OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures

Objectives

Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement.

This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP.

Methods

A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process.

To assess the interRR of the OF-Pelvis categories, Fleiss’ kappa (κ_F) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall’s tau (τ_K). The presence of a modifier was calculated with κ_F for interRR and Cohen’s kappa (κ_C) for intraRR.

Results

The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination.

In both surveys, the interRR for subgroups was substantial: κ_F = 0.764 (Survey 1) and κ_F = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κ_F Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κ_F min.–max. Survey 1/Survey 2: 0.708–0.827/0.747–0.852). The existence of at least one modifier was rated with substantial agreement (κ_F Survey 1/Survey 2: 0.646/0.629).

The intraRR for subgroups showed almost perfect agreement (τ_K = 0.894, DR: τ_K = 0.901, UR: τ_K = 0.889). The modifier had an intraRR of κ_C = 0.684 (DR: κ_C = 0.723, UR: κ_C = 0.651), which is also considered substantial.

Conclusion

The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany

PURPOSE

The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany.

METHODS

Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed.

RESULTS

Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability.

CONCLUSIONS

OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure

BACKGROUND

Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown.

METHODS

A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF).

RESULTS

We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023).

CONCLUSIONS

There was a complex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

Classification of Osteoporotic Thoracolumbar Spine Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Expert opinion.

OBJECTIVES

Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed.

METHODS

The working group "Osteoporotic Fractures" of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature.

RESULTS

The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63).

CONCLUSIONS

The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.

Nonsurgical and Surgical Management of Osteoporotic Vertebral Body Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Prospective clinical cohort study (data collection); expert opinion (recommendation development).

OBJECTIVES

Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations.

METHODS

a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score.

RESULTS

A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately.

CONCLUSIONS

The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.

Reduction and fixation of displaced U-shaped sacral fractures using lumbopelvic fixation: technical recommendations

PURPOSE

U-shaped sacral fractures are extremely rare injuries that usually occur as a result of falls from considerable heights. Almost all treatment methods described to date aim solely at stabilizing the fracture but do not contribute to supporting the reduction of such fractures. Using existing implants the purpose of this study is to present a surgical technique that facilitates both the reduction and the stabilization of these injuries. The presented technique was evaluated in a series of three cases.

METHODS

Polyaxial pedicle screws were placed through vertebral bodies L4 and L5. Two long pedicle screws were implanted in the posterior iliac spine. The lumbar pedicle screws were held with two longitudinal rods, and the pelvic screws with one transverse connecting rod. The lumbar longitudinal and pelvic transverse rods were connected via two hinge-like connecting elements. First, distraction was performed between lumbar pedicle screws L5 and the sacral transverse rod. Lordosis was then restored via the hinge joint, thereby eliminating kyphosis. After tightening all moving elements, the fracture was reduced and stabilized.

RESULTS

Computed tomography documented anatomical reduction and fracture healing was achieved in all cases. Two of three patients could be fully mobilized immediately; mobilization of the third patient was delayed due to multiple injuries. Two patients showed neurological symptoms. In one case, complete remission was achieved within 3 weeks, while in the other patient a clear improvement was observed. In all cases, the implant was removed after 8-12 months. There were no post-operative complications, such as infections, wound-healing disorders, neurological deterioration, implant failure, or premature loosening.

CONCLUSIONS

The surgical procedure was successful, since it considerably facilitated reduction, thereby shortening surgery time. The stabilization was sufficient to fully mobilize the patients. The procedure is based on existing implant components and is thus routinely available.

Female sex protects from organ failure and sepsis after major trauma haemorrhage

INTRODUCTION

Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage.

PATIENTS AND METHODS

We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences.

RESULTS

Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function.

CONCLUSIONS

Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.

Simvastatin reduces leucocyte- and platelet-endothelial cell interaction in murine antigen-induced arthritis in vivo

OBJECTIVES

The use of statins in the prevention and treatment of cardiovascular diseases is well established. Their use as anti-inflammatory and immunomodulatory agents in the treatment of rheumatoid arthritis (RA) has also been investigated, with several clinical and experimental studies indicating an anti-inflammatory effect of statins for RA, but other studies showing no effect or even the opposite. The current study was designed to examine the effect of simvastatin in an in vivo murine model of arthritis using intravital microscopy.

