Background Retrograde drilling in osteochondrosis dissecans (OCD) is a widely used surgical intervention. A radiation-free electromagnetic navigation system (ENS)-based method was compared with the standard freehand fluoroscopic (SFF) method regarding clinical applicability. Methods We performed a clinical cohort study at a department of Orthopaedics in a Level 1 children’s hospital with 40 patients (20 SFF and 20 ENS). Retrograde drilling of the talar dome was used in patients with unstable medial OCD (MRI stage 2 according to Hepple’s revised classification; stage 2 according to the International Cartilage Repair Society). The outcome measurements were: (a) Intraoperative fluoroscopy exposure and length of surgery and (b) Postoperative serial follow-up MRIs every 6 months. Results 22 female and 18 male patients aged 13.8 ± 1.6 years (range: 11–17 years) were included. Using the ENS technique, length of surgery was significantly reduced to 20.2 ± 6.4 min compared to 36.1 ± 11.8 min (p < 0.01) for the SFF technique. The average x-ray radiation time for the SFF technique was 23.5 ± 13.5 sec and 1.9 ± 1.7 sec for the ENS technique ( p < 0.01). Radiation exposure was significantly reduced from 44.6 ± 19.7 mSv (SFF technique) to 5.6 ± 2.8 mSv (ENS technique) ( p < 0.01). Intraoperative perforation of cartilage occurred once in the SFF group. Correct placement of the drilling channel was verified in all patients on follow-up MRI after six months and a timely healing was seen after two years. Conclusions The ENS method provides for a significant reduction in length of surgery and radiation exposure. ENS was without intraoperative cartilage perforation. The clinical and radiological follow-up parameters are comparable for SFF- and ENS-guided retrograde drilling. Trial registration WF – 085/20, 05/2020 “retrospectively registered” https://www.aerztekammer-hamburg.org/ethik_kommission.html .

A variety of different plate designs and materials are available to treat distal radius fractures. This study evaluates clinical results with a carbon fibre- reinforced (CFR)-polyether ether ketone (PEEK) plate in comparison to a standard titanium plate. Thirty-one distal radius fractures were included in this randomised controlled trial. Five fractures were classified as type A, 6 as type B and 20 as type C, in accordance with the AO classification. Patients were randomly allocated into two groups : 15 patients for titanium palmar plating (TPP) and 16 patients for PEEK palmar plating (PPP). Follow-up examinations were set at 2 weeks, 6 weeks, 3 months, 6 months and 3 years postop. In terms of wrist range of motion, radiological evaluation (alignment and fracture healing), DASH score (Disabilities of Arm, Shoulder and Hand), and VAS (visual analogue scale), no statistically significant differences were detected between the two groups, at all follow-up intervals. PEEK palmar plating and titanium plates give equivalent clinical and radiological outcomes up to 3 years follow-up.

Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p < 0.001).Conclusion: PCCD was applied more often in patients with severe pelvic trauma according to ISS and AISpelvis as well with deterioration in circulatory status. PCCDs did not reduce mortality or reduce the need for blood transfusion.Trial registration: TR-DGU ID 2017-003, March 2017; German clinical trial register DRKS00024948.

A Glasgow Coma Scale (GCS) score of 8 or less in patients suffering from severe traumatic brain injury (TBI) represents a decision-making marker in terms of intubation. This study evaluated the impact of prehospital intubation on the mortality of these TBI cases among different age groups.

OBJECTIVE:The treatment of severe spinal deformities in pediatric patients is very challenging. Posterior only vertebral column resection (PVCR) allows for correcting of severe deformities of the vertebral column via a posterior only procedure. We analyzed radiologic outcome of PVCR performed on a series of pediatric patients with severe congenital and acquired spinal deformities. METHODS:A case series of 11 pediatric patients with severe spinal deformity who were treated by PVCR between 2009 and 2013 were retrospectively analyzed. All patients had posterior instrumentation and reconstruction of the anterior column with titanium cages filled with autologous bone. Seven patients had pure kyphosis or kyphoscoliosis, whereas 4 patients were treated because of scoliotic deformities. The patient records were reviewed for demographic and general clinical data. Complications and adverse events, transfusion rates, and surgical time were recorded. Radiologic analysis included Cobb angles and percentage of correction, analysis of sagittal profile, time to fusion, and possible complications related to instrumentation. RESULTS:Average preoperative scoliosis of 61° was corrected to 32°, resulting in a 50% correction at final follow-up. Coronal imbalance was improved to 36% at the most recent follow-up. Mean preoperative kyphotic deformity was 90° and was corrected to 43° at the last follow-up evaluation. Intraoperative complications included loss of the neuromonitoring signals in 2 cases and pleural laceration in 1 case. CONCLUSIONS:PVCR for children is an effective and safe technique providing a successful correction of complex pediatric spinal deformities. Nevertheless, it remains a technically highly demanding procedure, implying the possibility of severe complications.

