Eine Applikation des Titannagels bei A- und B-Frakturen scheitert perioperativ bisweilen aufgrund eines zu kleinen oder verlegten Markraums, was bis dato zu einer offenen Plattenosteosynthese geführt hat. Bei C-Frakturen beobachtet man ein Telescoping-Effekt, sodass diese Fraktur – neben der konservativen Therapie – ausschließlich für eine Plattenosteosynthese geeignet ist. Die minimal-invasive Lösung für C-Frakturen (Stückfrakturen) und als Salvageprozedur für intraoperativ gescheiterte Markraumschienungen mit Hilfe eines Titannagels von A- und B-Frakturen ist die hier erstmals publizierte perkutane LC-Plattenosteosynthese der Klavikula.

Insertion of titanium nails for type A and B clavicular fractures can fail intraoperatively due to the small diameter or irregular nature of the medullary canal. At present, such failures lead to open reduction and fixation (ORIF) with plates. In type C fractures (comminuted fractures), a telescoping effect is observed so that ORIF is the only suitable alternative besides nonoperative therapy. A suitable minimally invasive solution for type C fractures and as a salvage procedure for failed intramedullary nailing of type A and B fractures is presented here for the first time with a percutaneous application of an LC plate to the clavicle.

Despite the favourable prognosis, the results of conservative treatment for clavicular fractures are unsatisfactory in 10-20% of cases. The intramedullary fixation technique presented in this paper is based on stabilization of a lengthy section of bone by means of elastic bracing of a straight titanium nail in the S-shaped clavicula according to the principle of elastically stable intramedullary nailing. In 132 patients (136 clavicular fractures) treated by this method, it became obvious that realignment of the fracture and achievement of elastic stability at the fracture gap are essential for rapid freedom from pain postoperatively and for mobility of the injured shoulder. In a prospective comparative study 53 patients with clavicular fractures were allowed to choose between conservative and operative treatment (27 conservative/26 operative). In terms of pain, subjective satisfaction, aesthetic and functional results, unfitness for work, differences in length and Constant and DASH scores the results were significantly better after surgery than after conservative treatment. The method presented is therefore indicated for type A and B clavicular fractures of the middle third (OTA Classification) in the mature skeleton.

Trotz der günstigen Prognose weisen 10–30% der konservativ behandelten Patienten mit Klavikulafraktur unbefriedigende Ergebnisse auf. Die vorgestellte Technik der intramedullären Osteosynthese beruht auf einer langstreckigen intramedullären Stabilisierung durch die elastische Verspannung eines geraden Titannagels in der S-förmig gebogenen Klavikula nach dem Prinzip der „elastisch stabilen intramedullären Nagelung“. Bei mit dieser Methode versorgten 132 Patienten (136 Klavikulafrakturen) zeigte sich, dass die Reposition der Fraktur und die Herstellung einer elastischen Stabilität am Frakturspalt Voraussetzung für eine rasche postoperative Schmerzfreiheit und Beweglichkeit der verletzten Schulter sind. In einer prospektiv vergleichenden Untersuchung konnten 53 Patienten mit Klavikulafraktur frei zwischen konservativer und operativer Behandlung wählen (27 konservativ/26 operativ). Hinsichtlich Schmerzen, subjektiver Zufriedenheit, ästhetischem und funktionellem Ergebnis, Arbeitsunfähigkeit, Längendifferenz, Constant- und DASH-Score waren die Resultate nach Operation signifikant besser als nach konservativer Behandlung. Die vorgestellte Methode ist somit bei Klavikulafrakturen des mittleren Drittels der Typen A und B der OTA-Klassifikation am ausgewachsenen Skelett indiziert.

