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1.  Temperature control with internally applied cooling in solid material drilling: an experimental, biomechanical study 
International Orthopaedics  2013;37(7):1355-1361.
The purpose of this study was to evaluate the different temperature levels while drilling solid materials and to compare different cooling solutions for possible temperature control. An additional purpose was to develop an internal cooling device which can be connected to routinely used manual drilling devices in trauma surgery.
Drilling was performed on a straight hip stem implanted in bovine femora without cooling, with externally applied cooling and with a newly developed internal cooling device. Temperature changes were measured by seven thermocouples arranged near the borehole. Additionally, thermographic scans were performed during drilling.
Drilling without cooling leads to an immediate increase in temperature to levels of thermal osteonecrosis (over 200 °C). With externally applied cooling temperatures were decreased, but were still up to a tissue damaging 85 °C. Internally applied cooling led to a temperature decrease to tissue-preserving levels during the drilling procedure (24.7 °C).
Internal cooling with HPC-drillers lowered the measured temperatures to non-tissue damaging temperatures and should avoid structural tissue damage.
PMCID: PMC3685654  PMID: 23512602
2.  Two-stage multilevel en bloc spondylectomy with resection and replacement of the aorta 
European Spine Journal  2012;22(Suppl 3):363-368.
We report a case of multilevel spondylectomy in which resection and replacement of the adjacent aorta were done. Although spondylectomy is nowadays an established technique, no report on a combined aortic resection and replacement has been reported so far.
The case of a 43-year-old man with a primary chondrosarcoma of the thoracic spine is presented. The local pathology necessitated resection of the aorta. We did a two-stage procedure with resection and replacement of the aorta using a heart–lung machine followed by secondary tumor resection and spinal reconstruction.
The procedure was successful. A tumor-free margin was achieved. The patient is free of disease 48 months after surgery.
En bloc spondylectomy in combination with aortic resection is feasible and might expand the possibility of producing tumor-free margins in special situations.
PMCID: PMC3641252  PMID: 22972602
Chondrosarcoma; Spondylectomy; Resection of the aorta; Multilevel
3.  Elective thoracotomy for pedicle screw removal to prevent severe aortic bleeding 
We present a case of a 33-year-old female who sustained multiple injuries of her spine, including spinous process fractures of C5 to C7 and a lamina fracture of C6 and C7. Her thoracic spine showed transverse process fractures of T4 to T10, a compression fracture and lamina fracture of T3, spinous process and transverse process fractures of T4 and T5, a rotation injury of T6, as well as a compression fracture of L1. Thirteen months after posterior thoracic spinal instrumentation, a pedicle screw was suspected to be in contact with the aorta, which was proved by computed tomography angiograms. Consequently, implant removal was planned with direct exposure of the aorta in order to allow for immediate repair if needed. So far, studies that compare different techniques to remove pedicle screws that are suspected to penetrate the aorta are missing. However, different techniques have been described in case reports, mainly minimally invasive endovascular techniques vs open techniques such as thoracotomy.
PMCID: PMC3985037  PMID: 24749121
Spine; Pedicle screw; Aorta; Bleeding; Implant removal; Hemorrhage
5.  Physical and psychological long-term outcome after traumatic brain injury in children and adult patients 
Several studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient’s age, direct comparison between different pediatric age groups as well as an adult population was performed.
This investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10 years. According to their age at time of injury, patients were divided in pre-school (0–7 years), school (8–17 years) and adult (18–65 years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed.
135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients’ age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (p = 0.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (p = 0.010) and depression (p = 0.026) was evaluated in older patients.
Long-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child’s ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.
PMCID: PMC3941774  PMID: 24571742
Traumatic brain injury; Long-term outcome; Morbidity; Children
6.  Near-Infrared Spectroscopy Correlates with Established Histological Scores in a Miniature Pig Model of Cartilage Regeneration 
Near-Infrared Spectroscopy (NIRS) could be of clinical relevance in modern cartilage regeneration.In a miniature pig model correlation of measurements and histologic scores have never been used before. The data analysis was part of an animal project that investigated the effects of seeding a chondrogenic and osteogenic scaffold with a bone-marrow-derived cell concentrate and reports the histological and mechanical properties. We created 20 osteochondral defects in the femoral condyles of 10 miniature pigs.The defects were left empty (E), filled with the grafted cylinder upside down (U), or with a combined scaffold (S) containing a spongy bone cylinder covered with a collagen membrane. In the fourth group, the same scaffolds were implanted but seeded with a stem cell concentrate (S+BMCC). The animals were euthanized after 3 months, and histologic and spectrometric analyses were performed. NIRS measurements were significantly higher in the central area of the defects of group S+BMCC compared to the central area of the defects of group U. In all groups, a correlation between NIRS and the histologic scores could be demonstrated though on different levels. In the central area, a good NIRS measurement correlates with low (good) histologic scores. In group E and group S, this negative correlation was significant (p=0.01). For the first time, NIRS was successfully used to evaluate osteochondral constructs in a miniature pig model.
