Introduction: Optimal placement of the femoral neck screw is essential during osteosynthesis of pertrochanteric fractures. A low tip-apex distance (TAD) is crucial to avoid a cut-out of the femoral neck screw. Whether the use of a navigation system during osteosynthesis with Gamma3 nails positively influences the TAD, fluoroscopy time and surgery duration has been assessed differently in the initial clinical applications. We tested the ADAPT system for positioning Gamma3 nails as part of a standardised laboratory experiment. Methods: An inexperienced surgeon and an experienced surgeon each implanted 20 Gamma3 nails in artificial bones. Each surgeon performed 10 conventional interventions and 10 using the ADAPT system. Subsequently, TAD, femoral neck screw positioning, fluoroscopy time, number of X-ray images and surgery duration were compared. The experimental set-up also assessed whether the ADAPT system offers advantages over distal freehand locking for long Gamma3 nails. Results: The inexperienced surgeon was able to implant the nail significantly faster when using the ADAPT system (99.10 s/60.20 s; p = 0.005), while the experienced surgeon required more time to implant the femoral neck screws (59.70 s/94.00 s, p < 0.001). The fluoroscopy times of both surgeons were somewhat shorter when using the ADAPT system. All femoral neck screws were placed correctly with a TAD of less than 20 mm. Only the TAD of the inexperienced surgeon was reduced with the use of the ADAPT system (16.30 mm/12.40 mm; p < 0.001). Conclusions: The ADAPT system could reduce TAD and possibly fluoroscopy time, especially in inexperienced surgeons. For experienced surgeons, there was no influence on TAD and only a minimal effect on fluoroscopy time.

After structured (S3 guideline, ATLS®) acute care of multiple trauma patients in trauma centers, post-acute missed injuries continue to occur with incidence rates ranging from 1.3 to 39

Purpose With the decline in the mortality of severely injured patients, the scientific question and the perspective in clinical practice have changed in the direction of qualitative outcome parameters. This long-term survey of patient-reported out-comes is intended to support the argument of structured follow-up care and seamless trauma rehabilitation. Methods Patients were surveyed ten years after a serious injury with an Injury Severity Score of 16 points using the Polytrauma Outcome Chart. Thanks to its modular structure, consisting of the European Quality of Life Index, Short-Form-36 and Trauma Outcome Profile, the health-related quality of life of those affected could be systematically analyzed as a multidimensional construct. Results From 1 January 2019 to 31 December 2019, the health-related quality of life of 78 patients treated for a serious injury between 2007 and 2009 was surveyed. Even ten years after treatment, the state of health and quality of life of those affected were significantly lower compared to the normal German population. Age, overall injury severity, level of education, occupation, and relevant restrictions in social interaction as well as pain and symptoms of depression, anxiety and post-traumatic stress disorder were found to be predictors. Conclusion Psychosocial factors seem to play an important part in the assessment of health-related quality of life over the long term. A needs-oriented and interdisciplinary rehabilitation process offers the chance of continuing professional and social participation.

Mit dem Rückgang der Letalität von Schwerverletzten haben sich die wissenschaftliche Fragestellung und die Sichtweise in der klinischen Praxis in Richtung qualitativer Ergebnisparameter verändert. Mit der Langzeiterhebung des patientenberichteten Outcomes soll die Argumentation für eine strukturierte Nachsorge und eine lückenlose Traumarehabilitation unterstützt werden. Patienten sollen zehn Jahre nach einer schweren Verletzung mit einem Injury Severity Score von mind. 16 Punkten mithilfe des Polytrauma-Outcome-Charts befragt werden. Durch seinen modularen Aufbau aus European Quality of Life Index, Short-Form-36 und Trauma Outcome Profil kann die gesundheitsbezogene Lebensqualität der Betroffenen als multidimensionales Konstrukt systematisch analysiert werden. Vom 01.01.2019 bis 31.12.2019 ist die gesundheitsbezogene Lebensqualität von 78 Patienten der Schwerverletzten-Versorgung in den Jahren 2007 bis 2009 erhoben worden. Gesundheitszustand und Lebensqualität von Betroffenen sind sogar nach einem durchschnittlichen Nachbefragungszeitraum von zehn Jahren im Vergleich zur deutschen Normalbevölkerung signifikant herabgesetzt. Als Prädiktoren haben sich Alter, Gesamtverletzungsschwere, Bildungsstand, Berufstätigkeit und relevante Einschränkungen der sozialen Interaktion sowie Schmerz und Symptome von Depression, Angst und posttraumatischer Belastungsstörung herausgestellt. Im Langzeitverlauf scheinen psychosoziale Faktoren einen hohen Stellenwert für die Selbstbeurteilung der gesundheitsbezogenen Lebensqualität zu haben. Ein bedürfnisorientierter und interdisziplinärer Rehabilitationsprozess bietet die Chance auf eine dauerhafte berufliche sowie soziale Teilhabe.