For the success of Latarjet procedure a correct graft positioning is mandatory. Furthermore, the correct screw placement is important to avoid cartilage damage and soft tissue irritation. Due to a cadaveric experimental study, the accuracy of graft and screw positioning utilizing a novel drill guide for a minimal-invasive Latarjet procedure was analyzed.

Berger-Groch, Josephine MD; Rupprecht, Martin MD; Hoffmann, Michael MD Author Information

There is a lack of studies reporting on rhBMP-2 application in pediatric orthopaedics, although few reports demonstrated promising results of the use of rhBMP-2 in children, especially for spine fusion and for the treatment of congenital pseudarthrosis of the tibia. The objectives of this study were (1) to examine clinical and radiographic healing after rhBMP-2 application for the treatment of congenital pseudarthrosis of the tibia (CPT) or persistent tibial nonunion in children and adolescents, and (2) to investigate the safety of rhBMP-2 use in these cases. Therefore we reviewed the medical records of ten patients with a mean age of 8.6 years (2.3–21) with CPT (n = 7) or persistent tibial nonunion for at least six months (n = 3) who had been treated with rhBMP-2. Nine of ten patients had union at final follow-up, after a mean of 72.9 months (25–127). In the CPT group, primary healing of the pseudarthrosis occurred in six of seven patients at a mean of 5.2 months (3–12). Repeat rhBMP-2 application was performed in three patients; two patients had one additional application each, and one patient had three additional applications. Complications that may be attributed to the use of rhBMP-2 were seen in two of fifteen applications, including a compartmemt syndrome and a hematoma. In this retrospective case series rhBMP-2 has been used successfully to treat CPT or persistent tibial nonunion in pediatric patients. However, prospective randomized controlled trials are warranted to investigate the long-term efficacy and safety of rhBMP-2 use in these cases.

To evaluate different stabilisation techniques for acromioclavicular (AC) joint separations, including direct AC repair, and to compare the properties of the stabilised and native joints.

Osteoporotic fractures with severe kyphosis and neurologic deficits often require decompression and stabilisation. To reduce the risk of procedure-related complications, single-stage posterolateral vertebrectomy and a 360-degree fusion can be performed. An adequate reduction of kyphotic deformity through this approach has not been reported. The aim of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in osteoporotic situation. A retrospective analysis and chart review was performed for 10 consecutive patients who underwent posterolateral decompression and posterior vertebrectomy with dorsal mesh stabilisation and reduction of kyphotic deformity. Preoperative back pain was 8.6 on a visual analogue scale; it was reduced to 5.5 at discharge and 3.7 at the latest follow-up (18 months). The Frankel score improved from D to E (three patients) or was equal (E). Radiological segmental kyphosis was corrected from a mean of 25° to 5° (p < 0.008) postoperatively with a loss of 3° at follow-up (p < 0.005). Single-stage posterolateral vertebrectomy allow for a fast and safe reconstitution/preservation of neurological function in patients with osteoporotic fracture and kyphotic deformity. A significant correction of often-accompanied hyperkyphosis is possible without neurological deterioration and with an improved sagittal profile and good pain reduction.

