Background: Targeted muscle reinnervation (TMR) is increasingly used to enhance prosthetic control and to reduce post-amputation pain. Its implementation across new centers raises questions about the reproducibility of outcomes and the impact of surgical experience. Methods: We compared the first three TMR patients treated in a newly established center in Nantes, France, with three patients treated in a high-volume center in G & ouml;ttingen, Germany. Functional outcomes were measured using the Box and Block test (BBT), and operative time was recorded. Two French cases were performed with the assistance of a G & ouml;ttingen-based surgeon. Conclusions: The functional outcomes showed a similar trend in both groups. The mean BBT scores were equivalent, suggesting reliable reinnervation and prosthetic integration even in early cases. Operative times were longer in Nantes, but did not impact outcomes. TMR appears not to have a pronounced learning curve, particularly regarding functional success in early cases under guided protocols. Factors such as assistance from experienced surgeons and favorable donor-to-recipient nerve ratios likely contribute to consistent outcomes. These findings support the reproducibility of TMR across institutions. Results: Within the first two years of rehabilitation we observed improvements in both functional performance and patient-reported quality of life. All six patients across both centers in-creased in BBT scores. All the patients reported an increase in social relationships and psychological health, and two of three patients reported an increase in physical health. Importantly, all six patients discontinued the use of pain medication at 2 years fol-lowing TMR. Furthermore, the French patients reported a decrease from 65-82 mm to 0-31 mm across the patients' Visual Analog Scale (VAS) pain scores.

BACKGROUND:Odontoid fractures are the most common cervical spine injuries in geriatric patients and are associated with substantial morbidity and mortality. Their incidence is increasing with population aging. Optimal management remains controversial, particularly due to poor bone quality and comorbidities in this patient group. While surgical treatment is associated with lower nonunion rates, its impact on survival and patient-reported outcomes is unclear. METHODS:This retrospective single-center study included patients with odontoid fractures who were treated conservatively or surgically between 2017 and 2020. Demographic and clinical data were obtained from medical records. Survival was analyzed using Kaplan-Meier estimates and Cox regression. Health-related quality of life was evaluated in surviving patients using Visual Analog Scale (VAS), Neck Disability Index (NDI), and Short Form-36 (SF-36) questionnaires. Comorbidity burden was determined using the age-adjusted Charlson Comorbidity Index (CACI). RESULTS:A total of 93 patients were included. The mean age was 78.9 ± 13.7 years, and 75% of fractures were Type II. Surgical treatment was performed in 59% of patients, whereas 41% received conservative management, primarily due to comorbidities. The 1-year mortality rate was 26.9% and increased with age and comorbidity burden. Higher CACI scores and conservative treatment were associated with reduced survival. Among 40 respondents, pain levels were low (mean VAS 2.5 ± 2.4). Conservatively treated patients reported significantly lower pain and higher SF-36 scores, while no significant differences were observed in NDI between groups. CONCLUSION:Odontoid fractures in geriatric patients are associated with substantial morbidity and mortality. Surgical treatment showed improved survival, whereas conservative management resulted in better patient-reported quality of life. These findings emphasize a clinically relevant contrast and support individualized, patient-centered treatment decisions based on comorbidity burden and overall patient condition.

With age, both men and women experience a decline of sex-hormones and impaired bone repair. This study examined whether bone healing could be improved by combined treatment with the selective androgen and estrogen receptor modulators ostarine (Ost) and raloxifene (Ral), and compared its efficacy with monotherapy in female and male rat models. Three‑month‑old female (Experiment 1, n = 15/group) and 8‑month‑old male (Experiment 2, n = 15/group) Sprague–Dawley rats were either intact (healthy control) or ovariectomized/orchiectomized (Ovx/Orx). Ovx/Orx rats received daily either no treatment, Ost, Ral, or combined Ost + Ral at the respective monotherapy doses. Eight weeks after Ovx or 12 weeks after Orx, rats underwent bilateral metaphyseal osteotomy of the tibia with plate fixation. Healing was assessed five in females or 6 weeks in males later by micro‑CT, biomechanics, and histology. Increased total, callus, and cortical densities as well as bone volume fraction were observed in the Ost + Ral group, accompanied by reduced callus volume and surface area, indicating advanced healing. The effect of Ost + Ral was stronger than that of Ral, whereas Ost alone did not alter bone parameters. Biomechanical properties were improved in the Ral and Ost + Ral groups relative to Ovx/Orx controls. Uterus weight was lowest in Ovx and Ovx + Ral groups and enhanced by Ost and Ost + Ral. Prostate weight was lowest in Orx and Orx + Ral rats and increased by Ost. The combination with Ral reduced the androgenic effect of Ost on prostate. Combined treatment may represent a promising approach for osteoporotic bone repair in both sexes, though potential side effects of Ost require consideration.

