Background context Many institutions' retrospective studies investigated the effect of the timing of surgery on outcomes of polytraumatized patients with severe lesions of the thoracic spine and mainly found a better outcome for patients who were operated on less than 72 hours posttrauma. Purpose We conducted a prospective study in a Level I trauma center to validate the retrospective data and to investigate other variables, in addition to the timing of surgery that may influence patient outcomes. Study design Prospective observational clinical study. Patient sample Within this prospective study at a Level I trauma center, we enrolled 38 multiple injured patients with unstable fractures of vertebral column from Level Th1 to L1. Further inclusion criteria consisted of an injury severity score of 16 or more and an intensive care unit (ICU) stay of more than 7 days. The age of included patients was limited from 16 or more to 75 or less years. Outcome measures Hospital stay, stay on ICU, and mortality. Methods Twenty-two patients were operated on less than or equal to 72 hours posttrauma, and 16 received late surgery greater than or equal to 72 hours posttrauma. Results Patients who received early surgery had a significantly higher mortality rate (p<.01) than those who received late surgery. Sixty-seven percent of our patients who had an initial hemoglobin (Hb) less than 10 mg/dL died. Seventy-five percent of those patients who had an Hb less than 10 mg/dL and received a thoracic drain died. Conclusions Although some reports indicate advantages for early surgery for thoracic spine trauma in the polytraumatized patient, careful patient selection should be used. Based on the results of this prospective study, early surgery for thoracic spine trauma in patients with concomitant severe thoracic trauma and low initial Hb levels may pose a risk for poor clinical outcomes.

BACKGROUND:Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia. PATIENTS AND METHODS:In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention. RESULTS:A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group. CONCLUSION:A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

Allergies against bone cement or bone cement components have been well-described. We report on a 63-year-old patient who presented with progressive vitiligo all over the body after implantation of a cemented total knee replacement. A dermatological examination was performed and an allergy to benzoyl peroxide was found. A low-grade infection was diagnosed 5 months after implantation of the total knee replacement and the prosthesis was replaced with a cement spacer. After treating the infection of the knee replacement non-cemented arthrodesis of the knee was performed. In cases of new, unknown skin efflorescence, urticaria and periprosthetic loosening of cemented joint replacement, the differential diagnosis should include not only infections but also possible allergies against bone-cement and components such as benzoyl peroxide or metal components.

The amount of weight bearing and the force transmission to the frame have an important influence on the results of treatment with an Ilizarov external fixator.The frame provides beneficial interfragmentary movements and compressive loads at the fracture site through elastic wires.Mobilisation can be achieved by applying a weightbearing platform at the distal end of the fixator.The effect on the interfragmentary movements and the compressive loads in indirect and direct loading were analysed in this study using a composite tibia bone model.Displacement transducers were attached to measure the interfragmentary movements and to detect relative movements of the bone fragments and movements between the rings.The compressive loads in the osteotomy were measured with loading cells in the defect zone.The weight-bearing platform had a substantial effect on the biomechanical behaviour of the frame.It led to an indirect force transmission through the fixator with respect to the osteotomy, resulting in lower compressive loads, lower interfragmentary movements and higher mechanical stress on the frame.

