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1.  Biographical Sketch: Harald Tscherne, MD (1933–Present) 
This biographical sketch on Prof. Harald Tscherne corresponds to the historic text, The Classic: Der Straßenunfall [Traffic Accidents]. Wien Med Wochenschr. 1966;116:105–108 (Translated by Dr. Roman Pfeifer), available at DOI 10.1007/s11999-013-3012-9.
doi:10.1007/s11999-013-3011-x
PMCID: PMC3734397  PMID: 23625576
3.  The ‘Aachen Falls Prevention Scale’ - development of a tool for self-assessment of elderly patients at risk for ground level falls 
Background
The incidence of falls in the elderly population is difficult to determine and therefore potentially underestimated. Screening algorithms usually have in common that the evaluation is undertaken by trained individuals in a hospital setting. This leads to the inclusion of a high proportion of low-risk people and a waste of resources. It would be advantageous to pretest the individuals at risk in their own environment using a simple self-assessment approach.
Methods
The consensus process of our group of clinicians and physical therapists included: 1. a preparative literature review about risk profiles and assessment tools for ground level falls; 2. a selection of appropriate questions that cover all health aspects involved in an increased risk for falling; and 3. a selection of a simple physical test that can be used at home without the need of a health care professional. We thus searched to develop a scale that can be used by older citizen at higher risk of falling. The current manuscript summarizes the results of this review, consensus and selection process.
Results
The literature search was undertaken between March and August 1, 2013. The selection process for the questions used (Part I) lasted between March 2013 and January 2014. Among all tests evaluated the 20 second standing test (Part II) was deemed to be safe to be performed even by an individual at risk for a fall, as it closely resembles activities of daily living. The `Aachen Falls Prevention Scale` finally uses a self-assessment tool grading falls risk on a scale of 1 to 10 by the individual itself after completion of Part I and Part II. In summary, we present a scale that might offer a self-assessment option to improve the measures of falls prevention pass for elderly citizens.
Conclusions
The introduction of the `Aachen Falls Prevention Scale` which combines a simple questionnaire with a safe and quick balance tool, meets the criteria to identify whether or not a balance problem exists – the first step in evaluation of falls risk. Further studies will have to assess the ability of an individual to estimate his or her individual falls risk on a longitudinal basis and possibly trigger the necessity for the assessment by a physician.
doi:10.1186/s13037-014-0055-0
PMCID: PMC4328308
Orthogeriatrics; Co-managed care; Fractures in the elderly; Geriatric trauma center; Fall prevention; Balance assessment
4.  Compartment elasticity measured by pressure-related ultrasound to determine patients “at risk” for compartment syndrome: an experimental in vitro study 
Background
Decision-making in treatment of an acute compartment syndrome is based on clinical assessment, supported by invasive monitoring. Thus, evolving compartment syndrome may require repeated pressure measurements. In suspected cases of potential compartment syndromes clinical assessment alone seems to be unreliable. The objective of this study was to investigate the feasibility of a non-invasive application estimating whole compartmental elasticity by ultrasound, which may improve accuracy of diagnostics.
Methods
In an in vitro model, using an artificial container simulating dimensions of the human anterior tibial compartment, intra-compartmental pressures (p) were raised subsequently up to 80 mmHg by infusion of saline solution. The compartmental depth (mm) in the cross-section view was measured before and after manual probe compression (100 mmHg) upon the surface resulting in a linear compartmental displacement (∆d). This was repeated at rising compartmental pressures. The resulting displacements were related to the corresponding intra-compartmental pressures simulated in our model. A hypothesized relationship between pressures related compartmental displacement and the elasticity at elevated compartment pressures was investigated.
Results
With rising compartmental pressures, a non-linear, reciprocal proportional relation between the displacement (mm) and the intra-compartmental pressure (mmHg) occurred. The Pearson coefficient showed a high correlation (r2 = −0.960). The intra-observer reliability value kappa resulted in a statistically high reliability (κ = 0.840). The inter-observer value indicated a fair reliability (κ = 0.640).
Conclusions
Our model reveals that a strong correlation between compartmental strain displacements assessed by ultrasound and the intra-compartmental pressure changes occurs. Further studies are required to prove whether this assessment is transferable to human muscle tissue. Determining the complete compartmental elasticity by ultrasound enhancement, this application may improve detection of early signs of potential compartment syndrome.
Electronic supplementary material
The online version of this article (doi:10.1186/s13037-014-0051-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s13037-014-0051-4
PMCID: PMC4305259  PMID: 25621009
Compartment syndrome; Intra-compartmental pressure; Non-invasive diagnostic; Elasticity measurement; Elastography
5.  Plate osteosynthesis versus hemiarthroplasty in proximal humerus fractures – Does routine screening of systemic inflammatory biomarkers makes sense? 
Background
Increases in C-reactive protein (CRP) and white blood cell (WBC) counts after orthopedic surgical procedures can give evidence of postoperative infection. However, there is a lack of knowledge about the kinetics of these biomarkers in cases with an uneventful clinical course after osteosynthesis of upper limb fractures. This study investigated CRP and WBC serum levels after osteosynthesis or hemiarthroplasty of humeral head fractures.