Das schwere Thoraxtrauma gehört zu den häufigsten und potenziell letalen Verletzungen beim Schwerverletzten. Fast 50

Study DesignCadaveric biomechanical analysis.ObjectivesThe specific vertebral region that contributes most critically to pedicle screw fixation remains controversial. This study evaluates screw anchorage under cyclic fatigue loading to determine how bone quality affects the relative contributions of the pedicle and vertebral body to stability.MethodsTwelve human lumbar vertebrae (L1-L4) from donors aged 71.3 ± 14.2 years were selected, including six with normal bone density (>120 mg/cm3) and six osteoporotic (<80 mg/cm3). Each vertebra was bilaterally instrumented with the largest self-tapping polyaxial screws fitting the inner cortical diameter. One pedicle received a 35 mm screw, and the contralateral pedicle received the longest screw without cortical breach. Screw side and specimen order were randomized. Sinusoidal cranial-caudal loading at 0.5 Hz was applied, starting at 100 N and increasing by 1 N per cycle, until 5.4 mm screw head displacement (∼20°) was reached.ResultsIn healthy vertebrae, mean fatigue loads were similar for short (315.6 ± 148.7 N) and long screws (309.0 ± 138.3 N). In osteoporotic bone, long screws (230.9 ± 55.0 N) showed significantly greater fatigue resistance than short screws (175.1 ± 45.5 N; P = .045). Short screws in osteoporotic vertebrae also failed after fewer cycles than long screws in osteoporotic vertebrae (P = .047) and short screws in healthy bone vertebrae (P = .049).ConclusionsIn healthy vertebrae, screw anchorage is mainly pedicular, and extending screw length into the vertebral body adds no benefit. In osteoporotic bone, overall fixation strength declines, but vertebral body contribution increases, so longer screws provide significantly greater stability, whereas shorter screws remain adequate in healthy bone.

Background Pelvic insufficiency fractures are increasingly common in older adults and frequently involve the posterior pelvic ring. However, their population-based three-dimensional distribution has not yet been systematically characterized across the complete Fragility Fractures of the Pelvis (FFP) classification. This study aimed to generate a standardized CT-based three-dimensional fracture map, identify reproducible anatomical hotspots, and visualize fracture distribution across FFP types I–IV. Methods CT datasets from 67 geriatric patients with pelvic insufficiency fractures (mean age 82.78 ± 6.84 years; 77.6% women) were retrospectively analyzed. Fractures were classified according to the FFP classification of Rommens and Hofmann, segmented in 3D Slicer, registered to a standardized pelvic template, and visualized as frequency-based three-dimensional heatmaps in Blender. Results A total of 184 fracture lines were mapped. Fracture clustering was most pronounced in the sacral alae, accounting for 54% of all mapped fracture locations, followed by the parasymphyseal region (22%) and the remaining anterior pelvic ring (15%). Iliac wing and acetabular involvement was less frequent, accounting for 6% and 3%, respectively. FFP-specific heatmaps demonstrated a transition from isolated anterior fractures in FFP type I to progressively broader posterior and bilateral involvement in FFP types II–IV. Conclusion Standardized CT-based three-dimensional fracture mapping identified the sacral alae as the principal hotspot of pelvic insufficiency fractures and visualized characteristic spatial patterns across the FFP classification. This approach provides an anatomical framework for improved CT interpretation and future biomechanical, diagnostic, and surgical-planning studies. MINI ABSTRACT Pelvic insufficiency fractures are an increasing consequence of osteoporosis, but their three-dimensional distribution remains poorly understood. CT-based heatmapping identified the sacral alae as the principal fracture hotspot and visualized progressive posterior extension across the FFP classification. These findings improve the anatomical understanding of osteoporotic pelvic fragility fractures.