PMCID: PMC4040933  PMID: 24895022
Cartilage; miniature pig; near-infrared spectroscopy; NIRS; steochondral lesion; Pineda; Wakitani.
7.  Tibial Inlay Press-fit Fixation Versus Interference Screw in Posterior Cruciate Ligament Reconstruction 
Orthopedic Reviews  2013;5(4):e35.
Reconstruction of the posterior cruciate ligament (PCL) by a tibial press-fit fixation of the patellar tendon with an accessory bone plug is a promising approach because no foreign materials are required. Until today, there is no data about the biomechanical properties of such press-fit fixations. The aim of this study was to compare the biomechanical qualities of a bone plug tibial inlay technique with the commonly applied interference screw of patellar tendon PCL grafts. Twenty patellar tendons including a bone block were harvested from ten human cadavers. The grafts were implanted into twenty legs of adult German country pigs. In group P, the grafts were attached in a press-fit technique with accessory bone plug. In group S, the grafts were fixed with an interference screw. Each group consisted of 10 specimens. The constructs were biomechanically analyzed in cyclic loading between 60 and 250 N for 500 cycles recording elongation. Finally, ultimate failure load and failure mode were analyzed. Ultimate failure load was 598.6±36.3 N in group P and 653.7±39.8 N in group S (not significant, P>0.05). Elongation during cyclic loading between the 1st and the 20th cycle was 3.4±0.9 mm for group P and 3.1±1 mm for group S. Between the 20th and the 500th cycle, elongation was 4.2±2.3 mm in group P and 2.5±0.9 mm in group S (not significant, P>0.05). This is the first study investigating the biomechanical properties of tibial press-fit fixation of the patellar tendon with accessory bone plug in posterior cruciate ligament reconstruction. The implant-free tibial inlay technique shows equal biomechanical characteristics compared to an interference screw fixation. Further in vivo studies are desirable to compare the biological behavior and clinical relevance of this fixation device.
PMCID: PMC3883076  PMID: 24416479
posterior cruciate ligament reconstruction; tibial press-fit fixation; interference screw; biomechanical properties
8.  Tip apex distance, hip screw placement, and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures 
International Orthopaedics  2012;36(11):2347-2354.
To describe the quality of osteosynthesis after intertrochanteric fractures evaluation of tip apex distance (TAD) and position of the hip screw have been established. Furthermore, a slightly valgus fracture reduction has been suggested to reduce the risk of cut-out failure. However, uniform recommendations for optimal screw positioning and fracture reduction are still missing. The purpose of our study was to confirm potential risk factors for cut-out of hip screws of intertrochanteric fractures and to provide recommendations for practical clinical use.
A retrospective analysis of all patients with intertrochanteric fractures treated with a DHS or a gamma nail between January of 2007 and May of 2010 was performed at a level I trauma center.
Two hundred thirty-five patients with intertrochanteric fractures after intra- and extramedullary stabilization were analyzed. A TAD of more than 25 mm was demonstrated to be the most important factor for cut-out in stable and unstable fractures. Fracture reduction with a valgus NSA of 5–10° was associated with a trend towards a lower rate of screw cut-out while an anterior placement of the screw (Parker’s ratio index of <40) significantly increased cut-out incidence.
According to our results, the TAD should not exceed 25 mm in stable (AO/OTA A1) as well as unstable (AO/OTA A2) fractures. An increased anterior hip screw placement should be avoided while fracture reduction with a slight valgus Neck Shaft seems favorable.
PMCID: PMC3479298  PMID: 23011721
9.  Simultaneous Bilateral Transitional Fractures of the Proximal Tibia after Minor Sports Trauma 
Case Reports in Orthopedics  2013;2013:724802.
We report a very rare case of a 16-year-old healthy athletic boy who sustained simultaneous bilateral transitional fractures of the proximal tibia after kicking a football with his right leg during a soccer game. Following minimal invasive plate osteosynthesis with bridging of the growth plate, the patient recovered rapidly without any growth disturbances.
