, implant placement and articular impressions in a distal humeral fracture model. AO type 13-B2 fracture pattern were created in upper extremity cadaver specimens. Articular step-offs, intra-articular screw placement and intraarticular impressions of different degrees of severity were created. All specimens had imaging performed. For each articular pattern 3D fluoroscopy in standard (3Ds) and high quality (3Dh) were performed (Arcadis Orbic, Siemens, Germany) as well as an intraoperative CT scan (iCT, Airo, Brainlab, Germany). Three observers evaluated all imaging studies regarding subjective and objective parameters. iCT is more precise than 3D fluoroscopic imaging for detection of articular impressions. Articular step-offs and intraarticular screw placement are similar for iCT and 3D. Subjective imaging quality is the highest for iCT and lowest for 3Ds. Intraoperative CT may be particularly useful in assessing articular impressions and providing a good subjective image quality for the surgeon.

Monteggia-like lesions in adults treated with radial head arthroplasty-mid-term follow-up of 27 cases

Background

The aim of the study was to analyze the functional and radiological outcome of Monteggia-like lesions in adults with unreconstructible fracture of the radial head and treatment with radial head arthroplasty.

Methods

Twenty-seven patients (mean age 56 years; range 36 to 79 years) with a Monteggia-like lesion and treatment with radial head replacement were included in this retrospective study. Minimum follow-up was 2 years. Clinical assessment included the pain level with the visual analog scale in rest (VAS_R) and under pressure (VAS_P), range of motion, Mayo Elbow Performance Score (MEPS), and Disability of the Arm, Shoulder, and Hand score (DASH). A detailed radiological evaluation was performed. Complications and revisions were also analyzed.

Results

After a mean follow-up period of 69 months (range, 24 to 170) the mean DASH score was 30 ± 24, the MEPS averaged 77 ± 20 points, the mean VAS_R was 2.1 ± 2.4, and VAS_P was 4.5 ± 3.5. Mean loss of extension was 24° ± 18 and flexion was 124° ± 20. Heterotopic ossifications were noted in 12 patients (44%). A total of 17 complications were noted in 11 patients (41%), leading to 15 revision surgeries in 9 patients (33%). Patients with a complicated postoperative course showed a worse clinical outcome compared with patients without complications measured by MEPS (68 ± 22 vs. 84 ± 16), DASH (49 ± 16 vs. 20 ± 22) and ulnohumeral motion (77° ± 31 vs. 117° ± 23).

Conclusions

Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions.

Distal radioulnar joint instability with three different injury patterns assessed by three-dimensional C-arm scans: a cadaveric study

The aim of this study was to establish a radiographic method for detecting distal radioulnar joint instability intraoperatively. We created three successive instabilities in 12 intact Thiel-fixed upper limb specimens: lesion of the triangular fibrocartilage complex, Galeazzi injury and Essex-Lopresti injury. We made three-dimensional scans of the wrists in pronation and supination with a mobile C-arm. We used four validated measurement methods to quantify ulnar migration in the standard axial planes: the radioulnar line method, the subluxation ratio method, the epicentre method and the radioulnar ratio method. All types of instability showed significantly increased migration of the ulna compared with the control group. The subluxation ratio and the radioulnar ratio methods showed the highest sensitivity and specificity in detecting the instabilities. We conclude that these two methods are feasible for radiographically assessing distal radioulnar joint instability. Instability may be assumed if the migration of the ulna in the sigmoid notch is at least 45% of the length of the sigmoid notch, in which case wire transfixation of the distal radioulnar joint is advised.

[Polytrauma in old age-Knowledge from the TraumaRegister DGU®]

The geriatric fracture patient is becoming more and more in the forefront due to the demographic development. It is expected that the number of polytraumatized geriatric patients in the coming years will rise in line with demographic trends. The TraumaRegister DGU® of the German Trauma Society (DGU) provides interesting insights into the age structure and patient outcome. In 2017 in total 26.2% of the patients included were over 70 years old. Geriatric polytraumatized patients show significant differences in the injury patterns as well as in the treatment strategy compared to younger patients. This is often due to the pre-existing diseases and various drugs that alter the physiology. With respect to the injury patterns an increase in severe head injuries and a decrease in severe abdominal injuries can be seen with increasing age. Hospitals and professional societies are currently dealing with numerous challenges. The implementation of the General Data Protection Regulation leads to conflicts and uncertainties. The further development of the TraumaRegister DGU® is important in order to collect more outcome-relevant data from patients because more than ever the objective should be the survival of an accident with a high quality of life. To measure this, a structured survey of patients is necessary. The TraumaRegister DGU® is one of the most important tools to make treatment comparable and to measure structural changes.