Background/Objectives: A neck of femur (NOF) fracture is one of the most common fractures, and its treatment in the geriatric population using cemented bipolar hemiarthroplasty (HA) is a standard procedure worldwide. Various surgical approaches have been described for this operation, aiming to reduce complications and improve early mobilization. The present study compares two minimally invasive approaches, the anterolateral minimally invasive approach (ALMIS) and the direct superior approach (DSA), with respect to their intraoperative and early postoperative complications in cemented bipolar HA. Methods: The medical records of all patients undergoing cemented bipolar HA for a NOF fracture between January 2017 and December 2023 were analyzed. The aim of the study was to compare the two surgical approaches. The evaluation focused on intraoperative parameters and early complications. Results: A total of 226 patients were included in the analysis, with 62 undergoing DSA and 164 ALMIS, with an average age of 83.5 years. The two approaches did not differ significantly in terms of stem implantation quality, length of hospital or intensive care unit stay, postoperative mobilization, or the need for transfusions. However, the ALMIS was associated with a significantly shorter operative time (DSA: 89.7 min vs. ALMIS: 77.2 min; p < 0.01). On the other hand, the DSA had a significantly lower complication rate (DSA: 0/61 vs. ALMIS: 11/163; p = 0.04). Conclusions: In a comparison of the two minimally invasive approaches, DSA and ALMIS, for treating a NOF fracture with cemented bipolar HA, the DSA demonstrated a lower complication rate, though it had a slightly longer operating time.

Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study

Background The leading cause of death among people under 45 years of age is trauma. However, there is little information from the last 10 years on the exact causes of death of seriously injured people after hospital admission in Germany. The aim of the study is to evaluate the data of a level I trauma centre from the last 10 years. The reliability of the data, frequency of the causes of death and correlations with the mechanism of injury as well as the confirmability of the data in the TraumaRegister DGU are to be investigated. Materials and Methods The University Hospital Jena data were analysed for 203 deceased trauma patients from accidental death between 2007 and 2017. Results A clear determination of the cause of death is possible in about 85% of cases on the basis of hospital data. The most frequent cause of death of severely injured patients after admission to the hospital is traumatic brain injury (59.6 %), followed by organ failure (17 %), haemorrhage (14 %) and other causes of death (9.4 %). Verification using data from the TraumaRegister DGU is possible. There is a clear correlation between mechanism of injury and cause of death. Conclusions The cause of death is very often a subjective assessment of the recording doctor. In particular, there are difficulties with patients who die in the resuscitation room before further diagnosis. The most frequent cause of death today is traumatic brain injury. For future evaluations, the new information in the TraumaRegister DGU is helpful because the cause of death can only be partially derived from other registry data. The correlation between the type of accident and the cause of death could be used for preventive measures.

Abstract Background Treatment of pertrochanteric femoral fractures is often associated with significant blood loss. It has already been demonstrated that the administration of tranexamic acid (TXA) for endoprosthetic procedures reduces blood losses and leads to a decreased frequency of postoperative complications. The aim of this study is to demonstrate whether the administration of TXA as part of osteosynthesis treatment for pertrochanteric fractures using a proximal femoral nail reduces perioperative blood losses and haemorrhage-related complications. Methods In a two-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 294 patients who had suffered from pertrochanteric femoral fractures. The subjects were compared clinically to a historical control group who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, transfusion requirement, and occurrence of complications. Results The TXA group showed evidence of a reduction in blood loss (TXA = 0.97 ± 0.47 l; nonTXA = 1.06 ± 0.47 l; p = 0.004) and a lower frequency of transfusion (TXA = 20%; nonTXA = 31%; p = 0.032) as compared to the nonTXA group. However, evidence of this therapeutic effect could only be demonstrated at one of the centres on subgroup comparison between the two centres. At the second centre, the data did not show a significant difference. A trend could be seen towards a reduction in postoperative renal failure. No complications occurred resulting from the administration of tranexamic acid. Conclusion Preoperative administration of TXA does not lead to an increased rate of thromboembolic complications when applied for treatment of pertrochanteric femoral fractures. Evidence of a positive effect could be seen in principle in relation to the reduction in perioperative blood loss and the frequency of transfusion. The difference in effect between the two centres remains to be clarified: for this reason, it is possible to assume that further factors influencing the efficacy of TXA administration are at play which were not taken into account in this study.