In einer retrospektiven Analyse der Daten der BG Feinmechanik und Elektrotechnik wurden 42 Patienten (39 Männer, 3 Frauen, Durchschnittsalter 44 Jahre) mit einseitiger isolierter Fersenbeinfraktur nach Arbeitsunfällen von der Erstmeldung bis zum ersten Rentengutachten ausgewertet (Zeitraum: 01.01.2004–30.06.2006). Die mittlere Sturzhöhe lag unter 2 m. Operiert wurden 27 (dislozierte Frakturen), konservativ behandelt 17 Patienten. Die mittlere Arbeitsunfähigkeitzeit war 7,5 Monate. Zum Zeitpunkt des 1. Rentengutachtens betrug die durchschnittliche Bewegungseinschränkung der verletzten Seite im Mittel 40% im oberen, 50% im unteren Sprunggelenk. Eine Umschulung war bei 23% der Patienten erforderlich, 13% wurden arbeitslos. Die durchschnittliche MdE betrug 19,1% (0–30%). Die mittleren Behandlungskosten für die BG bis zum 1. Rentengutachten lagen bei 25.540 EUR/Fall, wobei 61% durch Hilfsmittel, Rehabilitation, Sozialversicherungsbeiträge usw.; 24% durch stationäre bzw. 14% durch ambulante Behandlung verursacht wurden. Somit sind die Ergebnisse nach Fersenbeinfrakturen nach wie vor unbefriedigend. Dislozierte intraartikuläre Frakturen führen zu langen Arbeitsunfähigkeiten, hohen Kosten und Arbeitslosenquoten. Sofort nach Diagnosestellung sollten Case-Manager eingesetzt werden, um die Ergebnisse zu verbessern.

Presentations at medical conferences can sometimes confuse or compromise understanding of current topics. Although considerable time and financial costs may be taken to be present at such events, all too often one must go through inferior presentations that are poorly structured and do not contribute to one's understanding of the topic at hand. A good presentation is distinguishable by the clear intentions of the speaker to give a good lecture. The presenter has worked extensively with his topic and is familiar with the audience. The presentation has a clear structure and finishes with a take-home message. The speaker takes the listener from his previous level of knowledge to a new understanding. To do so, both voice and body language are used. The supporting slides are simple and direct, and not overloaded with information. The speech conforms exactly with the pre-determined time limit.

Die Diagnostik bei einem schwerstverletzten Patienten soll so kurz wie möglich sein. Durch die Einführung der Spiral-CT-Technik lässt sich die Diagnostikzeit verringern.

The goal of the current investigation was to make a comparative analysis of regenerative tissue after autologous de novo cartilage transplantation on the femoral condyles of sheep after a chondral defect. One chondral defect measuring 4 mm in diameter was placed in the center of one medial femoral condyle of each of 48 Suffolk sheep. Twelve defects were left to heal spontaneously, 16 defects were covered with periosteal flaps, and 20 defects were filled with autologous de novo cartilage graft. Macroscopic and microscopic assessments were performed at 26 and at 52 weeks. Regeneration was significantly better (p < 0.05) in the transplant group than in the control groups at both 26 weeks and 52 weeks. The differences were most evident in the grade of defect filling, cartilage stability, cell distribution, and matrix assessments. Transplantation of immature, autologous de novo cartilage leads to qualitatively better regeneration both macro- and microscopically than does periosteal flap placement alone. The transplanted, immature cartilage tissue undergoes maturation in vivo. The regenerated tissue has hyaline-like features.

BACKGROUND:In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized.QUESTION:Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner?MATERIAL AND METHODS:Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3-81 years) were evaluated retrospectively. The average ISS score was 32.8+/-12 points (range: 17-75 points).RESULTS:The average time in the ED, prior to CT, was 33+/-14 min. The CT scans lasted 16+/-5 min and the total diagnostic time was 48+/-14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days.CONCLUSION:The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.

Das Ziel der hier vorliegenden Untersuchung besteht in einer vergleichenden Analyse des Regeneratgewebes in einem chondralen Knorpeldefekt der Schafsfemurkondyle nach autologer De-novo-Knorpeltransplantation. Bei 48 Schafen wurde an der medialen Femurkondyle ein chondraler Knorpeldefekt mit einem Durchmesser von 4 mm platziert. 12 Defekte wurden der spontanen Heilung überlassen, 16 Defekte mit einem Periostlappen bedeckt, und 20 Defekte wurden mit einem autologen De-novo-Knorpeltransplantat gefüllt. Im Vergleich zu den Kontrollgruppen wurde die Transplantatgruppe sowohl nach 26 Wochen als auch nach 52 Wochen signifikant (p<0,05) besser bewertet. Die Unterschiede zeigten sich v. a. im Grad der Defektfüllung, der Knorpelstabilität, der Zellverteilung und der Matrixbeurteilung. In einigen Defekten konnte ein hyalinartiges Knorpelgewebe nachgewiesen werden. Die Transplantation von De-novo-Knorpel führt makroskopisch und mikroskopisch zu qualitativ besseren Regeneraten als eine Periostlappentransplantation. Das transplantierte unreife Knorpelgewebe unterliegt in vivo einem Reifungsprozess.