PMCID: PMC3804443  PMID: 24191212
10.  Emergency Closed Reduction of a C4/5 Fracture Dislocation with Complete Paraplegia Resulting in Profound Neurologic Recovery 
Case Reports in Orthopedics  2013;2013:272865.
Introduction. Cervical spinal cord injuries due to traumatic fractures are associated with persistent neurological deficits. Although clinical evidence is weak, early decompression, defined as <24–72 h, has been frequently proposed. Animal studies show better outcomes after early decompression within one hour or less, which can hardly ever be achieved in clinical practice. Case Presentation. A 37-year-old patient was hospitalized after being hit by a shying horse. After diagnosis of C4/5 fracture dislocation and complete paraplegia, she was intubated and sedated with deep relaxation. Emergency reduction was performed at approximately 120 minutes after trauma. Subsequently, a standard anterior decompression, discectomy, and fusion were carried out. She was then transferred to a specialized rehabilitation hospital. Her neurologic function improved from AIS grade A on admission to grade B postoperatively and grade D after four months of rehabilitation. One year after the accident, she was ambulatory without walking aids and restarted horse riding. Discussion and Conclusion. Rarely in clinical practice, decompression of the spine canal can be performed as early as in this case. This case highlights the potential benefit of utmost early reduction in cervical fracture dislocations with compression of the spinal cord.
PMCID: PMC3789362  PMID: 24151573
11.  Simultaneous Bilateral Quadriceps Tendon Rupture following Long-Term Low-Dose Nasal Corticosteroid Application 
Case Reports in Orthopedics  2013;2013:657845.
Simultaneous bilateral quadriceps tendon rupture is a very rare injury, which was previously only described in slightly more than 100 cases in the English literature. Occurrence after minor trauma is predominantly associated with certain medical conditions including chronic diseases and long-term use of certain drugs. We report the case of a 61-year-old healthy patient who sustained a simultaneous bilateral quadriceps tendon rupture following minor trauma. Medical history was completely clear except of a long-term nasal corticosteroid medication due to allergic rhinitis.
PMCID: PMC3747487  PMID: 23984143
12.  Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients 
Critical Care  2013;17(3):R124.
Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive.
Traumatized patients (Injury Severity Score; ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score.
A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n = 8,231) were transported by GEMS and 37.7% (n = 4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P < 0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P < 0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P < 0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P < 0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P < 0.001) resulting in an increased length of ICU treatment and in-hospital time (P < 0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862).
Afterwards, a subgroup analysis was performed on patients transported to level I trauma centers during daytime with the intent of investigating a possible correlation between the level of the treating trauma center and posttraumatic outcome. According to this analysis, the Standardized Mortality Ratio, SMR, was significantly decreased following the Trauma Score and the Injury Severity Score (TRISS) method (HEMS: 0.647 vs. GEMS: 0.815; P = 0.002) as well as the Revised Injury Severity Classification (RISC) score (HEMS: 0.772 vs. GEMS: 0.864; P = 0.045) in the HEMS group.
Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.
PMCID: PMC4056624  PMID: 23799905
13.  The Phosphate Source Influences Gene Expression and Quality of Mineralization during In Vitro Osteogenic Differentiation of Human Mesenchymal Stem Cells 
PLoS ONE  2013;8(6):e65943.
For in vitro differentiation of bone marrow-derived mesenchymal stem cells/mesenchymal stromal cells into osteoblasts by 2-dimensional cell culture a variety of protocols have been used and evaluated in the past. Especially the external phosphate source used to induce mineralization varies considerably both in respect to chemical composition and concentration. In light of the recent findings that inorganic phosphate directs gene expression of genes crucial for bone development, the need for a standardized phosphate source in in vitro differentiation becomes apparent. We show that chemical composition (inorganic versus organic phosphate origin) and concentration of phosphate supplementation exert a severe impact on the results of gene expression for the genes commonly used as markers for osteoblast formation as well as on the composition of the mineral formed. Specifically, the intensity of gene expression does not necessarily correlate with a high quality mineralized matrix. Our study demonstrates advantages of using inorganic phosphate instead of β-glycerophosphate and propose colorimetric quantification methods for calcium and phosphate ions as cost- and time-effective alternatives to X-ray diffraction and Fourier-transform infrared spectroscopy for determination of the calcium phosphate ratio and concentration of mineral matrix formed under in vitro-conditions. We critically discuss the different assays used to assess in vitro bone formation in respect to specificity and provide a detailed in vitro protocol that could help to avoid contradictory results due to variances in experimental design.
