Abstract:Pelvic injuries have increased in frequency over the last few decades, whether due to high-impact trauma or minor trauma in geriatric patients. Treatment ranges from conservative measures to surgical interventions. With the use of minimally invasive surgical procedures, the importance of navigated pelvic surgery also increases.In the case shown, an anterior and posterior pelvic ring fracture is surgically treated using O-Arm. Navigation helps with complex anatomy and facilitates intraoperative verification of the correct implant position, from which less experienced teams in particular can benefit. Increased precision reduces the revision rate. However, it requires a longer operation time and good interdisciplinary training, as well as special coordination with the surgical and anesthesia staff.This video demonstrates our step-by-step procedure for navigated screw osteosynthesis of a pelvic ring fracture.

ZusammenfassungDie obere Sprunggelenksfraktur als häufigste Fraktur der unteren Extremitäten, verursacht vor allem durch Pro- und Supinationstraumata, stellt junge Operateure im Fach der O&U immer wieder vor spezielle Herausforderungen. Nicht zuletzt aufgrund des fragilen Weichteilmantels rund um das Sprunggelenk, auch aufgrund der anatomischen Gegebenheiten im Bereich des oberen Sprunggelenks und der postoperativen biomechanischen Belastungen bedarf es operativer Erfahrung, um gute operative Ergebnisse zu erzielen. Im folgenden Video werden die wichtigsten Schritte sowie Tipps und Tricks der operativen Versorgung einer Bimalleolarfraktur aufgegriffen und erklärt. Ziel des Lehrvideos ist es, die wichtigsten Schritte der Operation zu vermitteln und so den jungen Kollegen der O&U für ihren klinischen Alltag nahezubringen.

ObjectiveIntermittent claudication (IC) is known to be associated with impaired gait parameters, e.g. higher incidence of falls and higher oxygen consumption due to uneconomic walking. However, the influence of arterial desobliteration in patients with intermittent claudication (IC) on gait pattern has hardly been investigated so far. The aim of this study was to examine gait patterns before and after inflow revascularization by surgical desobliteration of pelvic and inguinal arteries (common iliac artery (CIA), external iliac artery (EIA), common femoral artery (CFA), profound femoral artery (PFA), superficial femoral artery (SFA)) in IC patients. Successful surgical desobliteration of inflow arteries (improvement of ankle-brachial-index (ABPI) 1 0,2 or more, patent CIA, EIA, CFA, PFA, SFA) is known to improve painless walking distance in patients with intermittent claudication (IC) due to peripheral arterial disease (PAD), but its influence on gait parameters is unclear. We hypothesized that gait parameters improve after operation as well. Improved gait parameters can lead to a more economic walking process, lower oxygen consumption, lower risk of falls and higher quality of life.MethodsIn a single-center exploratory longitudinal study, we examined gait parameters of 20 IC inpatients of our hospital before and after surgical desobliteration of pelvic and inguinal arteries. Spatiotemporal parameters such as range of motion (ROM) of hip and knee joint, stance phase, cadence, and foot rotation were obtained using the “Diers 4D motion Lab®”. Gait parameters were obtained under painful walking conditions preoperatively and walking pain free at the same speed postoperatively.ResultsA total of 20 patients were examined. Surgical revascularization led to a higher walking cadence (mean plus 7,88 steps, 95.5 steps/min vs 87.6; p =0,024), an increased ROM of the hip joint (mean plus 2°, 35.1° vs 33.1°; p =0.038) and improved foot rotation (mean plus 2,0°, 11.0° vs 9.0°; p=0.02). Regarding other parameters such as step length, stance phase and step duration smaller differences could be detected in this study.ConclusionsIn this exploratory study, we were able to see that surgical revascularization of pelvic and inguinal arteries in IC patients improved certain gait parameters. Further studies with larger patient numbers are needed to confirm this data and provide more evidence on this subject.

The ankle fracture - the most common fracture of the lower extremities - is usually due to pro- and supination trauma and is commonly challenging for junior doctors of orthopaedics and traumatology. To accomplish sufficient surgical results, it is necessary to have surgical experience, not only because of the surrounding fragile soft tissue, but also due to the specific anatomical structures surrounding the ankle joint and the postsurgical biomechanical stress to osteosynthesis. In the following video, the most relevant steps of surgery as well as some useful tips and tricks are mentioned. The intention of the video is to convey to junior orthopaedic surgeons the most important surgical steps for their clinical daily routine.