Background and Objectives: Ventral stabilization of thoracolumbar spine fractures can be achieved using different interbody reconstruction techniques, including titanium cages, vertebral body replacements (VBR), and autologous pelvic bone grafts (APBG). Although all approaches aim to restore anterior column stability and alignment, comparative data on long-term patient-reported outcomes remain limited. The objective of this study was to compare long-term patient-reported wellbeing following ventral stabilization using these three techniques. Materials and Methods: A retrospective, non-randomized single-center cohort study with prospective follow-up was analyzed. Treatment allocation was indication-based. Ninety-one patients treated between 2008 and 2018 underwent ventral stabilization using cage implantation (n = 12), vertebral body replacement (n = 45), or autologous pelvic bone grafting (n = 34). Clinical outcome was assessed at least 12 months postoperatively using a modified Visual Analog Scale Spine Score (VAS-Spine). Statistical analysis included linear and ordinal regression adjusted for age and sex. Potential baseline differences between groups were considered in the interpretation of the results. Results: Sixty-three patients (mean age 52 ± 15 years; 41% female) completed follow-up. The mean VAS-Spine score was lowest after cage implantation (2.7 ± 3.6), followed by VBR (3.9 ± 2.8) and APBG (4.9 ± 1.8; p* = 0.021). The observed difference between cage and APBG approached the minimal clinically important difference reported for VAS-based measures. Patients treated with cage implantation reported less pain during rest and activity and fewer limitations in daily life. No significant differences were observed regarding age or sex. Conclusions: In this observational cohort, cage implantation was associated with more favorable patient-reported outcomes compared with VBR and APBG. Autologous pelvic bone grafting was associated with worse patient-reported outcomes, potentially related to donor-site morbidity. Given the non-randomized design and potential confounding, these findings should be interpreted as associative and hypothesis-generating.

Non-union of the chest wall is an underrecognized but functionally significant complication of thoracic trauma, particularly when involving posterior ribs, parasternal cartilage, and the costal margin. Complex instability patterns can result in persistent pain, mechanical dysfunction, and impaired respiration. We describe two patients with symptomatic chest wall non-union. Case 1 was a 62-year-old man with posterior non-union of the seventh and eighth ribs and a secondary costal margin rupture with intercostal hernia. He underwent combined posterior rib plating and costal margin reconstruction, nerve-sparing fibre-tape sutures, and double-layer mesh. Case 2 was a 25-year-old man with a radiographically occult rupture and pseudarthrosis of the third parasternal costal cartilage. He was treated with trans-costosternal osteosynthesis and local bone grafting. These cases illustrate that dynamic and multimodal imaging are often required to diagnose non-unions, and that contemporary plating and mesh techniques can restore stability, relieve pain, and permit early mobilization.

Background Spinopelvic alignment plays a crucial role in the biomechanical load distribution of the lumbosacral junction. Pelvic tilt (PT), as a key sagittal alignment parameter, reflects compensatory pelvic rotation and increases with age and degenerative spinal changes. While sacral insufficiency fractures represent a growing clinical problem in elderly populations, the relationship between pelvic orientation and regional sacral bone mineral density remains poorly understood. Purpose To investigate the association between pelvic tilt and regional trabecular bone mineral density within the S1 vertebra using quantitative computed tomography (QCT). Methods In this retrospective study, 204 patients who underwent CT imaging of the spine and standing radiographs of the lumbar spine between 2017 and 2024 were analyzed. Trabecular volumetric bone mineral density (vBMD) was measured using QCT at five predefined anatomical regions within S1: right lateral mass of S1 (MLR), right sacral ala (ALR), vertebral body S1 (CS1), left sacral ala (ALL), and left lateral mass of S1 (MLL). Pelvic tilt was measured on standing lateral radiographs. Associations between pelvic tilt, bone mineral density, age, and sex were assessed using correlation analysis and multivariable linear regression. Results Pelvic tilt increased significantly with age and was higher in women than in men. Trabecular bone mineral density decreased across all measured regions with increasing age. Pearson correlation analysis demonstrated a significant negative association between pelvic tilt and vBMD at all anatomical regions. After adjustment for age and sex, pelvic tilt remained an independent negative predictor of bone mineral density at ALR, CS1, and ALL. Conclusion Pelvic tilt is associated with regional variations in sacral bone mineral density, particularly in the sacral alae and the S1 vertebral body. These findings suggest that sagittal spinopelvic alignment is associated with regional differences in trabecular bone density within the sacrum.