PMCID: PMC3688813  PMID: 23823126
14.  Pectus excavatum in blunt chest trauma: a case report 
Blunt cardiac rupture is an exceedingly rare injury.
Case presentation
We report a case of blunt cardiac trauma in a 43-year-old Caucasian German mother with pectus excavatum who presented after a car accident in which she had been sitting in the front seat holding her two-year-old boy in her arms. The mother was awake and alert during the initial two hours after the accident but then proceeded to hemodynamically collapse. The child did not sustain any severe injuries. Intraoperatively, a combined one-cm laceration of the left atrium and right ventricle was found.
Patients with pectus excavatum have an increased risk for cardiac rupture after blunt chest trauma because of compression between the sternum and spine. Therefore, patients with pectus excavatum and blunt chest trauma should be admitted to a Level I Trauma Center with a high degree of suspicion.
PMCID: PMC3567954  PMID: 23320897
Blunt cardiac rupture; Pectus excavatum; Seatbelt injury
15.  The role of stem cells in fracture healing and nonunion 
International Orthopaedics  2011;35(11):1587-1597.
Nonunion and large bone defects present a therapeutic challenge to the surgeon and are often associated with significant morbidity. These defects are expensive to both the health care system and society. However, several surgical procedures have been developed to maximise patient satisfaction and minimise health-care-associated and socioeconomic costs. Integrating recent evidence into the diamond concept leads to one simple conclusion that not only provides us with answers to the “open questions” but also simplifies our entire understanding of bone healing. It has been shown that a combination of neo-osteogenesis and neovascularisation will restore tissue deficits, and that the optimal approach includes a biomaterial scaffold, cell biology techniques, a growth factor and optimisation of the mechanical environment. Further prospective, controlled, randomised clinical studies will determine the effectiveness and economic benefits of treatment with mesenchymal stem cells, not in comparison to other conventional surgical approaches but in direct conjunction with them.
PMCID: PMC3193959  PMID: 21863226
16.  Intraprosthetic fixation techniques in the treatment of periprosthetic fractures-A biomechanical study 
World Journal of Orthopedics  2012;3(10):162-166.
AIM: To develop new fixation techniques for the treatment of periprosthetic fractures using intraprosthetic screw fixation with inserted threaded liners.
METHODS: A Vancouver B1 periprosthetic fracture was simulated in femur prosthesis constructs using sawbones and cemented regular straight hip stems. Fixation was then performed with either unicortical locked-screw plating using the less invasive stabilization system-plate or with intraprosthetic screw fixation using inserted liners. Two experimental groups were formed using either prostheses made of titanium alloy or prostheses made of cobalt chrome alloy. Fixation stability was compared in an axial load-to-failure model. Drilling was performed using a specially invented prosthesis drill with constantly applied internal cooling.
RESULTS: The intraprosthetic fixation model with titanium prostheses was superior to the unicortical locked-screw fixation in all tested devices. The intraprosthetic fixation model required 10 456 N ± 1892 N for failure and the unicortical locked-screw plating required 7649 N ± 653 N (P < 0.05). There was no significant difference between the second experimental group and the control group.
CONCLUSION: Intraprosthetic screw anchorage with special threaded liners enhances the primary stability in treating periprosthetic fractures by internal fixation.
PMCID: PMC3536858  PMID: 23326763
Periprosthetic fracture; Less invasive stabilization system; Plate fixation; Intraprosthetic screw fixation; Material science; Biomechanical testing; Axial load-to-failure
18.  Injury patterns of seniors in traffic accidents: A technical and medical analysis 
World Journal of Orthopedics  2012;3(9):151-155.
AIM: To investigate the actual injury situation of seniors in traffic accidents and to evaluate the different injury patterns.
METHODS: Injury data, environmental circumstances and crash circumstances of accidents were collected shortly after the accident event at the scene. With these data, a technical and medical analysis was performed, including Injury Severity Score, Abbreviated Injury Scale and Maximum Abbreviated Injury Scale. The method of data collection is named the German In-Depth Accident Study and can be seen as representative.
RESULTS: A total of 4430 injured seniors in traffic accidents were evaluated. The incidence of sustaining severe injuries to extremities, head and maxillofacial region was significantly higher in the group of elderly people compared to a younger age (P < 0.05). The number of accident-related injuries was higher in the group of seniors compared to other groups.