Objectives. The aim of this prospective study was to compare the results achieved in two groups of patients treated for mid-clavicular fracture.Methods. The first group of 27 patients was treated nonoperatively with a rucksack bandage, whereas the second group underwent intramedullary fixation with a titanium pin, using a minimally invasive technique. Within the follow-up period of 6 months, results were evaluated seven times.Results. During the whole period significantly (p < 0.05) better results were observed in the group of operated patients concerning shoulder function, Constant score, DASH score, personal satisfaction, pain, and cosmetic result. In the second group return to work occurred in less than half the time of the first group.Conclusion. Intramedullary nailing of mid-clavicular fractures is a safe and minimally invasive operation technique. Early functional and cosmetic results are not worse than results after nonoperative treatment with a rucksack bandage.

Biodegradable polylactide implants allow secure fixation of osteochondral fractures with minimal adverse effects. The goal of this prospective, randomized animal study was to show whether osteoconductive effects can be achieved through the development of poly-L/DL(70/30)lactide composite implants with 10% beta-tricalcium phosphate, and whether degradation can be positively influenced and adverse effects minimized using such implants. An additional goal was to clarify which radiological procedure is most suitable to observe the course of follow-up.Thirtysix medial femoral condyle osteotomies of sheep were fixed with either 3 poly-L/DL-lactide pins or 3 composite pins, and the pin canal widths were measured with conventional radiographs, with CT, MRI, and histologically after 3, 18, and 36 months.All fractures healed completely without displacement or clinically relevant complications. The pin canals dilated secondary to pin degradation at the 12th month, and then decreased in size later. At 36 months, the pins had microscopically disappeared, and the canals were filled with bone or scar tissue. There were no statistically significant differences between the pin-types.Poly-L/DL-lactide pins and composite C-pins are suitable for secure fixation of small osteochondral fractures. Osteoconductive effects of biocompatibility or osseous integration relating to composite development were not evident. Conventional radiography and computer tomography were suitable techniques for observation of pin canals. Due to frequently observed artifact, MRI was not suitable to observe the course of the implants. (C) 2004 Elsevier Ltd. All rights reserved.

This prospective study investigated medium-term outcomes for 51 children treated from 1997 to 2001 for displaced diaphyseal forearm fractures with elastic stable intramedullary nailing. Forty-three patients included achieved excellent/good functional results at an average follow-up of 38 months. Four patients required open fracture-manipulation at surgery. Complications included eight cases of soft-tissue irritation at nail-insertion site (three required shortening procedures), two temporary radial nerve branch injuries, four minimal rotational mobility deficits, one 10 degrees elbow extension deficit after splinting, and five small keloid scars. All patients were pain-free, without limitations in activities for daily life or sport/play activities by 12 months after hardware removal. Elastic stable intramedullary nailing is appropriate therapy for these injuries.

Tecnica quirurgica Incision quirurgica justo por encima del extremo esternal de la clavicula. Se realiza una perforacion en la cortical anterior, aproximadamente a 1 cm lateral de la articulacion esternoclavicular. Se prepara un clavo de titanio de diametro entre 2,5 y 3,5 mm en un mango universal en “T”. Mediante movimientos rotatorios oscilantes se introduce el clavo de titanio hasta el foco de fractura. Si las maniobras a cielo cerrado fracasan, se realiza una incision cutanea adicional a nivel del foco de fractura para permitir la manipulacion directa de los fragmentos fracturarios.

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: <18 years or >70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p<0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

Das Ziel der hier vorliegenden Untersuchung bestand in der prospektiven Erhebung der Ergebnisse nach der elastisch stabilen intramedullären Nagelung von Klavikulapseudarthrosen. In einem Zeitraum von 2,5 Jahren konnten 14 Patienten in die Untersuchung einbezogen werden. Ausschlusskriterien waren Pseudarthrosen bei pathologischen Frakturen, Infektpseudarthrosen, atrophe Pseudarthrosen, knöcherne Defekte, vorausgegangene operative Maßnahmen, ein Patientenalter <18 und >70 Jahre.