Objective Osteoarthritis (OA) is a major cause of musculoskeletal pain and disability worldwide. The investigation of disease-modifying treatment options for OA has become an important aspect of orthopedic care. To assess the effect of intra-articular and oral glucosamine sulfate (GS) versus placebo on osteoarthritis in a canine model. Materials In this randomized, placebo-controlled, double-blinded study, OA was induced by anterior cruciate ligament transection (ACLT) according to the Pond-Nuki model in 32 canines. All canines were allocated into 4 treatment subgroups with treatment administered for 8 weeks: GS (400 mg) intra-articular, placebo intra-articular, GS (200 mg/kg body weight) oral, and placebo oral. The contralateral nonoperated stifle (knee) served as control. After 8 weeks, the medial and lateral femoral condyles, the medial and lateral tibial plateau and patella were histologically examined and anatomic changes quantified by light microscopy using the modified Mankin score. Results After 8 weeks, mean Mankin score values significantly (P < 0.002) decreased in the intra-articular GS group (8.1; range 7.9-8.8) compared with the intra-articular placebo group (13.9; range 11.6-15.9) and again significantly (P < 0.002) in the oral GS group (12.1; range 9.9-12.7) compared with the oral placebo group (15.1; range 12.5-17.0). Mean Mankin score values were significantly (P < 0.002) lower in the intra-articular GS group compared with the oral GS group. Conclusion Both, intra-articular and oral administered GS significantly reduced histological signs of OA in the Pond-Nuki model, with the intra-articular application being more effective compared to oral administration.

OBJECTIVES:To compare the radiological and functional outcome after fixation of intertrochanteric fractures (IF) using either an integrated 2-screw cephalomedullary nail [InterTan (IT); Smith & Nephew] or a single-screw device [Gamma3 (G3); Stryker] with a 5-year follow-up.DESIGN:Prospective, randomized.SETTINGS:A single-center study.PATIENTS:One hundred four patients with a mean age of 81.2 ± 9.2 years were included, 33 patients were available for the final 5-year follow-up, 63 patients died, and 8 patients were lost for follow-up.INTERVENTION:Internal fixation of intertrochaneteric femur fractures using a cephalomedullary nail with either a single screw or an integrated 2-screw system.MAIN OUTCOME MEASUREMENTS:Length of hospital stay, SF-36-questionnaire, Harris-Hip-Score, radiographs.RESULTS:SF-36 index at 6 months indicated that 93% of the IT group returned to their prefracture status compared with only 80% in the G3 group. For the mental health SF-36 index, the IT patients showed a significant increased level 6 months after the index procedure (IT: P = 0.02; G3: P = 0.20). The length of hospital stay was significantly (P = 0.03) shorter in the IT group. After 5 years however, neither group had significant implant-related complications or differences in terms of functional outcome.CONCLUSIONS:Regarding functional outcome and hospital stay, the IT collective performed better in the 6-month follow-up. After 5 years, no significant differences were recorded.LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was to determine the incidence of OCLs after ORIF of displaced ankle fractures using MRI at medium-term follow-up, and to analyse if the severity of fracture or the clinical outcome correlates with the incidence of OCLs. Patients and methods Following institutional review board approval a total of 100 patients (mean age, 41.3 years; range, 17.9–64.3 years) with a displaced ankle fracture who had undergone ORIF according to the AO principles were included in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to quantify the clinical outcome and MR images were evaluated for OCLs of the talus and distal tibia after a mean of 34.5 months (range, 17.5–54.1 months). Results OCLs were found in 40.4% of the patients. Logistic regression revealed a significant correlation between the severity of fracture and the incidence of OCLs. Patients with a trimalleolar fracture (p = 0.04) or an ankle fracture dislocation (p = 0.003) had a significantly higher risk for developing an OCL compared to those with a type B fracture. Logistic regression also demonstrated a significant correlation between the clinical outcome (AOFAS score) and the incidence of OCLs (p = 0.01). The risk for developing an OCL increases up to 5.6% when the AOFAS score decreases by one point. Conclusion OCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. Considering the disadvantages of MRI including the high cost and limited availability, the results of this study may help to explain why anatomic surgical realignment of displaced ankle fractures may still be associated with poor clinical outcomes.

Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis. By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20A degrees, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised. The use of the electromagnetic guidance system SureShotA (R) generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.