METHOD

We assigned four groups (n = 7, female C57Bl6 mice), two with and two without antigen-induced arthritis (AiA), from which one of the non-AiA groups and one of the AiA groups were treated with simvastatin 40 mg/kg i.p. daily for 14 consecutive days after induction of arthritis. Platelet- and leucocyte-endothelial cell interaction was assessed by measurement of rolling and adherent fluorescence-labelled platelets and leucocytes, functional capillary density (FCD) was evaluated, and knee joint diameter was determined as a clinical parameter.

RESULTS

In arthritic mice treated with simvastatin, a significant reduction in platelet- and leucocyte-endothelial cell interaction was observed in comparison to arthritic mice treated with vehicle. In addition, a significant reduction in FCD was seen in arthritic mice treated with simvastatin, along with a reduction in knee joint swelling of the AiA mice.

CONCLUSIONS

Treatment of AiA mice with simvastatin showed significant reductions in platelet- and leucocyte-endothelial cell interactions, in FCD, and in the swelling of the knee joint. These results support the hypothesis of the anti-inflammatory effects of statins in the treatment of RA.

Clinical benefit of hydroxyapatite-coated pins compared with stainless steel pins in external fixation at the wrist: a randomised prospective study

BACKGROUND

The purpose of this study was to determine the clinical benefit of hydroxyapatite (HA)-coated pins compared with standard stainless steel pins in external fixators applied for unstable fractures of the distal radius.

METHODS

A total of 40 patients (160 pins) with unstable wrist fractures were randomised for uniplanar fixator treatment with the use of identically designed, commercially available pins either composed of stainless steel (steel group) (n = 20) or coated by hydroxyapatite (HA group) (n = 20). Each pin site was clinically evaluated concerning erythema and grade of drainage as well as pain intensity (numeric rating scale (NRS) 0–10) and, additionally, radiological assessment was performed concerning pin-loosening/infection as well as fracture healing at T1 (Ø18 days), T2 (Ø44 days) and T3 (Ø65 days). In case of pintrack complication, the patient was followed continuously. The need for intensified pin-site care, oral or intravenous antibiotic medication, re-admission for additional surgery and premature fixator removal was documented. Bone mineral density (BMD) was determined by dual energy X-ray absorptiometry. At fixator removal (T2), the pin-extraction strength was measured by the use of an electronic torque wrench.

RESULTS

Two pin-track infections requiring daily pin-site care and oral antibiotics occurred in the HA group (2.6%) compared with four in the steel group (5.3%) (p = 0.601) and although a trend towards a superior performance of HA pins was detectable, the majority of clinical pin-site-parameters were comparable in both groups. At the end of the fixator therapy, the HA group showed a non-significant lower rate of loose pins (n(steel group) = 9; n(HA group) = 6; p = 0.864) and both hydroxyapatite-coated pins showed at the radius a significantly stronger pin-bone bonding measured by the torque wrench (p(proximal radius pin) = 0.007; p(distal radius pin) = 0.031). Except for elderly patients of the steel group (p = 0.018), all demographic-, health- and injury-related data including BMD were not correlated to any type of pin-site complication in both groups (p > 0.05). Since all fracture healed uneventfully without any type of additional surgery, the number of patients suffering clinically relevant pin-related complications showed no significant difference between both groups (p = 0.707).

CONCLUSIONS

The use of HA-coated pins compared with standard stainless-steel pins in external fixation for unstable wrist fractures yields only a trend towards a superior clinical outcome.

Seniority of the first-treating doctor does not influence the outcome of acute whiplash injury: a prospective cohort study

The aim of the prospective cohort study was to investigate the outcome of acute whiplash injury first treated either by junior doctors (JD) [≤3 postgraduate years (PGY)] or more experienced doctors (MED) (>3 PGY). At baseline, crash-related data and health parameters including the SF36 were evaluated in whiplash patients (WP), who fulfilled criteria for whiplash-associated disorders grade I-II and presented up to 48 h after motor vehicle accident to our Emergency Department. 81 WP were recruited and treated by either one of 14 JD (35 WP) or one of 22 MED (46 WP). The follow-up examination included the course of pain intensity [numeric rating scale (NRS) 0-10] by the use of a 28 days-pain-diary and the incidence of symptoms (standardized-telephone-interview at 1, 3, and 6 months post trauma) in terms of neck pain NRS > 2, analgesic medication, work-off, and utilization of further medical services as well as SF36 evaluated at the end of the study. Although the entry population seemed similar, all outcome parameters were comparable between the JD- and MED-group (p > 0.05). Therefore, we conclude that seniority of the first-treating physician does not influence the outcome of acute whiplash injury.