Biodegradable polylactide implants allow secure fixation of osteochondral fractures. This quasirandomized parallel-group animal study investigates whether a composite implant of poly-L/DL-lactide (PLDLLA) with additional 10% beta-tricalcium phosphate produces an osteoconductive effect, whether the admixture positively influences implant degradation (assessed by comparing time to implant degradation), and whether the pin sites of degraded implants are replaced with bone tissue. On 36 medial femoral condyles of sheep, osteotomies were fixed with either three PLDLLA pins or three composite pins. At 3, 18, and 36 months, the pin sites were measured histologically and the state of degradation assessed according to Pistner's classification. All fractures healed without clinically relevant complications and without displacement. Both pin types led to asymptomatic pin-site enlargement at 18 months, which disappeared by 36 months. At 18 months, 14 of 18 PLDLLA pins were no longer evident, whereas 16 of 18 composite pins showed only peripheral degradation. By 36 months, all implants from both groups were completely degraded and replaced with scar (2/18) or bone tissue (16/18). At 36 months there was no evidence for significant improvement of either degradation performance or osseointegration through use of the 10% TCP composite mixture.

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: < 18 years or > 70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p < 0.001). There were no infections, no implant displacements or refractures. Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

The current study was designed to clarify whether biodegradable poly-L/DL lactide pins provide an operative alternative for fixation of Pipkin fractures. Nine patients with Pipkin fractures (one with Pipkin Type I, one with Pipkin Type II, and seven with Pipkin Type IV fractures) were treated surgically between 1996 and 2002. In all patients, the femoral head fractures were fixed with biodegradable, 2.7-mm and 2.0-mm polylactide pins. Eight patients were followed up for an average of 54.2 months. One patient died before the final followup. Eight fractures healed uneventfully. In one patient, a persisting femoral head defect led to posttraumatic arthritis requiring insertion of a femoral endoprosthesis at 1 year. The average range of motion of the affected hips of all patients at followup was 109degrees-0degrees-0degrees in flexion and extension. External and internal rotation averaged 37degrees-0degrees-29degrees. One patient had Brooker Grade I heterotopic ossification develop, and another had a Grade II heterotopic develop. Merle d'Aubigne and Postel ratings showed two excellent and five satisfactory results (average score, 13.1). Adverse effects from the polylactide implants were not observed. Pipkin fractures can be fixed successfully with biodegradable polylactide pins.

Das Ziel dieser prospektiven Anwendungsbeobachtung war die Erfassung der Probleme und Komplikationen sowie der mittelfristigen funktionellen Ergebnisse der elastisch stabilen intramedullären Nagelung (ESIN) diaphysärer Unterarmfrakturen im Kindesalter. Von Januar 1997 bis Dezember 2001 wurden bei 51 Kindern im mittleren Alter von 8 Jahren dislozierte Unterarmfrakturen mit elastischen Titannägeln stabilisiert. Das mittlere Follow-up beträgt 38 Monate. Die Durchleuchtungszeit betrug im Mittel 2,2 Minuten. In 4 Fällen war eine offene Reposition erforderlich. Die mittlere Dauer des stationären Aufenthaltes der nicht polytraumatisierten Kinder betrug 2,0 Tage. Bei 8 Kindern trat eine schmerzhafte Weichteilirritation am Eintrittspunkt der Nägel auf. Alle Frakturen heilten zeitgerecht. Infektionen oder Wundheilungsstörungen traten nicht auf. Die Metallentfernung erfolgte im Mittel nach 5,4 Monaten. Funktionelle Einschränkungen, sowie klinische Achs- oder Rotationsfehler > 10° wurden nicht beobachtet. Bei 3 Kindern war eine Einschränkung der Pro- und/oder Supination zwischen 10 und 30°, sowie in einem Fall ein Extensionsdefizit am Ellenbogen von 10° messbar. Die vorliegenden Ergebnisse zeigen, dass die intramedulläre Osteosynthese mit elastischen Titannägeln eine biologische, sichere und kindgerechte Therapie diaphysärer Unterarmfrakturen im Kindesalter ist.