Comparison of pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture

OBJECTIVE

Dorsal stabilization is a frequently used procedure in the treatment of acute traumatic vertebral body fractures. Besides the traditional open surgical procedure, the percutaneous positioning of pedicle screws is now widely used. The aim of the current study is to compare pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture of the thoracic and lumbar spine and to assess possible risk factors associated with pedicle screw misplacement.

METHODS

All patients who suffered a traumatic spinal fracture that were treated with dorsal stabilization in our level I trauma center in the period from 01/2007 to 03/2014 were included in this retrospective therapeutic cohort study. From 01/2007 to 06/2009, an open surgical procedure was used, and from 06/2009 to 03/2014, the percutaneous procedure was used for all types of fractures. Retrospectively, the positioning of every single pedicle screw was evaluated in the post-operative computed tomography scan and classified. Epidemiological data were also documented to compare the two treatment groups.

RESULTS

A total of 491 patients with 681 vertebral body fractures were included. Of 733 pedicle screws placed during the open surgery procedure, 96.0% were within the safe zone. There was no significant difference compared with pedicle screws placed percutaneously (95.3% of 1884 screws). In all other categories, the number of misplaced pedicle screws also showed no differences between the two treatment groups. There is a positive correlation between pedicle screw misplacement and duration of the operation. Most pedicle screws are misplaced at the levels T12, L1 and T7, T8.

CONCLUSION

The current study shows that percutaneous surgery using dorsal stabilization allows the positioning of pedicle screws in an equivalently safe manner compared with an open surgical procedure in the acute care of spinal trauma.

Computer-assisted intra-operative verification of surgical outcome for the treatment of syndesmotic injuries through contralateral side comparison

PURPOSE

Fracture reduction and fixation of syndesmotic injuries is a common procedure in trauma surgery. An intra-operative evaluation of the surgical outcome is challenging due to high inter-individual anatomical variation. A comparison to the contralateral uninjured ankle would be highly beneficial but would also incur additional radiation and time consumption. In this work, we pioneer automatic contralateral side comparison while avoiding an additional 3D scan.

METHODS

We reconstruct an accurate 3D surface of the uninjured ankle joint from three low-dose 2D fluoroscopic projections. Through CNN complemented 3D shape model segmentation, we create a reference model of the injured ankle while addressing the issues of metal artifacts and initialization. Following 2D-3D multiple bone reconstruction, a final reference contour can be created and matched to the uninjured ankle for contralateral side comparison without any user interaction.

RESULTS

The accuracy and robustness of individual workflow steps were assessed using 81 C-arm datasets, with 2D and 3D images available for injured and uninjured ankles. Furthermore, the entire workflow was tested on eleven clinical cases. These experiments showed an overall average Hausdorff distance of [Formula: see text] mm measured at clinical evaluation level.

CONCLUSION

Reference contours of the contralateral side reconstructed from three projection images can assist surgeons in optimizing reduction results, reducing the duration of radiation exposure and potentially improving postoperative outcomes in the long term.

Low return-to-sports rate after elbow injury and treatment with radial head arthroplasty

BACKGROUND

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.

METHODS

A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).

RESULTS

After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P < .001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P < .001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P < .001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).

CONCLUSION

The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

Normal values of distal radioulnar translation assessed by three-dimensional C-arm scans: a cadaveric study

We investigated whether mobile C-arm cone beam computer tomography (CBCT) could be used to measure radioulnar translation. The study was conducted on 31 Thiel-fixed intact cadaver arms. Three-dimensional scans of each wrist were carried out in pronation and supination. Four established measurement methods were used (radioulnar line, subluxation ratio, epicentre and radioulnar ratio methods) to measure radioulnar translation. The intraclass correlation coefficient for inter-observer and intra-observer reliability were excellent in three of four methods (>0.94). The reference ranges for physiological radioulnar translation were between -30% and 91% (radioulnar line method), -32% and 87% (subluxation ratio method), -40% and 23% (epicentre method), and 2% and 73% (radioulnar ratio method). Our results indicate that radioulnar translation in the distal radioulnar joint can be determined reliably using mobile C-arm CBCT. The normal values provide a basis for further experimental and clinical studies.