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

Background: The treatment of severe bacterial infections of the ankle joint is difficult and complex. In the case of a chronic infection with destruction of the ankle joint, a tibiotalar arthrodesis with external fixation is the treatment of choice. In this study the results of ankle arthrodesis due to bacterial infection using the Ilizarov external fixator are presented. Patients and Methods: Between 2001 and 2004 37 patients (10 female, 27 male, mean age 58 years) were treated with a tibiotalar arthrodesis using the Ilizarov fixator. All patients had a confirmed infection in the course of their disease. Active infection was present in 20 patients at the time of the operation. Most secondary ankle arthritides (81%) were caused post-traumatically after various internal fixation procedures. Previous ankle arthrodeses were tried in 14 cases (12 cases with internal fixation, two cases with external monolateral fixation). Patients were treated with a four-ring Ilizarov frame (in two cases with a five-ring frame) and stainless steel wires. All patients could be included at a mean follow-up of 46 (12-49) months. A modified AOFAS score was used for the functional outcome. Results: The operation took 141 minutes at an average ranging from 90 to 252 minutes. The inpatient treatment lasted between 10 and 63 days (mean 26 days). The time spent in the fixator was 116.7 (69-245) days. All patients were mobilised under full weight bearing with the external fixator. Surgical revision was necessary in 13 patients: four patients needed wound revisions due to ongoing infection, six patients needed wire exchange due to deep infection in three cases and wire breakage in three cases, one patient needed additional wires because of an initially instable frame configuration and two patients needed secondary skin grafting. Bony consolidation was achieved in 32 patients (86.5%). With a re-arthrodesis performed in four patients using the Ilizarov fixator, the overall fusion rate was 94.6%. Infection was persistent in two cases with one solid ankle fusion and one ankle pseudarthrosis. At the time of follow-up 35 patients were able to walk under full weight loading with orthopaedic shoe modifications, four patients needed support of a cane and three patients wore an ankle- foot orthesis. The two patients with persistent pseudarthrosis were mobilised in a lower-leg orthesis after declining another surgical revision. The positioning of the hindfoot showed in seven cases an equinus of 10 degrees, in one case a varus of 10 degrees and in two cases a valgus positioning of 10 degrees. A plantigrade foot positioning or with minimal degrees of deviation could be achieved in all other cases. The modified AOFAS score at the time of the follow-up examination ranged from 19 to 86 with an average score of 67.9 points. All patients except three were satisfied or rather satisfied with the treatment procedure and its results. Conclusion: The Ilizarov external fixator is a safe method for ankle fusion in cases of infection. The advances are a possible application at acute infection and immediate mobilisation at full weight bearing. However, it remains a time-consuming and stressful procedure for the patient.

Introduction: Heterotopic ossification (HO) is a common and serious complication after spinal cord injury, with an incidence of 5-50%. Single-dose radiation therapy with 7 Gy is an established procedure for HO prophylaxis after total hip replacement. The aim of our study was to determine the clinical outcome after single-dose radiation therapy in the prophylaxis of HO in paraplegic patients.Patients and Methods: Between January 2006 and July 2009, 75 paraplegic patients with heterotopic ossification were treated in our hospital. On the basis of the defined inclusion and exclusion criteria, 62 patients were included in our study, whereas 55 patients participated in our follow-up examination. All patients received a bi-weekly ultrasound of the hip for an attempt at early diagnosis of the condition. In case of an ultrasound suspicion of HO, a computed tomography (CT) or magnetic resonance imaging (MRI) of the hip was performed. After confirmation of HO, a single-dose radiation therapy with 7 Gy was performed. In group A, the patients were irradiated with an electrode voltage of 15 MeV (36 patients) and in group B with 6 MeV (26 patients). All patients were assessed with a standardised questionnaire with a mean follow-up of 30.6 months (range 678 months).Results: The mean interval time between the initial spinal injury and HO development was 58,2 days (range 14-125). 69,4% of all patients revealed a Brooker grade I, 27.4% grade II and 3.2% a grade III. No cases of Brooker grade IV (ankylosis) occurred. No patient showed side-effects after radiation therapy. However, in group A one patient (3,2%) and in group B three patients (12.5%) developed HO relapse. Those patients were treated again with a single-dose radiation therapy with 7 Gy and 15 MeV and, afterwards, they were free of complaints. Deep vein thrombosis was confirmed in 11 patients (32.3%) in group A and in 8 patients (33.3%) in group B.Conclusions: Single-dose radiation therapy with 7 Gy in the treatment of heterotopic ossification is an effective option. A higher electrode voltage improves the effectiveness of the irradiation and the clinical outcome. Essential for the outcome is the early detection and treatment of HO with single-dose radiation therapy. Randomised, prospective studies should be undertaken in order to confirm these findings.