ObjectivePosterior trans-iliac plate osteosynthesis (TPO) is commonly used for the stabilization of unilateral vertically unstable sacral fractures. However, its biomechanical performance across different Denis fracture patterns remains unclear. This study aimed to investigate the fracture pattern-dependent biomechanical behavior of posterior trans-iliac plate osteosynthesis (TPO) in unilateral vertically unstable sacral fractures, using bilateral triangular osteosynthesis (BTO) as a high-stability reference construct.MethodsA validated three-dimensional finite element model of the lumbopelvic complex was developed to simulate unilateral vertically unstable sacral fractures corresponding to Denis type I, II, and III patterns. Two posterior fixation strategies, TPO and BTO, were constructed for each fracture type. Seven physiological loading conditions were applied, including standing, flexion, extension, axial rotation, and lateral bending. Von Mises stress distribution and fracture displacement were evaluated. Fracture micromotion was quantified by calculating relative displacement changes between paired points along the fracture gap.ResultsWhen interpreted relative to the high-stability BTO reference construct, TPO showed fracture pattern-dependent variation in fracture displacement. The difference was most pronounced in Denis type I fractures and progressively decreased in Denis type II and III patterns.ConclusionThe biomechanical performance of posterior trans-iliac plate fixation is influenced by the Denis fracture pattern. Fracture micromotion associated with the non-reinforced TPO construct evaluated in this study decreased as the fracture line approached the sacral midline, indicating improved mechanical compatibility in more medially located fracture patterns. These findings provide biomechanical reference data for understanding fracture pattern-dependent fixation compatibility of TPO in unilateral sacral fractures. However, it remains unclear how much fixation strength is actually required to achieve sufficient construct stability for fracture healing and how postoperative management strategies, such as weight-bearing status, may influence this requirement.

Severe thoracic trauma is among the most frequent and potentially lethal injuries in severely injured patients. Almost 50% of polytrauma patients present with relevant chest trauma (AIS >= 3). The spectrum ranges from chest wall instability and pulmonary contusions to life-threatening injuries of the heart, great vessels, and tracheobronchial tree. While initial ATLS-based management is well established, treatment strategies for severe chest wall injuries have shifted in recent years from predominantly non-operative care towards early surgical stabilization. This paradigm change is driven by growing evidence that rapid restoration of chest wall integrity and biomechanics significantly reduces morbidity (e.g. pneumonia, ventilation time, ICU stay) and mortality. This CME article summarises current diagnostics and therapy, outlines indications and contraindications for operative interventions, and reviews complication management in severe thoracic trauma management.

BACKGROUND:Since the 2018 decision of the Federal Joint Committee (G-BA) inpatient emergency care in Germany has undergone a profound structural change. Although musculoskeletal injuries account for around 40-45% of the emergency department (ED) caseload, current regulations lack binding requirements for primary trauma/orthopedic surgical treatment. This raises questions regarding quality of care, legal certainty and postgraduate training. OBJECTIVE:This study investigated to what extent injured patients in German trauma centers receive primary care from physicians with trauma surgery qualifications and which structural consequences result from this. METHODS:In a nationwide online survey all 626 trauma centers listed in the German Society for Trauma Surgery (DGU) TraumaNetwork were contacted. Data were collected on ED structures, the qualifications of physicians involved in primary care and responsibilities for setting the indications for trauma/orthopedic surgery. In addition, a qualitative content analysis of voluntary free-text comments was performed. RESULTS:Responses from 225 trauma centers were analyzed (response rate 36%). The primary care of non-polytraumatized trauma/orthopedic surgery patients was provided predominantly by trauma surgery residents (53% local trauma centers, 56% regional trauma centers, 59% supraregional trauma centers). The on-site presence of board-certified trauma surgeons was lower (16-28%). In 78 hospitals emergency physicians from other disciplines provided initial care in fewer than 10% of cases. The free-text comments emphasized deficits in quality of care and postgraduate training. DISCUSSION:The results demonstrate a relevant discrepancy between the epidemiological importance of trauma/orthopedic clinical conditions and their structural anchoring in the emergency department. The G‑BA requirements ensure organizational standards but do not guarantee specialty-specific depth. To ensure quality of care, legal certainty and postgraduate training, binding regulations for trauma/orthopedic surgical competence in the ED are necessary.