Acute ankle sprains are frequently accompanied by syndesmotic injuries. These injuries are often overlooked in clinical examinations. The aim of this study was (1) to evaluate the incidence of syndesmotic injuries in acute ankle sprains using MRI, (2) to determine the accuracy of common clinical diagnostic tests, (3) to analyse their inter-rater reliability, and (4) to evaluate the role of clinical symptoms in the diagnosis of syndesmotic injuries.

Die operative Stabilisierung geschlossener Tibiaschaftfrakturen ist eine Domäne der Marknagelung. Waren kleine distale Fragmente früher ein mögliches Problem in Bezug auf die axiale Ausrichtung und deren sichere anatomische Fixierung, ist dieses Problem heute durch die neuen Nageldesigns und -technologien nahezu vollständig gelöst. Noch nicht im selben Ausmaß gelöst bzw. unter Kontrolle sind das Problem der distalen Verriegelung, die mühselig sein und zu einer hohen Strahlenexposition führen kann, sowie die Kontrolle kleinerer, proximal gelegener Frakturfragmente, d. h. also isolierter Fakturen in der proximalen Tibiametaphyse oder segmentaler Frakturen der Tibia, bei denen der proximale Frakturverlauf des entstandenen Segments ebenfalls metaphysär verläuft.

Advanced states of vertebral osteomyelitis accompanied by spinal instability, epidural abscess formation, and neurological deficits require surgical decompression, stabilization, and often reconstruction of the anterior and posterior columns. The efficacy of a posterolateral approach with resection of inflammatory tissue, and interbody (titanium cages) and dorsal fusion was investigated and the clinical and radiological parameters (correction of kyphosis and fusion rates) were evaluated.

BACKGROUND:Acetabular fracture surgery is demanding and screw placement along narrow bony corridors remains challenging. It necessitates x-ray radiation for fluoroscopically assisted screw insertion. The purpose of this cadaver study was to evaluate the feasibility, accuracy and operation time of a novel electromagnetic navigation system for screw insertion along predefined acetabular corridors.METHODS:A controlled laboratory study with a total of 24 electromagnetically navigated screw insertions was performed on 8 cadaveric acetabula. 3 peri-acetabular bony corridors (QSS, Quadrilateral Surface Screw; IAS, Infra-Acetabular Screw; PCS, Posterior Column Screw) were defined and screws were placed in a defined order without fluoroscopy. Operation time was documented. Postoperative CT scans were performed to analyse accuracy of screw placement.RESULTS:Mean cadaver age was 70.4 ± 11.7. Successful screw placement was accomplished in 22 out of 24 (91.7%) cases. The overall mean time for all 3 acetabular screws was 576.6 ± 75.9s. All 3 complications occurred during the placement of the IAS due to an impassable narrow bony corridor. QSS mean length was 50 ± 5mm, IAS mean length was 85 ± 10mm and PCS mean length was 120 ± 5mm.CONCLUSION:In this cadaver study the novel electromagnetic navigation system was feasible to allow accurate screw placement without fluoroscopy in defined narrow peri-acetabular bony corridors.

The Stoppa approach in its modified form is an intrapelvine approach for the treatment of acetabular fractures. It is an alternative to the ilioinguinal approach. Goals are the gentle soft-tissue preparation, anatomic reduction and stable internal fixation. Here, the approach is described in detail together with possible expansion possibilities.The Stoppa approach in particular is used for the treatment of fractures of the anterior column with participation of the quadrilateral surface, transverse fractures, T-type fractures, but also 2-column fractures when the main pathology is located in anterior portions of the acetabulum.This intrapelvic approach allows a direct view of the quadrilateral surface and the direct reduction of these fragments. In contrast to the ilioinguinal access the Stoppa approach dispenses with the preparation of the 2nd window with exposure of the vessels. The preparation is carried out via a Pfannenstiel access following transection of the median line alba. The further dissection is performed along the anterior pubic ramus, on the pelvic rim, towards the ipsilateral sacroiliac joint.The modified Stoppa approach is a soft-tissue-friendly approach for the treatment of acetabular fractures. With its options for expansion, possibility for osteotomy of the anterior superior iliac spine and the use of the first ilioinguinal window, almost all types of fractures of the acetabulum whose primary pathology is on the anterior side can be treated.