Allergien gegen Knochenzement oder dessen Bestandteile sind im Rahmen der Endoprothetik eine Seltenheit. Wir berichten über einen 63-jährigen Patienten, der eine Woche nach Implantation einer zementierten Knieprothese bei Gonarthrose eine ausgeprägte Vitiligo entwickelte. Ein Epikutantest ergab ein positives Ergebnis auf Benzoylperoxid, einem Bestandteil des Knochenzements. Fünf Monate nach der Implantation kam es zum Auftreten eines Protheseninfekts, woraufhin eine Explantation der Knieprothese vorgenommen wurde. Nach Sanierung des Infekts erfolgte die Implantation eines zementfreien Arthrodesenstabs. Bei der Erstmanifestation unklarer Hauteffloreszenzen nach Implantation zementierter Fremdmaterialien sollte neben dem Ausschluss einer Infektion auch ein Augenmerk auf eine mögliche Allergie auf Inhaltstoffe von Knochenzement gelegt werden.

Die ankylosierende Spondylitis (AS) ist eine entzündlich-rheumatische Systemerkrankung. Durch die vermehrte Steifigkeit der Wirbelsäule können schon bei geringer Krafteinwirkung Frakturen im Bereich der Wirbelsäule auftreten. Die operative Stabilisierung ist ein etabliertes Therapieverfahren. Anhand dieser Studie wurde bei 119 Patienten mit einer AS das klinische Outcome nach operativer Versorgung untersucht.

Background: Low-intensity pulsed ultrasound (LIPUS) was proven to have a positive impact on bone healing in animal and clinical studies. Methods: In this prospective, randomized controlled trial the effect of LIPUS during distraction osteogenesis was investigated. Thirty-six patients who underwent distraction osteogenesis (>2 cm) were enrolled. Sixteen patients in the treatment group received LIPUS, and 20 patients as control group did not. Ultrasound treatment device was transcutaneously applied at the distraction gap for 20 minutes daily (frequency 1.5 MHz, signal burst with 200 μs, signal repetition frequency 1.0 kHz, intensity 30 mW/cm2). Evaluation of patients was performed by standard radiographs every 3 weeks to 4 weeks. Results: Average transport distance was 7.0 cm in the ultrasound group and 6.3 cm in the control group. Mean Paley index for the ultrasound group was 1.09 mo/cm and 1.49 mo/cm for the control group. Mean distraction consolidation index for the ultrasound group was 32.8 d/cm and 44.6 d/cm for the control group. The calculated indices indicated no significant statistical difference between the two groups (p < 0.116) but the fixator gestation period could be decreased for 43.6 days in the treatment group. Conclusions: Therapeutic application of LIPUS during callus distraction constitutes a useful adjuvant treatment during distraction osteogenesis and has a positive effect on healing time with no negative effects.

INTRODUCTION:Complex vertebral fractures can lead to injury of the spinal cord with resulting paraplegia. High-speed accidents are common causes, especially in younger patients. Malignant or inflammatory processes play an important role in the elderly. Less common reasons for a spinal cord injury are congenital malformations. We here report about a 17-year-old patient who suffered from paraplegia after an isolated rupture of the spinal cord without an injury of the vertebral bodies, intervertebral disc or ligamentous structures. This type of injury has not been reported in the literature before.PATIENT AND METHOD:We report about a 17-year-old patient, referred to our hospital, presenting with lumbal paraplegia after a high-speed accident 8 days prior to admission. After initial stabilisation of the polytraumatised patient, he was referred to our hospital for further treatment.RESULTS AND CONCLUSION:The radiological examination showed a bilateral acetabular fracture, a right anterior pelvic ring fracture and shaft fractures of the left humerus and right femur. Furthermore, the spinal cord at thoracic level 10/11 was ruptured. Interestingly, there was no injury of the vertebral bodies, intervertebral disc or ligamentous structures. A tethered cord as a possible anatomic variation could be excluded in this case by MRI. However, anatomic variations could be the reason for this injury and should be kept in mind.