Zusammenfassung Einleitung Pathologische Knochenmorphologie und Frakturen, sei es durch osteoporotische Veränderungen oder bösartige Prozesse, erfordern besonders stabile, im Idealfall auch minimalinvasive Osteosyntheseverfahren. Die additive Nutzung von Knochenzement hat hier Vor- aber auch Nachteile. Ziel dieses Literaturreviews ist es daher, die führenden Indikationen sowie Vor- und Nachteile für die Zementapplikation am Becken näher zu beleuchten. Material und Methoden Es wurde eine PubMed-Recherche mit Fokus auf die Suchbegriffe „cement, pelvic“ durchgeführt (648 Einträge) und die für die vorliegende Fragestellung besonders relevanten Artikel wurden ausgewertet. Ergebnisse und Diskussion Die aktuelle Literatur setzt sich im Wesentlichen mit folgenden 4 Themenfeldern auseinander: Zementoplastie, Zementaugmentation sakroiliakaler Schrauben bzw. iliakaler Schrauben und perkutane Fixierung durch interne zementierte Schraube. Es zeigt sich – bei strenger Indikationsstellung – eine weitgehend zuverlässige, sichere und zumeist minimalinvasive Anwendbarkeit von Zement bei o. g. Techniken, die eine niedrige Komplikationsrate aufweisen.

Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44-0.62) and 0.42 (95% CI 0.34-0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior-posterior fixation. Despite the consensus on an anterior-posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon's preference.

Abstract Background Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. Patients and Methods In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. Results There was a relative increase in the insufficiency fracture within the FFP (2008 – 2009: 5.0% vs. 2015 – 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: − 3.66 vs. − 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). Conclusion We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP. Zusammenfassung Hintergrund Innerhalb der Fragilitätsfrakturen des Beckens (Fragility Fractures of the Pelvis, FFP) existieren mit der Fraktur nach niedrigenergetischem Trauma und der Insuffizienzfraktur ohne Trauma 2 Frakturentitäten. Unklar ist, ob sich beide Subgruppen bez. Diagnostik und Therapie differenzieren. Ziel dieser retrospektiven Studie war es, die Insuffizienzfrakturen hinsichtlich definierter Parameter zu evaluieren und spezifische Parameter mit den Frakturen nach niedrigenergetischem Trauma zu vergleichen. Patienten und Methoden Im Zeitraum von 2008 bis 2017 waren an unserer Klinik (überregionales TraumaZentrum DGU, SAV-Zulassung) 203 Patienten mit FFP zu verzeichnen. Davon hatten 25 eine Insuffizienzfraktur und 178 eine Beckenringfraktur nach niedrigenergetischem Trauma. Beleuchtet wurden epidemiologische, diagnostische und therapeutische Parameter. Ergebnisse Es zeigte sich eine relative Zunahme der Insuffizienzfraktur innerhalb der FFP (2008 – 2009: 5,0% vs. 2015 – 2017: 17,8%). Bei diesen Patienten war tendenziell eine ausgeprägtere Osteoporose im Vergleich zu Patienten nach niedrigenergetischem Trauma (t-Wert: − 3,66 vs. − 3,13) festzustellen. Diagnostisch zeigte sich bei Insuffizienzfrakturen ein vermehrter Einsatz von MRT und DECT (60,9 vs. 26,0%) und ein hoher Anteil an Typ-IV-Frakturen nach FFP (40,0 vs. 7,9%). Therapeutisch wurde häufiger eine operative Versorgung der Insuffizienzfraktur angestrebt (68,2 vs. 52,1%) mit tendenziell vermehrtem Einsatz kombinierter Osteosyntheseverfahren (14,3 vs. 7,6%). Schlussfolgerung Wir konnten zeigen, dass bei steigenden Fallzahlen die Insuffizienzfraktur innerhalb der FFP an Bedeutung gewinnt. Bei einer tendenziell ausgeprägteren Osteoporose dieser Patienten sollte insbesondere bei der Insuffizienzfraktur das Augenmerk auf die Diagnostik und adäquate Therapie der Osteoporose gelegt werden. Bemerkenswert ist neben der vermehrten Diagnostik mittels MRT und DECT zum Ödemnachweis und der vermehrten operativen Therapie bei dieser Frakturentität aber auch, dass die Insuffizienzfraktur höhere Frakturschweregrade nach FFP hervorrufen kann.