Interleukin (IL)-1β is an important pro-inflammatory cytokine in the progression of osteoarthritis (OA), which impairs mitochondrial function and induces the production of nitric oxide (NO) in chondrocytes. The aim was to investigate if blockade of NO production prevents IL-1β-induced mitochondrial dysfunction in chondrocytes and whether cAMP and AMP-activated protein kinase (AMPK) affects NO production and mitochondrial function. Isolated human OA chondrocytes were stimulated with IL-1β in combination with/without forskolin, L-NIL, AMPK activator or inhibitor. The release of NO, IL-6, PGE2, MMP3, and the expression of iNOS were measured by ELISA or Western blot. Parameters of mitochondrial respiration were measured using a seahorse analyzer. IL-1β significantly induced NO release and mitochondrial dysfunction. Inhibition of iNOS by L-NIL prevented IL-1β-induced NO release and mitochondrial dysfunction but not IL-1β-induced release of IL-6, PGE2, and MMP3. Enhancement of cAMP by forskolin reduced IL-1β-induced NO release and prevented IL-1β-induced mitochondrial impairment. Activation of AMPK increased IL-1β-induced NO production and the negative impact of IL-1β on mitochondrial respiration, whereas inhibition of AMPK had the opposite effects. NO is critically involved in the IL-1β-induced impairment of mitochondrial respiration in human OA chondrocytes. Increased intracellular cAMP or inhibition of AMPK prevented both IL-1β-induced NO release and mitochondrial dysfunction.

Zusammenfassung Hintergrund Trauma ist die häufigste Todesursache bei unter 45-Jährigen und trotzdem gibt es nur wenig Daten zu den genauen Todesursachen Schwerverletzter nach Klinikeinlieferung in Deutschland aus den letzten 10 Jahren. Ziel der Arbeit ist 1. eine Auswertung der Daten der verstorbenen Schwerverletzten eines überregionalen TraumaZentrums aus den letzten 10 Jahren. Erforscht werden sollen Verlässlichkeit der Daten, Häufigkeit der Todesursachen und Zusammenhänge mit dem Unfallmechanismus und 2. die Nachvollziehbarkeit der Daten im TraumaRegister DGU. Patienten und Methoden Es erfolgte die Auswertung der Daten von 203 verstorbenen schwerverletzten Patienten aus dem Universitätsklinikum Jena, die von 2007 bis 2017 verunfallt sind. Ergebnisse Eine eindeutige Festlegung der Todesursache ist anhand von Klinikdaten in ca. 85% der Fälle möglich. Häufigste Todesursache von Schwerverletzten nach Klinikeinlieferung ist mit 59,6% das Schädel-Hirn-Trauma, gefolgt von 17% Organversagen, 14% Hämorrhagie und 9,4% sonstigen Todesursachen. Die Verifizierung anhand von Daten aus dem TraumaRegister DGU ist möglich. Es besteht ein klarer Zusammenhang zwischen Unfallmechanismus und Todesursache. Schlussfolgerungen Welche Todesursache angegeben wird, unterliegt immer auch einer subjektiven Einschätzung. Insbesondere bestehen Schwierigkeiten bei Patienten, die vor weiterer Diagnostik im Schockraum versterben. Häufigste Todesursache ist heute das Schädel-Hirn-Trauma. Es ist sinnvoll, die Todesursache im TraumaRegister DGU extra zu erfassen, da diese anhand von anderen Registerdaten nur teilweise abgeleitet werden kann. Die Zusammenhänge zwischen Unfallmechanismus und Todesursache könnten ggf. für Präventionsmaßnahmen genutzt werden.