Hintergrund: Die Behandlung von chronischen Sprunggelenksinfekten ist aufwendig und komplikationsreich. Die Arthrodese über einen externen Fixateur ist im Fall einer Infektdestruktion des Sprunggelenks das Verfahren der Wahl. In einer retrospektiven Untersuchung wird über die Ergebnisse der Sprunggelenksarthrodese mit dem Ilizarov-Ringfixateur bei floridem oder abgelaufenem Infekt berichtet. Patienten und Methoden: Zwischen 2001 und 2004 wurden 37 Patienten (10 Frauen, 27 Männer, Durchschnittsalter 58 Jahre) mit einer Infektanamnese des oberen Sprunggelenks mit einer Ilizarov-Arthrodese behandelt. Eine aktive Infektion bestand zum Zeitpunkt der Operation bei 20 Patienten. Die Nachuntersuchung erfolgte nach durchschnittlich 46 (12–49) Monaten. Das funktionelle Ergebnis wurde in einem modifizierten AOFAS Score überprüft. Ergebnisse: Die durchschnittliche Operationszeit betrug 141 (90–252) Minuten. Die Fixateurtragezeit lag im Durchschnitt bei 117 (69–245) Tagen, wobei der stationäre Aufenthalt durchschnittlich 26 (10–63) Tage betrug. Eine Arthrodese wurde im primär angelegten Fixateur in 32 Fällen (86,5 %) erzielt. Über eine Ilizarov-Rearthrodese konnte eine Gesamtfusionsrate von 94,6 % erreicht werden. Der modifizierte AOFAS Score ergab einen Durchschnittswert von 67,9 (19–86) Punkten. Schlussfolgerung: Mit dem Ilizarov-Ringfixateur steht ein sicheres Verfahren für die Sprunggelenksarthrodese in Infektsituationen zur Verfügung. Die Vorteile liegen in der Anwendung auch im aktiven Infekt und der direkten Vollbelastbarkeit. Das Verfahren ist jedoch zeitaufwendig bei eingeschränktem Patientenkomfort durch den ausladenden Fixateur.

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

The purpose was to evaluate inflammatory and microcirculatory reactions after implantation of various calcium phosphate bone substitutes in an in vivo model.

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

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

BACKGROUND The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma. METHODS We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure. RESULTS : Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all. CONCLUSIONS Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.

PURPOSE:Mesenchymal stem cells (multipotent human mesenchymal stromal cells, MSC) are currently the most promising cell type for regenerative medicine. For a clinical approach, it is necessary to develop and establish methods for expansion, differentiation, and delivery.METHODS:A completely autologous plasma clot containing peripheral blood mononuclear cells (PBMC) was tested for the osteopromotive activity towards expanded human mesenchymal stem cells in vitro. The plasma clot was prepared from anticoagulated blood plasma after addition of isolated leukocytes and calcium chloride. Plasma clots after the gelation were added to subconfluently growing MSC or used in a transwell system. Cell proliferation, the activity of alkaline phosphatase, the release of osteoprotegerin, C-terminal procollagen peptide, as well as osteocalcin, the analysis of matrix mineralization as well as bone nodule formation were analyzed up to 3 weeks.RESULTS:In contrast to plasma clots with no exogenously added leukocytes, the presence of PBMC within the plasma clot significantly promoted osteogenic differentiation of MSC correlated to the time period of incubation. Proliferation of MSC was decreased at maximal mineralization time points. In addition, the osteopromotive activity was identified as soluble factor/factors by transwell assay system. There was a decrease in osteoprotegerin when the cells were cultured in the presence of plasma clots compared to control cell cultures without plasma clots. The osteocalcin expression was continuously higher after culture in the presence of plasma clots and significantly higher after 2- and 3-week after culture in the presence of leukocyte-containing plasma clots compared to 1-week cell culture. Differences in the concentration of the C-terminal procollagen peptide were not measured.CONCLUSIONS:The direct inoculation of an autologous mononuclear cell fraction (which contains leukocytes and MSC), e.g., isolated from a bone marrow aspirate or a different source into an autologous plasma gel, may be a further new strategy for bone fracture therapy.