Background Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. Patients and Methods In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. Results There was a relative increase in the insufficiency fracture within the FFP (2008-2009: 5.0% vs. 2015-2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: - 3.66 vs. - 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). Conclusion We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher- grade fractures after FFP.

Background Pelvic ring fractures type C present a special challenge due to their high instability, the possible accompanying injuries and the high mortality rate of up to 18.9%. The aim of this retrospective analysis was to use the data from the DGU pelvic register to identify changes in the epidemiology and therapy for type C pelvic ring fractures between 2004 and 2014. Materials and Methods 2,042 patients with type C pelvic ring injury were retrospectively included. Three time periods with roughly equal patient groups were specified and differences in epidemiology and the type of therapy were evaluated. For the surgical cases, the time of the operation, the duration of the operation, blood loss, the location of the fracture and the type of osteosynthesis were evaluated and the reduction result was recorded. Results For the period under review, there is an age shift in the incidence of a type C pelvic ring fracture towards older age. The isolated pelvic injury has increased, while the proportion of pelvic injuries in the context of polytrauma has steadily decreased. Complications and mortality decreased as a percentage. The tendency towards minimally invasive procedures could be shown in the surgical care. Navigated procedures in the area of the pelvic ring have so far not proven successful. Conclusions We were able to show that the majority of the patients are increasingly old, that there is no relevant trauma in the history and that there is an increase in the isolated pelvic fracture type C and a decrease in the number of polytraumatised or multiply injured patients. In conjunction with mortality from pelvic ring injuries, the successes of standardised, pelvic-specific emergency management, an adapted time of operation outside the vulnerable phase and stable osteosynthesis care, which enable early functional follow-up treatment, are also evident.

ZusammenfassungBei Sakrumfrakturen finden sich zwei Häufigkeitsgipfel: Einerseits das hochenergetische Trauma des jungen Erwachsenen, zumeist mit Begleitverletzungen verbunden, andererseits geriatrische Frakturen mit niederenergetischem oder nicht erinnerlichem Trauma. Hieraus ergibt sich auch die Anwendung unterschiedlicher Klassifikationen.Hochenergetische Verletzungen werden zumeist im Rahmen einer CT Polytraumaspirale abgeklärt. Fragilitätsfrakturen, die aufgrund demographischer Entwicklungen zunehmen, birgen hingegen diagnostische Herausforderungen. Das Spektrum eingesetzter Diagnostika reicht hier von konventioneller Röntgendiagnostik bis zu Ödem-sensitiven Nachweisverfahren wie Kernspintomographie und Dual-Energy-Computer-Tomographie, wobei ein konsentierter Standard bislang nicht etabliert ist.

Bei Fragilitätsfrakturen des Beckenringes (FFP) vom Typ IV und den traumatischen Beckenfrakturen Typ C besteht häufig eine spinopelvine Instabilität. Daraus ergibt sich die Indikation zur operativen Stabilisierung mittels einer spinopelvinen Abstützung. Unklar ist aufgrund diverser operativer Verfahren zur spinopelvinen Abstützung, welche Bedeutung hierbei eine minimal-invasive spinopelvine Schrauben-Stab-Osteosynthese haben kann. In die retrospektive, klinische Studie wurden über einen Zeitraum von 2 Jahren 23 Patienten (Median 67 Jahre, 5 m und 18 f) mit instabiler Beckenfraktur (FFP Typ IV: n = 12, AO/OTA Typ C: n = 11) mittels triangulärer minimal-invasiver spinopelviner Stabilisierung (TMSS) in die Studie eingeschlossen. Die Patientendaten wurden hinsichtlich der Parameter Geschlecht, Alter, Frakturmorphologie, intraoperativer Blutverlust, Operationszeit, postoperativer Infekt, postoperatives Repositionsergebnis (im CT) sowie Schraubenlockerung untersucht. Das Durchschnittsalter der 11 Typ-C-Frakturen lag bei 43 Jahren und das der 12 FFP Typ IV bei 80 Jahren. Der Nachuntersuchungszeitraum betrug im Durchschnitt 12,2 Monate. Die durchschnittliche Operationszeit lag bei 67 min, der Blutverlust bei 70 ml, es gab 2 postoperative Infekte und 4 Schraubenlockerungen. Die Reposition nach Matta war bei allen FFP < 4 mm, bei den traumatischen Beckenfrakturen zwischen 4 und 20 mm. Symptomatische Pseudarthrosen traten in 3 Fällen auf. Die TMSS zeigte eine stabile und suffiziente Versorgung der Fragilitätsfrakturen Typ IV und bei den gering dislozierten traumatischen Becken-C-Frakturen. Grobe Frakturdislokationen limitieren das Verfahren.