First experiences with the Airo mobile intraoperative CT scanner in acetabular surgery-An analysis of 10 cases

BACKGROUND

Being a proven method in trauma and spine surgery, intraoperative 3D imaging (CBCT) has intrinsic deficits in difficult anatomy and with artifacts because of metal implants. The purpose of this study was to evaluate the use of intraoperative computed tomography (iCT) in acetabular surgery.

METHODS

Ten cases of acetabular fractures that were operated with intraoperative use of the mobile CT scanner Brainlab Airo were analyzed. Data were compared with a historical group of 17 patients.

RESULTS

Additional fluoroscopy time was 24.2 seconds (6-91), which was significantly lower than in the control group where it was 211.4 seconds (77-446; P < 0.000). Operation time did not differ significantly (iCT group 196.8 min [122-288], control group 240.8 min [71-411], P = 0.234).

CONCLUSION

iCT provides images of a reliable high quality and assessability. Radiation exposure to the staff is reduced while surgery time is not altered significantly. Quality of intraoperative imaging and thus patient care can substantially improve patient outcome.

Injury patterns in professional motorbike racing: a retrospective analysis of 728 falls

BACKGROUND

In professional motorbike racing falls with high velocities are common. Nonetheless, severe injuries or deaths are rare when compared to regular road traffic.

METHODS

In this study, falls in all courses of the largest German race series IDM*Superbike between 2007 and 2013 were analyzed regarding injury patterns and hospital admissions. All races were accompanied by a medical team, including at least one physician who assessed every patient.

RESULTS

A total of 728 falls were included. A specific fall mechanism could be determined in 45.5% of the cases. 40.5% were admitted to a trauma center for further diagnostics. A definitive diagnosis was found in 45.4%. In most cases (29.9%) the injury pattern was a fracture of the extremities. In collisions a significantly higher odds ratio of 2.52 (P=0.0001) and in undetermined falls a significantly lower odds ratio of 0.47 (P<0.0001) was observed.

CONCLUSIONS

Fall patterns in professional motorbike racing do not significantly correlate with the severity of the injury. Thus, as in regular patient evaluation, each patient has to be examined thoroughly to avoid misinterpretation.

Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction-A study in two new cadaveric trauma models

Background

Unstable conditions of the craniocervical junction such as atlanto-occipital dislocation (AOD) or atlanto-axial instability (AAI) are severe injuries with a high risk of tetraplegia or death. Immobilization by a cervical collar to protect the patient from secondary damage is a standard procedure in trauma patients. If the application of a cervical collar to a patient with an unstable craniocervical condition may cause segmental motion and secondary injury to the spinal cord is unknown.

The aim of the current study is (i) to analyze compression on the dural sac and (ii) to determine relative motion of the cervical spine during the procedure of applying a cervical collar in case of ligamentous unstable craniocervical junction.

Methods and findings

Ligamentous AOD as well as AOD combined with ligamentous AAI was simulated in two newly developed cadaveric trauma models. Compression of the dural sac and segmental angulation in the upper cervical spine were measured on video fluoroscopy after myelography during the application of a cervical collar. Furthermore, overall three-dimensional motion of the cervical spine was measured by a motion tracking system.

In six cadavers each, the two new trauma models on AOD and AOD combined with AAI could be implemented. Mean dural sac compression was significantly increased to -1.1 mm (-1.3 to -0.7 mm) in case of AOD and -1.2 mm (-1.6 to -0.6 mm) in the combined model of AOD and AAI. Furthermore, there is a significant increased angulation at the C0/C1 level in the AOD model. Immense three-dimensional movement up to 22.9° of cervical spine flexion was documented during the procedure.

Conclusion

The current study pointed out that applying a cervical collar in general will cause immense three-dimensional movement. In case of unstable craniocervical junction, this leads to a dural sac compression and thus to possible damage to the spinal cord.

2D projection-based software application for mobile C-arms optimises wire placement in the proximal femur - An experimental study

PURPOSE

A new software application can be used without fixed reference markers or a registration process in wire placement. The aim was to compare placement of Kirschner wires (K-wires) into the proximal femur with the software application versus the conventional method without guiding. As study hypothesis, we assumed less placement attempts, shorter procedure time and shorter fluoroscopy time using the software. The same precision inside a proximal femur bone model using the software application was premised.