Fragestellung Bei der Versorgung von pertrochantären Frakturen (PF) mittels Marknagel ist aufgrund von Blutverlusten in ca. 20 % der Fälle postoperativ eine Transfusion erforderlich. In der Endoprothetik von Hüft- und Kniegelenk konnten durch die Gabe von Tranexamsäure (TXA) der Blutverlust und die Transfusionshäufigkeit signifikant gesenkt werden. Da TXA allgemein für chirurgische Eingriffe mit erhöhtem Blutungsrisiko zugelassen ist, wurde in unserer Klinik beschlossen, Transexamsäure bei diesen Eingriffen routinemäßig einzusetzen. Die Studie untersucht das perioperative Outcome vor und nach Einführung der standardisierten Gabe von 1g TXA.

Background: The end-tidal capnometry allows the continuous position control of the endotracheal tube and ventilation of ventilated trauma patients. It is of high value for quality and safety. The Trauma-Register DGU (R) has recently registered its prehospital application. The aim of this study is to explore application and effects of prehospital capnometry. Methods: The database is the Trauma-Register DGU (R). Inclusion criteria were admission via the shock room and complete information on airway management. Documentation completeness, frequency and type of application as well as effects of capnometry on clinical course and outcome were analysed descriptively. To identify situations that affect the frequency of use, subgroups have been formed (e.g. rescue facilities, injury pattern, injury severity, prehospital care time, etc.). Additionally, the consequences of a lack of capnometry on the clinical course and outcome were analysed. Results: 43,470 cases were included. Data on prehospital capnometry were available in 62.3%. The frequency of use in 27,099 cases was as follows: 82.9% after endotracheal intubation and 26.9% after alternative airway management using the supraglottic airway. This is independent of means of transport and injury patterns. Significant effects on clinical outcome, outcome or lethality could not be established. A significant impact on clinical course, outcome and mortality could not be proven. However, there is a tendency for higher mortality when prehospital capnometry is not used and patients had severe craniocerebral injuries. Conclusions: Although current guidelines recommend capnometry for the monitoring of ventilated trauma patients, it has to be stated that capnometry has either not been documented or not been performed in a relevant percentage of patients, especially when alternative methods of airway management were applied. The degree of fulfilment of this important indicator of care quality and patient safety should be further increased. Their importance must continue to be emphasised in education and training.

Background Volar locking plate fixation has become the gold standard in the treatment of unstable distal radius fractures. Juxta-articular screws should be placed as close as possible to the subchondral zone, in an optimized length to buttress the articular surface and address the contralateral cortical bone. On the other hand, intra-articular screw misplacements will promote osteoarthritis, while the penetration of the contralateral bone surface may result in tendon irritations and ruptures. The intraoperative control of fracture reduction and implant positioning is limited in the common postero-anterior and true lateral two-dimensional (2D)-fluoroscopic views. Therefore, additional 2D-fluoroscopic views in different projections and intraoperative three-dimensional (3D) fluoroscopy were recently reported. Nevertheless, their utility has issued controversies. Objectives The following questions should be answered in this study; 1) Are the additional tangential view and the intraoperative 3D fluoroscopy useful in the clinical routine to detect persistent fracture dislocations and screw misplacements, to prevent revision surgery? 2) Which is the most dangerous plate hole for screw misplacement? Patients and Methods A total of 48 patients (36 females and 13 males) with 49 unstable distal radius fractures (22 x 23 A; 2 x 23 B, and 25 x 23 C) were treated with a 2.4 mm variable angle LCP Two-Column volar distal radius plate (Synthes GmbH, Oberdorf, Switzerland) during a 10-month period. After final fixation, according to the manufactures' technique guide and control of implant placement in the two common perpendicular 2D-fluoroscopic images (postero-anterior and true lateral), an additional tangential view and intraoperative 3D fluoroscopic scan were performed to control the anatomic fracture reduction and screw placements. Intraoperative revision rates due to screw misplacements (intra-articular or overlength) were evaluated. Additionally, the number of surgeons, time and radiation-exposure, for each step of the operating procedure, were recorded. Results In the standard 2D-fluoroscopic views (postero-anterior and true lateral projection), 22 screw misplacements of 232 inserted screws were not detected. Based on the additional tangential view, 12 screws were exchanged, followed by further 10 screws after performing the 3D fluoroscopic scan. The most lateral screw position had the highest risk for screw misplacement (accounting for 45.5% of all exchanged screws). The mean number of images for the tangential view was 3 ± 2.5 images. The mean surgical time was extended by 10.02 ± 3.82 minutes for the 3D fluoroscopic scan. An additional radiation exposure of 4.4 ± 4.5seconds, with a dose area product of 39.2 ± 14.5 cGy/cm2 were necessary for the tangential view and 54.4 ± 20.9 seconds with a dose area product of 2.1 ± 2.2 cGy/cm2, for the 3D fluoroscopic scan. Conclusions We recommend the additional 2D-fluoroscopic tangential view for detection of screw misplacements caused by overlength, with penetration on the dorsal cortical surface of the distal radius, predominantly observed for the most lateral screw position. The use of intraoperative 3D fluoroscopy did not become accepted in our clinical routine, due to the technical demanding and time consuming procedure, with a limited image quality so far.