Spinal stabilization for patients with metastatic lesions of the spine using a titanium spacer

Anterior decompression in spinal metastases of the corporal type with impending (n = 5) or present (n = 36) neurological complications was performed in 41 patients. For reconstruction, a titanium cylinder was inserted after spondylectomy and augmented with an anterior plate. The titanium implant can easily be adjusted to the length needed without necessitating expensive additional equipment. Outside the patient the implant is filled with polymethylmetacrylate, facilitating plate transfixation for rotational locking. There was a 30-day mortality of 9.7%. Pain relief was apparent in 38 of 41 patients (92.7%), and motor improvement was manifest in 31 of 35 cases (88.6%). Six patients did not present with any neurological symptoms pre- or postoperatively. Neurological deterioration was registered in only 1 case (2.4%). Surgical efficacy was maintained until the death of the patients. Though tumor recurrence at a different spinal level led to consecutive surgery in 5 patients, no implant dislocation occurred during the observation period (maximum 44 months), characterizing the procedure as a mechanically reliable and safe technique.

Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones

Background

Non-unions are severe complications in orthopaedic trauma care and occur in 10% of all fractures. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. However, there is morbidity associated with the bone-graft donor site and some patients offer limited quantity or quality of autologous-bone graft material. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM).

Methods and results

From 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031).

Conclusion

With the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 €/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.

Interdisciplinary expert consultation via a teleradiology platform--influence on therapeutic decision-making and patient referral rates to an academic tertiary care center

In addition to teleradiological reporting as a nighthawking or a regular service, teleradiological communication can be used for interdisciplinary expert consultation. We intended to evaluate an interdisciplinary consultation system based on a teleradiology platform with regard to its impact on therapeutic decision-making, directed patient referrals to an academic tertiary care center and the economic benefit for the hospital providing the service. Therefore, consultations from five secondary care centers and consecutive admissions to an academic tertiary care center were prospectively evaluated over a time period of six months. A total of 69 interdisciplinary expert consultations were performed. In 54 % of the cases the patients were consecutively referred to the university hospital for further treatment. In all acutely life-threatening emergencies (n = 9), fast and focused treatment by referral to the academic tertiary care center was achieved (average time to treat 130 min). The admissions to the academic tertiary care center led to improved utilization of its facilities with additional revenue of more than 1,000000 euro p. a. An interdisciplinary expert consultation via a teleradiology platform enables fast and efficient expert care with improved and accelerated patient management and improved utilization of the service providing hospital.

Screw placement and osteoplasty under computed tomographic-fluoroscopic guidance in a case of advanced metastatic destruction of the iliosacral joint

We present a case of combined surgical screw placement and osteoplasty guided by computed tomography-fluoroscopy (CTF) in a 68-year-old man with unilateral osteolytic destruction and a pathological fracture of the iliosacral joint due to a metastasis from renal cell carcinoma. The patient experienced intractable lower back pain that was refractory to analgesia. After transarterial particle and coil embolization of the tumor-feeding vessels in the angiography unit, the procedure was performed under general anesthesia by an interdisciplinary team of interventional radiologists and trauma surgeons. Under intermittent single-shot CTF, two K wires were inserted into the left iliosacral joint from a lateral transiliac approach at the S1 level followed by two self-tapping surgical screws. Continuous CTF was used for monitoring of the subsequent polymethylmethacrylate injection through two vertebroplasty cannulas for further stabilization of the screw threads within the osteolytic sacral ala. Both the screw placement and cement injection were successful, with no complications occurring during or after the procedure. With additional nonsteroidal anti-inflammatory and opioid medication, the patient reported a marked decrease in his lower back pain and was able to move independently again at the 3-month follow-up assessment. In our patient with intolerable back pain due to tumor destruction and consequent pathological fracture of the iliosacral joint, CTF-guided iliosacral screw placement combined with osteoplasty was successful with respect to joint stabilization and a reduction in the need for analgesic therapy.