METHODS

The software detects a K-wire within the 2D fluoroscopic image. By evaluating its direction and tip location, it superimposes a trajectory on the image, visualizing the intended direction of the K-wire. The K-wire was positioned in 20 artificial bones with the use of software by one surgeon; 20 bones served as conventional controls. A brass thumb tack was placed into the femoral head and its tip targeted with the wire. Number of placement attempts, duration of the procedure, duration of fluoroscopy time and distance to the target in a postoperative 3D scan were recorded.

RESULTS

Compared with the conventional method, use of the application showed fewer attempts for optimal wire placement (p=0.026), shorter duration of surgery (p=0.004), shorter fluoroscopy time (p=0.024) and higher precision (p=0.018). Final wire position was achieved in the first attempt in 17 out of 20 cases with the software and in 9 out of 20 cases with the conventional method.

CONCLUSIONS

The study hypothesis was confirmed. The new application optimised the process of K-wire placement in the proximal femur in an artificial bone model while also improving precision. Benefits lie especially in the reduction of placement attempts and reduction of fluoroscopy time under the aspect of radiation protection. The software runs on a conventional image intensifier and can therefore be easily integrated into the daily surgical routine.

Subjective safety and self-confidence in prehospital trauma care and learning progress after trauma-courses: part of the prospective longitudinal mixed-methods EPPTC-trial

BACKGROUND

Prehospital trauma care is stressful and requires multi-professional teamwork. A decrease in the number of accident victims ultimately affects the routine and skills and underlines the importance of effective training. Standardized courses, like PHTLS, are established for health care professionals to improve the prehospital care of trauma patients. The aim of the study was to investigate the subjective safety in prehospital trauma care and learning progress by paramedics in a longitudinal analysis.

METHODS

This was a prospective intervention trial and part of the mixed-method longitudinal EPPTC-trial, evaluating subjective and objective changes among participants and real patient care as a result of PHTLS courses. Participants were evaluated with pre/post questionnaires as well as one year after the course.

RESULTS

We included 236 datasets. In the pre/post comparison, an increased performance could be observed in nearly all cases. The result shows that the expectations of the participants of the course were fully met even after one year (p = 0.002). The subjective safety in trauma care is significantly better even one year after the course (p < 0.001). Regression analysis showed that (ABCDE)-structure is decisive (p = 0.036) as well as safety in rare and common skills (both p < 0.001). Most skills are also rated better after one year. Knowledge and specific safety are assessed as worse after one year.

CONCLUSION

The courses meet the expectations of the participants and increase the subjective safety in the prehospital care of trauma patients. ABCDE-structure and safety in skills are crucial. In the short term, both safety in skills and knowledge can be increased, but the courses do not have the power to maintain knowledge and specific subjective safety issues over a year.

TRIAL REGISTRATION

German Clinical Trials Register, ID DRKS00004713 , registered 14. February 2014.

[Morel-Lavallée lesion : Severely injured 13 year old after being run over]

Accidents in which a person is run over are often associated with multiple serious injuries. Immediate bleeding control is crucial. Pressure and shear stress at the borders of subcutaneous tissue to the muscle fascia can cause hypoperfusion and the emergence of blood-filled cavities that are associated with a high risk of infection and necrosis, a so-called Morel-Lavallée lesion. Insufficient therapy can lead to local complications and furthermore to live-threatening sepsis.

[Trisegmental fusion by vertebral body replacement : Outcome following traumatic multisegmental fractures of the thoracic and lumbar spine]

BACKGROUND

Around 5% of all trauma patients suffer from spinal trauma. Spinal fractures are mainly located in the thoracic and lumbar spine. For multisegmental vertebral fractures categorized as instable, combined dorsal instrumentation and ventral stabilization is recommended. Numerous vertebral body replacement systems are available for ventral stabilization.

OBJECTIVES

The aim of the current study was to analyze radiological results following the implantation of a hydraulic expandable vertebral body replacement and the evaluation of patients' outcome three years after implantation.

MATERIALS AND METHODS

All patients who suffered traumatic multisegmental fractures of the thoracic or lumbar spine in the period from September 2009 to September 2012 were included in this study. Patients with additional injuries or abnormal sensitivity or motor function were excluded from the current study. All patients underwent dorsal percutaneous instrumentation. Afterwards, implantation of the vertebral body replacement was performed via the mini-open approach at our level I trauma center. In the computed tomography and X‑ray imaging, the sagittal kyphotic angle was measured. Furthermore, the clinical outcome (patients' satisfaction, VAS spine score) was analyzed using a questionnaire.