CONCLUSION: Seniors are more likely to be involved in traffic injuries and to sustain serious to severe injuries compared to other groups.
PMCID: PMC3502611  PMID: 23173111
Traffic accidents; Seniors; Head injury; Injury severity score; Abbreviated injury scale
19.  Comparison of 39 post-traumatic tibia bone transports performed with and without the use of an intramedullary rod: the long-term outcomes 
International Orthopaedics  2010;35(9):1397-1402.
Bone transport can be performed with an external fixator alone or with the monorail technique which entails the combination of a fixator and an intramedullary nail. The purpose of this study was to compare the complication rates and long-term outcomes of these methods. Two groups of patients, the external fixator (n = 21) and the monorail group (n = 18), were compared. The average follow-up period was 7.9 ± 5.6 years and the mean defect length 8.3 ± 3.1 cm. Healing was achieved in 19 (90%) and 13 (72%) of the fixator and monorail patients, respectively. Six patients underwent amputations because of persistent infections (two in the fixator and four in the monorail group). The rate of deformities was significantly higher in the fixator group (p = 0.049). No statistically significant difference was found when comparing categories of the SF-36 test or the ability to work or do sports. The main advantages of the monorail method are reduction of the external fixation time and the lower rate of deformities. However, the authors recommend segmental transport with external fixator in patients with chronic infections.
PMCID: PMC3167456  PMID: 20652249
20.  Knee injuries in severe trauma patients: a trauma registry study in 3.458 patients 
Purpose of the presented study is to answer the following questions: Are knee injuries associated with trauma mechanisms or concomitant injuries? Do injuries of the knee region aggravate treatment costs or prolong hospital stay in polytraumatized patients?
A retrospective analysis including 29.779 severely injured patients (Injury Severity Score [greater than or equal to] 16) from the Trauma Registry of the German Society for Trauma Surgery database (1993-2008) was conducted. Patients were subdivided into two groups; the "Knee" group (n=3.458, 11.6% of all patients) including all multiple trauma patients with knee injuries, and the "Non Knee" group (n=26.321) including the remaining patients. Patients with knee injuries were slightly younger, less often male gender and had a significantly increased ISS.
Patients in the Knee group suffered significantly more traffic accidents compared to the Non Knee group (82% vs. 52%, p<0.001). These injuries were more often caused by car or motorbike accidents. Severe thoracic and limb injuries (AIS[greater than or equal to]3) were more frequently found in the Knee group (p<0.001) while head injury was distributed equally. The overall hospital stay, ICU stay, and treatment costs were significantly higher for the Knee group (38.1 vs. 25.5 days, 15.2 vs. 11.4 days, 40,116 vs. 25,336 Euro, respectively; all p<0.001).
Traffic accidents are associated with an increased incidence of knee injuries than falls or attempted suicides. Furthermore, severe injuries of the limbs and chest are more common in polytraumatized patients with knee injuries. At last, treatment of these patients is prolonged and consequently more expensive.
PMCID: PMC3489801  PMID: 22866995
21.  Current state of computer-assisted trauma surgery 
Computer assisted surgery (CAS) was first used in neurosurgery. Currently, CAS has gained popularity in several surgical disciplines including urology and abdominal surgery. In trauma and orthopaedic surgery, computer assisted systems are used for fracture reduction, planning and positioning of implants as well as the accurate implantation of hip and knee prostheses. The patient’s anatomy is virtualized and the surgical instruments integrated into the digitized image background, thus allowing the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAS improves overall accuracy, reducing intraoperative radiation exposure and minimizing unnecessary surgical dissection combined with increased patient and surgeon safety. However, limitations include prolonged surgical time, technical errors and cost implications. This article will outline the current state of computer assisted trauma surgery including its implications and specific challenges in orthopaedic trauma surgery.
PMCID: PMC3535088  PMID: 22832946
Computer assisted surgery; Navigation; Trauma; SI-screw; Femur; Femoral malrotation
22.  Insufficient Bone Regenerate after Intramedullary Femoral Lengthening: Risk Factors and Classification System 
Control of distraction rate with an intramedullary skeletal kinetic distractor (ISKD) may be problematic and a high distraction rate may result in insufficient bone regenerate.
Are distraction problems preventable when using the ISKD, and what are the risk factors for and radiologic types of insufficient bone regenerate during ISKD lengthening?