[Midshaft clavicle fractures--classification and therapy. Results of a survey at German trauma departments]

INTRODUCTION

The therapy of the midshaft clavicle fracture, in particular dislocated midshaft fractures, remains controversial. Therefore the objective of this study was to obtain data about the current treatment for midshaft clavicle fractures.

METHODS

In a countrywide anonymous survey 240 German orthopaedic trauma departments were asked about their diagnostic and therapeutic procedures for midshaft clavicle fractures. A total of 142 questionnaires (59%) were returned and evaluated.

RESULTS

More than 80% of the hospitals dispense with a standardised fracture classification for midshaft fractures. Simple fractures are generally conservatively treated, in the majority using a figure-of-eight bandage (88%). On average 26% of all clavicle fractures are operatively stabilized, independent of whether the treatment was performed at a trauma centre or any other hospital (p=0.45). Indications for operative treatment of midshaft fractures include severe additional injuries in the shoulder region (81-95%), young and active adults (52-64%) and dislocated midshaft fractures (56-75%). All departments use plate fixation for midshaft fractures; in particular the reconstruction plate (56%) is most frequently applied. Alternatively, if the fracture pattern is considered suitable for intramedullary fixation, this procedure is performed by 43% of the clinics, although this operative technique is used significantly more often in trauma centres (55%) than in other hospitals (31%) (p=0.01).

CONCLUSION

This survey demonstrates a high rate (26%) of German trauma hospitals operating clavicular midshaft fractures. This result is consistent with recently published studies showing better results for operative treatment of dislocated midshaft clavicular fractures compared to conservative therapy.

Biomechanical evaluation of a bioabsorbable expansion bolt for hamstring graft fixation in ACL reconstruction: an experimental study in calf tibial bone

INTRODUCTION

The purpose of our study was to evaluate and compare the primary fixation strength of a novel bioabsorbable two shell expansion bolt (EB) with that of a well-established interference screw-fixation technique in hamstring reconstruction of the anterior cruciate ligament.

MATERIALS AND METHODS

Thirty calf tibia plateaus (age 5-6 months) were assigned to three groups: In group I (n = 10) triple-stranded hamstring grafts were fixed with titanium interference screws (7 mm thread / 8 mm head x 25 mm). Specimens of group II (n = 10) received bioabsorbable poly-L-lactide interference screws (8 x 23 mm). In group III (n = 10), the grafts were fixed using bioabsorbable poly-D,L-lactide expansion bolts (5.8/8.5/10 mm x 35 mm). The tensile axis was placed parallel to the bone tunnel. The construction was then loaded until failure under a displacement rate of 1 mm per second.

RESULTS

There were no significant differences concerning the maximum pullout force (group I: 357 N +/- 61; group II: 326 N +/- 92; group III: 343 N +/- 55). In case of the expansion bolt, we found the stiffness to be higher (61 N/mm) when compared to group I (48 N/mm), and group II (52N/mm) (P < 0.01 I vs. III). Using interference screws, we were able to demonstrate a strong correlation between torque and pullout forces (group I: r2 = 0.7; group II: r2 = 0.92). Ruptures of the suturing material occurred only in groups I and II.

CONCLUSION

We conclude that hamstring graft fixation, using the presented expansion bolt, demonstrates fixation strength similar to the established screw fixation and can therefore be regarded as a reasonable alternative fixation method. Especially, since some specific disadvantages of screw fixation can be prevented by application of the bolt fixation.

Fixation strength of a novel bioabsorbable expansion bolt for patellar tendon bone graft fixation: an experimental study in calf tibial bone

This biomechanical study compares the initial fixation strength of a novel bioabsorbable two-shell expansion bolt (EB) with that of a well-established interference-screw technique in bone-patellar tendon-bone (BPTB) reconstruction in a calf model. Thirty tibia plateaus (age 5-6 months) were assigned to three groups: In groups I and II, trapezoidal bone plugs of BPTB grafts were fixed with bioabsorbable poly-L-lactide interference screws (8 x 23 mm) or titanium interference screws (8 x 25 mm) respectively. In group III, semicircular grafts were fixed using bioabsorbable poly-D, L-lactide expansion bolts (5.8/8.7 x 10 x 35 mm). The tensile axis was parallel to the bone tunnel, and the construction was loaded until failure applying a displacement rate of 1 mm per second. In group II the mean ultimate loads to failure (713 N+/-218 N) were found to be significantly higher than those of groups I (487 N+/-205 N) and III (510 N+/-133 N). Measurement of stiffness showed 45 N/mm+/-13.3 in group I, 58 N/mm+/-17.4 in group II and 46 N/mm+/-6.9 in group III, and did not demonstrate significant differences. We found a correlation between insertion torque and wedge insertion force and ultimate loads to failure in all groups (r=0.53 in group I, r =0.54 in group II, and r =0.57 in group III). Cross-section planes of bone tunnel increased by 51%, 30% and 31% respectively, following insertion of screws or expansion of bolts (p<0.05). We conclude that ACL graft fixation by means of the presented expansion bolt demonstrates a fixation strength similar to the established bioabsorbable screw fixation, and is a reasonable alternative fixation method, especially since some of the specific pitfalls of screw fixation can be avoided.