Purpose: Proximal humerus fractures belong to the most common fractures. However the level of evidence is not very good. The aim of the study was therefore the identification of factors that influence the outcome. Materials and Methods: 62 patients with proximal humerus fractures were examined 6, 12 and 52 weeks after fracture. Furthermore 10 other subjects without any shoulder diseases were checked. The activation of 16 shoulder muscles on both sides was recorded by surface EMG during several situations in the scapula plane. Additionally CM- and DASH-Score as well as individual personal data were collected. Results: The results have shown that the severity of the fracture and the kind of treatment are the essential factors. Age, sex and handedness are not essential. A conservative treatment should be favoured if possible. The function of M. deltoideus is impaired by the fracture and is essential for the result of the treatment. EMG techniques deliver additional results related to the explanation of pathological mechanisms. An early therapy seems to be necessary. Discussion: A founded decision by the physician is relevant for the success of treatment.

Humeruskopffrakturen gehören zu den häufigsten Frakturen. Die Evidenzlage zur Nachbehandlung ist schlecht. Ziel der Studie war die Identifikation von Einflussfaktoren auf das Behandlungsergebnis. Untersucht wurden 62 Patienten mit proximalen Humerusfrakturen nach 6, 12 und 52 Wochen sowie 10 gesunde Probanden. Mittels Oberflächen-EMG erfolgte beidseitig die Ableitung von 16 Schultermuskeln in verschiedenen Untersuchungssituationen in der Scapulaebene. Zusätzlich wurden Constant-Murley-, DASH-Score sowie patientenspezifische Daten erhoben. Die Ergebnisse haben gezeigt, dass die Schwere der Fraktur und die Behandlungsart wichtige Einflussfaktoren sind. Alter, Geschlecht und Händigkeit spielten eine untergeordnete Rolle. Eine konservative Behandlung sollte nach Möglichkeit favorisiert werden. Die Funktion des M. deltoideus ist durch die Fraktur beeinträchtigt und beeinflusst das Ergebnis entscheidend. EMG-Verfahren liefern zusätzliche Erkenntnisse zur Erklärung von Pathomechanismen. Eine frühzeitige Nachbehandlung erscheint notwendig. Wichtig für den Behandlungserfolg ist ein begründeter Entscheidungsalgorhythmus des erstbehandelnden Arztes.

INTRODUCTION:Circulating histones have been identified as mediators of damage in animal models of sepsis and in patients with trauma-associated lung injury. Despite existing controversies on actual histone concentrations, clinical implications and mechanism of action in various disease conditions, histone levels in human sepsis, association with disease progression and mediated effects on endothelial and immune cells remain unreported. This study aimed to determine histone levels and its clinical implication in septic patients and to elucidate histone-mediated effects ex-vivo.METHODS:Histone levels, endogenous activated protein C (APC) levels and clinical data from two independent cohorts of septic patients were obtained. Histone levels were compared with various control groups including healthy individuals, intensive care unit (ICU) patients without sepsis, ICU patients with multiple organ failure and patients with minor or multiple trauma, all without infection. Endothelial and monocytic cells were stimulated with histones. Cellular integrity and sepsis prototypical cytokines were evaluated. The mechanism of action of histones via Toll-like receptor 4 (TLR4) was evaluated using a function blocking antibody. Histone degradation in plasma was studied by immunoblotting.RESULTS:Histone H4 levels were significantly elevated in patients with sepsis (cohort I; n = 15 and cohort II; n = 19) versus ICU controls (n = 12), patients with multiple organ failure (n = 12) or minor trauma (n = 7), associated with need for renal replacement therapy and decrease in platelet count during disease progression, and remarkably were significantly associated with increased mortality rates in septic patients (ICU-, 28 day- and 90 day mortality rates). There was an inverse correlation between plasma histones and endogenous APC levels. Histone stimulation induced the release of sepsis prototypic cytokines and decreased cell integrity indicated by a significant increase of lactate dehydrogenase (LDH) and propidium iodide (PI) staining. Blocking of TLR4 decreased cellular cytotoxicity on endothelial cells. The calculated half-life of histones in spiked plasma was 4.6 minutes.CONCLUSIONS:Histone levels in septic patients are significantly increased and might mediate disease aggravation by cellular injury and inflammation via TLR4 signaling, which potentially results in multiple organ failure and fatal outcome.