Patients and Methods
We analyzed 37 consecutive ISKD femoral lengthening procedures in 35 patients with a mean age 33 ± 11 years and minimum followup of 12 months (average, 27 ± 9 months; range, 12–55 months). The average length gain was 42.8 ± 12.9 mm.
Eight patients had problems during distraction: seven had “runaway nails” and one had a nondistracting nail. Insufficient bone regenerate developed in eight patients. Important risk factors were a distraction rate greater than 1.5 mm/day (9.1 times higher risk), age 30 years or older, smoking, and lengthening greater than 4 cm. Less important risk factors identified were creation of the osteotomy at the site of previous trauma or surgery and acute correction of associated deformities. We proposed a radiologic classification for failure of bone regeneration: partial regenerate failure (Type I) or complete failure resulting in a segmental defect subdivided according to a length of 3 cm or less (Type IIa) or greater than 3 cm (Type IIb).
Distraction problems with the ISKD were related mostly to internal malfunction of the lengthening mechanism. A distraction rate greater than 1.5 mm/day should be avoided in femoral intramedullary lengthening. Smoking should be a contraindication for femoral lengthening.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3008908  PMID: 20361281
23.  Pre-hospital trauma care: A comparison of two healthcare systems 
The management of trauma patients differs depending upon the healthcare system available.
To compare the pre-hospital management and outcome of polytrauma patients between two countries with differing approaches to pre-hospital management.
Materials and Methods:
The Scottish trauma and audit group (STAG) and the German trauma registry (GTR) databases were used to compare the management and outcome of trauma patients in Scotland and Germany. Severely injured patients (injury severity score (ISS) > 16) were analyzed for a 3 year period (2000 to 2002). Patient demographics, pre-hospital interventions, ISS, revised trauma score (RTS), time from scene of injury to arrival to the emergency department (ED), 120 day mortality and standardized mortality ratios using TRISS methodology were compared.
There were 227 patients identified from the STAG registry and 6878 patients from the GTR registry. There was a significant difference in ISS (24.9 vs. 29.8, P = 0.001, respectively). No significant difference was observed for the RTS (P = 0.2). There was a significantly higher rate of pre-hospital interventions in the German group (P < 0.001). The mean time from an injury to arrival to the ED (73 vs. 247 minutes, P = 0.001) was longer for the Scottish patients. There was no difference for an unadjusted mortality rate between the groups, but the standardized mortality ratio was significantly greater for the Scottish population (3.8 vs. 2.2, P = 0.036).
Despite variation in pre-hospital transfer times and interventions, no significant difference was demonstrated in RTS upon arrival, or for the unadjusted mortality rates.
PMCID: PMC3338234  PMID: 22557828
Acute liver failure; intensive; treatment
24.  Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective 
With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.
Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.
The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.
In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.
It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.
PMCID: PMC3196685  PMID: 21943304
Global perspective; Future trends and needs; Algorithms of patient care; Quality assurance in Patient care; Registries
25.  Blunt cerebrovascular trauma causing vertebral arteryd issection in combination with a laryngeal fracture: a case report 
The diagnosis and therapy of blunt cerebrovascular injuries has become a focus since improved imaging technology allows adequate description of the injury. Although it represents a rare injury the long-term complications can be fatal but mostly prevented by adequate treatment.
Case presentation
A 33-year-old Caucasian man fell down a 7-meter scarp after losing control of his quad bike in a remote area. Since endotracheal intubation was unsuccessfully attempted due to the severe cervical swelling as well as oral bleeding an emergency tracheotomy was performed on scene. He was hemodynamically unstable despite fluid resuscitation and intravenous therapy with vasopressors and was transported by a helicopter to our trauma center. He had a stable fracture of the arch of the seventh cervical vertebra and fractures of the transverse processes of C5-C7 with involvement of the lateral wall of the transverse foramen. An abort of the left vertebral artery signal at the first thoracic vertebrae with massive hemorrhage as well as a laryngeal fracture was also detected. Further imaging showed retrograde filling of the left vertebral artery at C5 distal of the described abort. After stabilization and reconfirmation of intracranial perfusion during the clinical course weaning was started. At the time of discharge, he was aware and was able to move all extremities.
We report a rare case of a patient with vertebral artery dissection in combination with a laryngeal fracture after blunt trauma. Thorough diagnostic and frequent reassessments are recommended. Most patients can be managed with conservative treatment.
PMCID: PMC3184109  PMID: 21843321

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