RESULTS

During the above mentioned period, seven patients (four female; three male) underwent dorsal instrumentation and ventral trisegmental fusion and were identified fitting the inclusion/exclusion criteria and thus could be included in the study. Most fractures were located in the thoracic-lumbar junction and were categorized A4 according to the AO Spine classification system. The analysis of the radiological data showed a pre-operative average traumatic segmental angle of 18.1 ± 14.9°, which could be decreased by reposition procedure to 6.4 ± 1.7°. The complete follow-up, including the data three years after implantation of the vertebral body implant, was available for three patients. The traumatic segmental angle remained stable in the follow-up three years later. In one case, a subsidence of the implant of 1.5 mm was observed, having no influence on the patients' satisfaction. All three patients indicated to be very satisfied with their outcome. The VAS spine score rating was in the range between 62.4 and 70.2.

CONCLUSIONS

The current study shows that in the case of multisegmental fractures complete reposition by ligamentotaxis and by the percutaneous instrumentation system is possible. In addition to the percutaneous dorsal instrumentation, the implantation of a hydraulically expandable vertebral body replacement may allow a stable fusion after complex traumatic fractures of the thoracic and lumbar spine. Patients are very satisfied with their outcome after this procedure.

Vascular Impulse Technology versus elevation in the treatment of posttraumatic swelling of extremity fractures: study protocol for a randomized controlled trial

BACKGROUND

Fractures of the extremities are often complicated by a variable degree of swelling secondary to hemorrhage and soft tissue injury. Patients typically require up to 7 days of inpatient bed rest and elevation to reduce swelling to an acceptable level for operative treatment with internal fixation. Alternatively, an intermittent pneumatic compression device, such as the Vascular Impulse Technology (VIT) system, can be used at the injured extremity to reduce the posttraumatic swelling. The VIT system consists of a pneumatic compressor that intermittently rapidly inflates a bladder positioned under the arch of the hand or the foot, which results in compression of the venous hand or foot plexus. That intermittent compression induces an increased venous velocity and aims to reduce the soft tissue swelling of the affected extremity.

METHODS/DESIGN

The VIT study is a prospective, monocenter, randomized controlled trial to compare the VIT system with elevation in the treatment of posttraumatic swelling in the case of a fracture of the upper and lower extremity. This study will include 280 patients with fractures of the upper and the lower extremity with nine different injury types. For each of the nine injury types a separate randomization to the two intervention groups (VIT group or control group) will be performed. The primary outcome parameter is the time taken for the swelling to resolve sufficiently to permit surgery. A separate analysis for each of the nine injury types will be performed.

DISCUSSION

In the proposed study, the effectiveness of the VIT system in the treatment of posttraumatic swelling of upper and lower extremity fractures will be evaluated.

TRIAL REGISTRATION

German Clinical Trial Register, No. DRKS00010510 . Registered on 17 July 2016.

Analysis of complications and perioperative data after open or percutaneous dorsal instrumentation following traumatic spinal fracture of the thoracic and lumbar spine: a retrospective cohort study including 491 patients

PURPOSE

The aim of the current study is to analyze perioperative data and complications of open vs. percutaneous dorsal instrumentation after dorsal stabilization in patients suffering from fractures of the thoracic or lumbar spine.

METHODS

In the time period from 01/2007 to 06/2009, open surgical approach was used for dorsal stabilization. The percutaneous surgical approach was used from 05/2009 to 03/2014. In every time period, all types of fractures were treated only by open or by percutaneous approach, respectively, to avoid any selection bias. Retrospectively, epidemiological data, complications and perioperative data were documented and statistically analyzed.

RESULTS

A total of 491 patients met the inclusion criteria. Open surgery procedure was carried out on 169 patients, and percutaneous surgery procedure was carried out on 322 patients. Fracture level ranged from T1 to L5, and fractures were classified types A, B, and C. In 91.4% of all patients, no complication occured following dorsal stabilization after traumatic spine fracture during their hospital stay. However, 42 complications related to dorsal stabilization have been documented during the hospital stay. The complication rate was 14.8% if open surgical approach has been used and was significantly reduced to 5.3% using percutaneous surgical approach. Post-operative hospital stay was also reduced significantly using the percutaneous surgical approach.

CONCLUSIONS

According to the current study, percutaneous dorsal stabilization of the spine could also be safely used in trauma cases and is not restricted to degenerative spinal surgery.

[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage]

BACKGROUND

Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing.

PATIENTS AND METHODS

A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year.

RESULTS

Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8).

CONCLUSION

A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.