Introduction As the average age of society increases, so does the number of cases of fragility fractures of the pelvis (FFP). Magnetic resonance imaging (MRI) can visualise associated oedema and is thus the gold standard for diagnosing such fractures. MRI, however, is costly, not always available, and involves certain exclusion criteria. Dual-energy computed tomography (DECT) appears to be a promising alternative. It is unclear, however, whether it could be used for diagnosing FFP with similar sensitivity/specificity. The aim of our study was thus to compare conventional CT and DECT with MRI in cases of suspected FFP. Materials and methods A total of 46 patients with suspected FFP underwent MRI, CT and DECT scans. There were three comparison groups for each of these patients: conventional CT image analysis without dual-energy modification (Arm 1), DECT analysis (Arm 2) and MRI as the gold standard (Arm 3). Diagnosis and FFP classification were performed by a radiologist in random order and without clinical information. The sensitivity and specificity of conventional CT and DECT were calculated in comparison with MRI as the reference standard. Results With 100% sensitivity and specificity, DECT is on par with MRI when it comes to diagnosing fragility fractures of the pelvis and is superior to conventional CT (90.3% sensitivity, 100% specificity). In terms of classification as well, there were no differences between DECT and MRI. On conventional CT, on the other hand, 16 patients were classified differently than they were on MRI. Conclusions Our study shows DECT to be reliable and superior to conventional CT in terms of oedema detection and specific fracture classification in FFP. DECT thus combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures).

INTRODUCTION:The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options - sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) - has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population. MATERIALS AND METHODS:We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us. RESULTS:The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 - 2009: 5.3% vs. 2015 - 2017: 60.3%). CONCLUSION:We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.

Introduction Isolated pelvic fractures are relatively rare with an incidence of 3-6% of all fractures, but their incidence in polytraumatized individuals increases to 25%. The S3 guideline Polytrauma gives a clear recommendation for diagnostics by means of pelvic radiography (X-ray) and computed tomography (CT). A recommendation for the diagnosis by means of magnetic resonance tomography (MRI) especially in patients with low energetic/missing trauma does not currently exist. It is unclear on the basis of which criteria the MRI can be indicated in pelvic fractures. The aim of our study was therefore to retrospectively record indications for the indication of MRI in pelvic fractures - with adequate as well as inadequate trauma. Material and Methods In a retrospective clinical study, a total of 140 patients (median 68 years, range 15-97, 75 female, and 66 male) with a pelvic fracture were included in the study over a period of three years. Overall, the trauma mechanism revealed 73 adequate and 67 inadequate fractures. 31/140 patients had undergone MRI of the pelvis in addition to a CT/X-ray scan. The two subgroups "with MRI" and "without MRI" were analyzed with regard to the parameters "sex", "age", "adequacy of the trauma", "fracture localization", "duration of admission to imaging", "type of therapy" and "duration to surgery" compared. Results It was shown that the MRI diagnosis was performed especially in female, elderly patients (81 years, range 19-94 years). Patients with inappropriate trauma have received MRI more frequently (74%) than patients with adequate trauma (26%). With regard to fracture localization no differences could be shown. The MRI was performed on a median 4 days after the CT examination. Regarding the decision "conservative" vs. "operationally" our two groups without and with MRT tended to differ not. Patients with MRI were operated on median 2 days later than patients who did not receive MRI. Conclusions Pelvic fracture MRI should be performed primarily in elderly female patients without adequate trauma. In patients with adequate trauma, MRI is of low value, especially as MRI diagnostics are performed with delay, resulting in later surgery.