Quantitative computed tomography (QCT) is increasingly used for preoperative bone quality assessment in spine surgery. However, established QCT osteoporosis thresholds are based on lumbar reference regions and are frequently extrapolated to the thoracic spine, despite anatomical and biomechanical differences. To evaluate whether lumbar QCT thresholds are transferable to the thoracic spine and to derive provisional thoracic-equivalent thresholds for anatomically defined thoracic subregions by statistical translation of established lumbar American College of Radiology (ACR) thresholds. In this retrospective single-center quantitative computed tomography (QCT) study, trabecular volumetric bone mineral density (vBMD, mg/cm3) was assessed in 227 patients. Thoracic vBMD was summarized as the mean of Th1–Th10, whereas Th11-Th12 were assigned to the lumbar reference region together with L1-L4 according to the American College of Radiology (ACR) QCT classification scheme. Segmental vBMD distribution was analyzed, and the thoracic–lumbar relationship was modeled using Deming regression. The overall Th1–Th10 conversion was retained as a secondary regional summary; provisional thoracic-equivalent thresholds corresponding to ACR lumbar thresholds (80/120 mg/cm3) were derived for upper (Th1–Th4), mid (Th5–Th8), and lower thoracic regions (Th9–Th10). Thoracic vBMD was significantly higher than lumbar vBMD (102.5 ± 44.1 vs. 85.1 ± 44.6 mg/cm3). In patients with evaluable measurements in both regions (N = 101), thoracic vBMD exceeded lumbar vBMD by 14.1 ± 19.7 mg/cm3 (p < 0.001) and showed strong correlation (r = 0.890, p < 0.001). A pronounced cranio-caudal decline in vBMD was observed across the thoracic spine (mixed-effects slope − 3.96 mg/cm3 per level, p < 0.001). Deming regression yielded Th(1–10) = 0.956 × Lum(Th11–L4) + 18.0; the resulting overall Th1–Th10 conversion values of 94 mg/cm3 and 133 mg/cm3 are reported as a secondary regional summary. Provisional subregional thoracic-equivalent thresholds differed substantially: upper thoracic (Th1–Th4) 118/148 mg/cm3, mid thoracic (Th5–Th8) 94/132 mg/cm3, and lower thoracic (Th9–Th10) 90/132 mg/cm3. Thoracic vBMD showed a systematic regional offset and substantial cranio-caudal variation. Because the vertebral-level composition of the overall Th1–Th10 mean varied between patients, the overall conversion should not be interpreted as a fixed anatomical thoracic threshold. The anatomically defined subregional values should be regarded as provisional thoracic-equivalent thresholds derived from lumbar ACR criteria and require prospective outcome-based validation before clinical implementation.

Background The preferred operative treatment of pertrochanteric femoral fracture (PFF) is internal fixation with a proximal femoral nail (PFN). Changes in femoral offset (CFO) greater than 15% after hip arthroplasty appear to be critical and can cause gait instability or clinical pain syndromes. It is currently unclear whether and to what extent this fracture treatment leads to a postoperative CFO. Methods Pre- and postoperative x-rays of 382 patients with PFF who underwent PFN osteosynthesis were analysed to assess CFO and CCD on operated (OS) and non-operated side (NOS). Results In 99.2% (379/382) a postoperative CFO could be found. In 43% (164/382) the FO decreased (FOD) and in 56% (215/382) the FO increased (FOI). A critical FOD was found in 40.9% and a critical FOI in 45.1%. In hip joints with FOD the mean FO between the NOS (54.30 mm [±7.60]) and OS (47.01 mm [±7.54]) likewise as in hip joints with postoperative FOI the mean FO between NOS (49.36 [±7.35]) and OS (57.43 [±7.69]) differed significantly (p<0.001). Preoperative FO (p<0.001) and CCD (p=0.02) correlated with postoperative CFO. Hips with a FO >55 mm and CCD <128° showed postoperative a FOD, while hips with a FO <55 mm and CCD >128° showed a FOI. Conclusion PFF treatment with PFN results in a clustered significant postoperative CFO. In order to avoid a critical CFO postoperatively, the individual morphological parameters of the contralateral hip side, respecting CCD and femoral offset, should be taken into account when treating PFF.