Pressure-sensitive K-Scan 4000 sensors (Tekscan, USA) provide new possibilities for the dynamic measurement of force and pressure in biomechanical investigations. We examined the sensors to determine in particular whether they are also suitable for reliable measurements of retropatellar forces and pressures. Insertion approaches were also investigated and a lateral parapatellar arthrotomy supplemented by parapatellar sutures proved to be the most reliable method. The ten human cadaver knees were tested in a knee-simulating machine at a torque of 30 and 40 Nm. Each test cycle involved a dynamic extension from 120° flexion. All recorded parameters showed a decrease of 1-2% per measurement cycle. Although we supplemented the sensors with a Teflon film, the decrease, which was likely caused by shear force, was significant. We evaluated 12 cycles and observed a linear decrease in parameters up to 17.2% (coefficient of regression 0.69-0.99). In our opinion, the linear decrease can be considered a systematic error and can therefore be quantified and accounted for in subsequent experiments. That will ensure reliable retropatellar usage of Tekscan sensors and distinguish the effects of knee joint surgeries from sensor wear-related effects.

Background Intramedullary nailing is a standard surgical procedure for fixation of proximal femoral fractures, but is associated with considerable radiation exposure for controlling the implant placement, due to the percutaneous insertion technique. The aim of this study was the evaluation of potential benefits of 2D-fluoroscopic based navigation focused on the reduction of radiation exposure, a decrease of procedure time, as well as an increase of accuracy for Gamma3 nail insertions. Methods Twenty randomized Gamma3 nail insertions were performed in non-fractured synthetic femora according to the manufactures operation guidelines (group I) or with use of a 2D-fluoroscopic based navigation system (group II). Time of different steps of the procedure and the radiation exposure were measured, as well as the accuracy evaluated in postoperative CT scans. Results and discussion All Gamma3 nails were placed without any technical problems. Independent of the used procedure, the overall operating time (group I: 584 ± 99.2 sec; group II: 662 ± 64.9 sec; p=0.06) and accuracy of the final nail-positions were equivalent, but the radiation exposure was significantly reduced (92% reduction in fluoroscopic images and 91% reduction in fluoroscopic time, p< 0.01), using the 2D fluoroscopic based navigation procedure. Conclusions 2D-fluoroscopic based navigation for Gamma3 nail insertion facilitates a relevant reduction of radiation exposure with equivalent accuracy of the final implant position and no prolonged operating time. This promising procedure modification is independent of different cephalomedullary implant manufacturers and specific implant designs, but needs to be evaluated in further clinical settings.

Isolated depression fractures of the femoral condyle are rare, but severe injuries due the destroyed congruency of the articular surface in the weight-bearing region of the joint. In most cases, an arthrotomy with fragment reduction and internal fixation by screws buttress or plates is performed. Disadvantages of this procedure are the approach-related complications. Furthermore, an implant removal is necessary, if a secondary osteoarthrosis develops. We present a female patient with a hyperflexion trauma of her right knee, resulting in an isolated depression fracture of the medial femoral condyle. To avoid arthrotomy-related morbidity, the impressed fragment was retrograde addressed using navigated guidance and reduced indirectly under arthroscopic control. Via the retrograde intraosseous tunnel a biodegradable screw was used as a buttress against the fragment to prevent a re-dislocation. The fracture healed without any complications and the patient re-administered her sports activities at 10 weeks follow-up. This procedure enables an accurate reduction and stable fixation of joint depression fragments via a minimal invasive approach.