Background Meniscus injuries lead to increased knee joint instability. Currently, however, it is unclear whether a relevant medial meniscus part resection leads to an increased ventral tibia translation with intact anterior cruciate ligament. The aim of our study was therefore to clinically examine the stabilizer function of at least 30% resected medial meniscus for anterior tibial translation. Materials and methods In this prospective study, 18 patients with unilateral medial meniscus lesion were treated before and after arthroscopic medial meniscus resection. They were treated on the healthy and on the sick leg through the use of two different apparatus methods (dynamic translation measurement using hamstring reflex apparatus and KT-1000 arthrometers) as well as a functional test (computer-supported dynamic posturography (CDP)) and a clinical hop test. Further, the mean values for significance using non-parametric Wilcoxon test. Results After completing all the studies, we were not able to detect any significant differences in our study that would indicate increased ventral instability in the knee joint after arthroscopic medial meniscus resection. Conclusions Inner meniscal partial resection does not lead to increased ventral knee instability in intact VKB. Whether in patients with instability (feeling) after partial meniscus resection, a rotation instability is the cause or whether further injuries or disturbances in the capsular ligament apparatus are present, must be examined in further studies. Anterior knee joint instability cannot be adequately explained according to our study.

BACKGROUND:Fractures of the pelvic ring in elderly patients have increased in frequency over time. These injuries are associated with a high morbidity and have a socio-economic impact. The diagnostic procedures and their influence of therapy decisions are still controversial.METHODS:In a retrospective study, we investigate the value of additional MRI examination on therapy decision of fragility fractures of the pelvis. The evaluation of all patients with pelvic fractures without adequate trauma and with performed CT and MRI was conducted at three large German hospitals. The imaging procedure took place within a maximum interval of 4 weeks. After evaluation of the imaging, the resulting therapeutic consequences either based on CT alone or on CT and MRI were reviewed by experienced pelvic surgeons.RESULTS:Of 754 patients with pelvic injuries, 67 (age 80 +/- 9.7 years, f: m 54:13) could be included. The detection of vertical fractures in CT (n = 40 unilateral, n = 11 bilateral) could be increased by the additional MRI (n = 44 unilateral, n = 23 bilateral). A horizontal fracture component was identified in CT in 9.0% (n = 6) vs. MRI in 25.4% (n = 17) of the cases. An anterior pelvic ring injury was detected in 71.6% (n = 44; 4x bilateral) in CT, in 80.6% in MRI (n = 50, 4 bilateral). Additive MRI imaging increased the decision rate for surgical therapy from 20.9% (n = 14) to 31.3% (n = 21).CONCLUSIONS:The results of this study further support the value of bone marrow edema detection by MRI diagnostics (or dual source CT which showed promising initial results) for the detection of pelvic ring fractures. For the first time, the study identifies an additional therapeutic consequence by an increased rate of surgical procedures.

Pelvic ring fractures in the elderly gain increasing importance. Nonetheless, data on factors influencing treatment decision in relation to fracture classification, age, and the resulting treatment are still rare.

Introduction Apophyseal avulsion fractures of the ischial tuberosity are rare injuries and therefore often not diagnosed in a timely manner. Healing may then result in massive hypertrophic ischial tuberosity. This can cause ischiofemoral impingement symptoms. Due to the low incidence and scarce literature, the optimal treatment and surgery is unclear. Materials and Methods A literature search was carried out using the online medical database "PubMed". The findings of the literature were then applied to a clinical case of delayed diagnosis of the apophyseal avulsion fracture of the ischial tuberosity. Results There is no gold standard in the literature for the treatment of avulsion fractures on the ischial tuberosity. Nearly 90% are treated conservatively and a fragment dislocation of more than 2 cm is often the indication for surgical care. However, the surgical procedures described are very diverse. An ischiofemoral impingement symptom may result from excessive ossification of the ischial tuberosity, bringing the ischiofemoral distance to the critical limit of 2 cm. Conclusions The timely correct diagnosis and initiation of a therapy is crucial for the later outcome of the patient. Ischiofemoral impingement symptoms may be the indication of bony displacement of the ischial tuberosity as a result of injury. Therapy is then surgical with partial resection of the ischial tuberosity and plate osteosynthesis.

Fragestellung: Die Inzidenz von Beckenfrakturen ist gering (0,3 -8%), zeigt jedoch uber die letzten zwei Dekaden einen deutlichen Anstieg. Dies ist nicht nur aufgrund traumatisch bedingter Frakturen, sondern im Speziellen auch wegen osteoporotisch bedingter Fragilitatsfrakturen relevant.[zum vollstandigen Text gelangen Sie uber die oben angegebene URL]

BACKGROUND:The fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking. METHODS:Six experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references. RESULTS:The intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III. CONCLUSIONS:The FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities. CLINICAL RELEVANCE:With moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.