Bioabsorbable expansion bolt fixation in anterior cruciate ligament reconstruction

The current study evaluated initial fixation strength of a bioabsorbable expansion bolt compared with interference screw fixation in anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Thirty calf tibial plateaus with adjacent patella and extensor ligaments were used. Bioabsorbable poly-L-lactide interference screws were used for graft fixation in Group I, titanium screws in Group II, and bioabsorbable poly-DL-lactide expansion bolts were used in Group III. The mean force-to-failure (+/- standard deviation) in the three groups was 487 +/- 205 N, 713 +/- 218 N, and 594 +/- 224 N, respectively. The differences between Groups I and II were significant. No statistical differences were found regarding stiffness. Graft damage was significantly less in Group III compared with screw fixation. The fixation concept of an expansion bolt shows similar fixation strength and less graft damage compared with the established interference screw fixation. Because of the total absence of torque forces in contrast to bioabsorbable screws, the risk of implant breakage is minimized.

[Surgical treatment of pulmonary metastases from renal cancer]

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

Long-term results after pulmonary resection of renal cell carcinoma metastases

BACKGROUND

Until now no conclusive data exist regarding the factors influencing long-term survival after pulmonary resection of renal cell carcinoma metastases. The aim of the present study, therefore, was to discover definitive prognostic factors for survival using a large and homogeneous single center patient cohort.

METHODS

Between 1980 and 2000, 105 patients, after curative resection of lung metastases from renal cell carcinoma, were followed in this long-term study. These patients underwent a total of 150 surgical procedures. Survival analysis was done using the Kaplan-Meier method and the log-rank test. Multivariate analysis of prognostic factors was performed using the Cox multivariate proportional hazard model.

RESULTS

Median survival after curative resection reached 43 months (range, 1 to 218 months). Survival at 3, 5, and 10 years was 54%, 40%, and 33%, respectively. Univariate analysis revealed that a complete resection, a less than 4-cm diameter of the metastases and tumor-free lymph nodes at the time of primary operation, were highly significant dependent prognostic factors (p < 0.001). These factors were also shown to be independent prognostic factors as suggested by multivariate analysis (p < 0.05).

CONCLUSIONS

The size of the metastatic nodule, the completeness of pulmonary resection, and the lymph node status at the time of nephrectomy are the most important prognostic factors that influence survival after resection of pulmonary metastases. Recurrence of resectable pulmonary metastases does not impair survival, thus favoring repeated resection in patients with recurrent disease.

[Treatment of per- and subtrochanteric femoral fractures by gamma nails and modular hip prostheses. Differential indications and results]

From January 1997 to August 1998 all stable and nonstable trochanteric femoral fractures (n = 72) were treated routinely by gamma nail using the correct operative technique. Patients showing additional osteoarthritis of the hip in radiographs hip replacement was performed by a cementless modular femoral hip prostheses from January 1996 to August 1998 (n = 28). Follow up period was 6 to 18 months. Operation time and blood loss were higher using the prostheses. However complications and lethality (< 5%) were not different during postoperative course. In each group three operative technical complications occurred. Using a modified Harris Hip Score (without range of motion, contractions) the score was decreased non significant comparing both groups first of all in unstable fractures until follow up. In each group one revision (loosening of prostheses, excessive shortening of femoral neck) was necessary. Using the correct operative technique, the gamma nail proved to be a save device with good outcome. Outcome using modular prostheses is comparable to gamma nail. Therefore the use of modular prostheses is justified in case of osteoarthrosis and in some cases of very unstable fracture.

Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases

Modern concepts of treating thoracic diseases suggest more and more the use of minimally invasive thoracoscopic techniques to reduce morbidity and save costs. For treatment of specific lesions at the thoracic spine, several thoracoscopic procedures have been performed successfully. The present report examines the feasibility of thoracoscopic osteosynthesis in two patients with ventral hyperextension injuries and anterior instability of the thoracic spine. After initial correction of the anatomical deformity, autologous bone was harvested from the anterior iliac crest. Using a ventral, thoracoscopic approach, the main location of the ventral, damaged spinal segment was identified by the covering pleural haematoma. After endoscopic ventral bone grafting, osteosynthesis was performed, using dynamic compression plates, cardan drills and screw drivers. The perioperative course was uneventful, and follow up examinations after 3 years and 9 months, respectively, revealed an unchanged stable spinal segment. Our results show thoracoscopic osteosynthesis to be technically possible, with a potential for yielding satisfying long-term results.

Kinetics of circulating adhesion molecules and chemokines after mechanical trauma and burns

OBJECTIVE

To assess the role of circulating adhesion molecules and chemotactic cytokines within different settings of major trauma.

DESIGN

Retrospective study.

SETTING

Teaching hospitals, USA and Germany.

SUBJECTS

Two groups of patients with multiple injuries (group I n = 155 and group II n = 12) with mean (SEM) injury severity scores (ISS) of 35 (4) and 32 (4) points, respectively, and 18 burned patients with a mean of ISS 38 (9) points.

INTERVENTIONS

Serum samples were collected at the site of the accident and on admission to the (Group I) as well as during the post-trauma course in the hospital (Group II: days 1, 3, 5, 7, 10; Group III; weekly, up to week 10).

MAIN OUTCOME MEASURES

Measurement of concentrations of soluble (s) adhesion molecules (sE-selectin, sP-selectin), and chemotactic cytokines (interleukin-8 [IL-8], epithelial cell derived neutrophil activating peptide 78 [ENA-78]) in serum after major mechanical trauma and burns.

RESULTS

High concentrations of ENA-78 and sP-selectin were already present at the site of accident as well as one hour after injury. During recovery from the injuries, persistently high concentrations of IL-8, ENA-78, and sP-selectin were found, but sE-selectin was increased only during the first week after major trauma.

CONCLUSION

Massive tissue trauma causes immediate activation of selected chemokines and adhesion molecules within minutes of the injury which will then persist depending on the type and severity of the injury for a substantial length of time. There was, however, no correlation between serum concentrations of the mediators investigated and susceptibility to complications or outcome.

[Results of operative therapy in sequential liver and lung metastasis]

During the last 16 years, 15 patients with colorectal (n = 12), gastric (n = 1), renal cell (n = 1) and adrenal (n = 1) carcinoma underwent sequential resection of both hepatic and pulmonary metastases. Median survival after diagnosis of primary tumor was 80 months (range 23-183), after liver resection 23 (range 10-131), and after lung resection 18 months (range 5-87). Compared to patients with only hepatic (median survival: 38 months) or pulmonary metastases (median survival: 30 months) survival time was not significantly different (p = 0.18).

Surgical treatment of tumor metastases: general considerations and results

The prerequisite for a curative resection of metastases is their restriction to the key organs, the liver and lungs, in the sense of a limited dissemination. For long-term prognosis, the type of primary tumor as well as the radical resection of lung and liver metastases is essential. To improve the process of surgical indication and therapy of tumors, clear definitions for the terms "tumor recurrence" and "metastases" have been agreed upon. Research and clinical investigation have led to a better understanding of tumor-regulating factors, some of which are briefly described: Metastasis promoting factors include the lack of E-cadherin, which leads to a local penetration of basal membranes by tumor cells; CD44 seems to play an important role in cell-cell and cell-matrix interactions, apparently increasing the metastatic potential of tumors and reducing the long-term survival of patients. High levels of urokinase in primary tumors are also associated with a poorer prognosis, as well as plasminogen inactivator inhibitor PAI II, which plays a crucial role in tumor growth. Positive findings in bone marrow aspirates of patients with different malignancies, stained for cytokeratin 18, either are associated with higher recurrence rates in colon and breast cancer or can be correlated to the prognosis of patients with gastric cancer. Technical aspects of surgery for hepatic, pulmonary and skeletal metastases are presented and discussed with respect to curative and palliative indications.