Die vorliegende Arbeit beschreibt den Einsatz von digitalen Lösungen für die Verbesserung der Versorgung von Traumapatienten in Deutschland. Im Mittelpunkt stehen die TraumaNetzwerke der Deutschen Gesellschaft für Unfallchirurgie (DGU). Der Einsatz von digitalen Lösungen umfasst Qualitätssicherungen durch das TraumaRegister, dass eine umfassende Datenanalyse ermöglicht, sowie Voranmeldung und Ressourcennutzung über Programme wie den Interdisziplinären Versorgungsnachweis IVENA eHealth, den Rescuetrack und das Rescue-Net. Zudem wird das Predictive Hospital Resource Planning, das die Ressourcenprognose mithilfe von künstlicher Intelligenz (KI) optimiert, vorgestellt. Telemedizinische Dienste wie Medgate und teleradiologische Lösungen (Nexus/Chili) bieten zusätzliche Unterstützung, insbesondere in ländlichen Gebieten. Die Arbeit zeigt, wie die Digitalisierung der medizinischen Versorgung entscheidend ist, um die Effizienz und Qualität in der Behandlung von Traumapatienten zu verbessern. Zudem zeigt die Arbeit mögliche Entwicklungen im Bereich der klinischen Entscheidungsfindung durch KI auf.

BackgroundFemoral neck fractures are prevalent in orthopedic injuries, often leading to complications such as nonunion and osteonecrosis of the femoral head (ONFH). Studies indicate that after healing and removal of internal fixation devices, some patients develop ONFH, while others experience osteosclerosis around the screw holes due to prolonged fixation, increasing ONFH risk. Despite such observations, biomechanical studies on this phenomenon are limited. This study assesses the risk of femoral head collapse post-internal fixation device removal and investigates the biomechanical effects of bone grafting at screw removal sites.MethodsUsing CT data, femoral anatomy was reconstructed. For control, the femoral head’s collapse area was identified. Experimental models, divided into those with and without bone grafts in screw holes, incorporated three fixation techniques, namely, triple cannulated screws (3CS), dynamic hip screws with cannulated screws (DHS+CS), and the femoral neck system (FNS), further subclassified into normal and sclerotic screw-hole models. Stress distribution, stress values, stress index, and strain range were assessed.ResultsIn both models, DHS+CS showed the highest stress in the overall model, while 3CS had the highest stress in the collapse area. The 3CS configuration also resulted in the largest strain range, which was observed in the central pillar of normal screw-hole models and the lateral pillar of sclerotic screw-hole models. The bone graft models exhibited lower peak, average stress, and strain values than the normal and sclerotic screw-hole models.ConclusionThe FNS screw hole demonstrates a relatively lower mechanical risk of femoral head collapse. In contrast, sclerotic screw holes increase this risk, while bone grafting may improve the biomechanical behavior after fixation removal, potentially reducing the likelihood of femoral head collapse.

Periprothetische distale Femurfrakturen (PPDFF) bei implantierter Knieendoprothese stellen eine zunehmende Herausforderung für die unfallchirurgische und orthopädische Versorgung insbesondere älterer, multimorbider Patient:innen dar. Die Behandlungskonzepte variieren je nach Frakturtyp, Prothesenstabilität, Knochenqualität und Patientenfaktoren [1, 6–10, 13]. Moderne winkelstabile Platten, retrograde Marknägel mit angulierten Schäften, Doppelplatten- und Nagel-Platten-Konstrukte bieten je nach Frakturtyp und Knochenqualität eine hohe Primärstabilität und ermöglichen meist eine frühfunktionelle Mobilisation [5, 6, 11, 13, 30–33]. Bei sehr distalen, osteoporotischen oder komplexen Frakturen sind Doppelplatten oft biomechanisch überlegen und reduzieren Komplikationen wie Nonunion und Implantatversagen [2, 10, 11, 13, 14, 22, 29]. Allerdings besteht auch die Gefahr, dass der Knochen hinter dem femoralen Schild nicht regelrecht konsolidiert. Bei ausgedehntem Knochenverlust oder primär gelockerter Prothese ist der distale Femurersatz indiziert [8]. Frühzeitige Mobilisation, insbesondere in der meist älteren Patientenpopulation, verbessert das funktionelle Ergebnis und senkt die Mortalität [1, 5, 11, 13, 16, 27, 30–33]. Ziel dieses Übersichtsartikels ist es, aktuelle Therapieoptionen, deren Evidenz sowie spezifische Komplikationen und funktionelle Ergebnisse systematisch darzustellen und zu bewerten.