Methods
A retrospective study on patients with humeral head fractures who had open reduction and internal fixation via plate osteosynthesis (PO) (n = 64) or hemiarthroplasty (HA) (n = 28) without any complications in the postoperative clinical course. C-reactive protein serum levels (mg/l) and leukocyte counts (g/l) were assayed at several time points. Multiple regression analysis was performed to evaluate the influence of several confounding variables (the surgical procedure, duration of surgery, patient’s health status, and comorbidities) on the kinetics of CRP and WBC.
Results
Our data showed that CRP levels were statistically significantly higher in the HA cohort when compared to the PO cohort (p = 0.003). Moreover, daily measurement of CRP levels during the postoperative course showed that CRP peaked on the 2nd and 3rd days postoperatively in both cohorts and started to decrease afterward, reaching normal values on day 8 to 10. However, WBCs did not show any significant differences between the HA and PO cohorts. Finally, the choice of surgical procedure and the patient’s health status were associated with higher peak levels of CRP.
Conclusions
After osteosynthesis or hemiarthroplasty of humeral head fractures, CRP is a responsive serum parameter in the postoperative course of an uneventful inflammatory response. Abnormalities from these values should be interpreted carefully as they may give a hint as to postoperative complications such as infection.
doi:10.1186/s40001-014-0079-z
PMCID: PMC4307175  PMID: 25585544
CRP; Infection; Perioperative monitoring; Plate fixation; Proximal humerus fracture; Shoulder arthroplasty; WBC
6.  Association of clinical parameters of operatively treated thoracolumbar fractures with quality of life parameters 
European Spine Journal  2013;22(10):2202-2210.
Purpose
The intention of the current work was to assess the association between clinical parameters and seven different quality of life (QoL) instruments after surgical treatment of thoracolumbar spinal fractures after an average follow-up of 4.2 years.
Methods
The following human-related quality of life and PRO measures of 66 patients were correlated to clinical parameters such as fingertip-to-floor distance (FFD), Schober measurement, pressure and percussion pain in the lumbopelvine area (PPP), and paravertebral muscle tension: reALOS, SF-36, VAS, VAS spine score, BDI, the GBB-24, and the IES-R.
Results
Overall, there was a significant association between the clinical parameters of the thoracolumbar spine such as PPP, paravertebral muscle tension, FFD and Schober’s sign on one side, and the seven tested instruments on the other side.
Conclusions
PPP and FFD as well as a small Schober measurement are clinical parameters which significantly influence QoL after surgical treatment of thoracolumbar fractures.
doi:10.1007/s00586-013-2799-0
PMCID: PMC3804682  PMID: 23649956
Trauma; Spine; Quality of life; Outcome measures; Lumbar region
7.  Cumulative Effects of Bone and Soft Tissue Injury on Systemic Inflammation: A Pilot Study 
Background
In multiply injured patients, bilateral femur fractures invoke a substantial systemic inflammatory impact and remote organ dysfunction. However, it is unclear whether isolated bone or soft tissue injury contributes to the systemic inflammatory response and organ injury after fracture.
Questions/purposes
We therefore asked whether the systemic inflammatory response and remote organ dysfunction are attributable to the bone fragment injection, adjacent soft tissue injury, or both.
Methods
Male C57/BL6 mice (8–10 weeks old, 20–30 g) were assigned to four groups: bone fragment injection (BF, n = 9) group; soft tissue injury (STI, n = 9) group; BF + STI (n = 9) group, in which both insults were applied; and control group, in which neither insult was applied. Animals were sacrificed at 6 hours. As surrogates for systemic inflammation, we measured serum IL-6, IL-10, osteopontin, and alanine aminotransferase (ALT) and nuclear factor (NF)-κB and myeloperoxidase (MPO) in the lung.
Results
The systemic inflammatory response (mean IL-6 level) was similar in the BF (61.8 pg/mL) and STI (67.9 pg/mL) groups. The combination (BF + STI) of both traumatic insults induced an increase in mean levels of inflammatory parameters (IL-6: 189.1 pg/mL) but not in MPO levels (1.21 ng/mL) as compared with the BF (0.82 ng/mL) and STI (1.26 ng/mL) groups. The model produced little evidence of remote organ inflammation.
Conclusions
Our findings suggest both bone and soft tissue injury are required to induce systemic changes. The absence of remote organ inflammation suggests further fracture-associated factors, such as hemorrhage and fat liberation, may be more critical for induction of remote organ damage.
Clinical Relevance
Both bone and soft tissue injuries contribute to the systemic inflammatory response.
doi:10.1007/s11999-013-2908-8
PMCID: PMC3734413  PMID: 23479238
8.  Do Parameters Used to Clear Noncritically Injured Polytrauma Patients for Extremity Surgery Predict Complications? 
Background
In multiply injured patients, definitive stabilization of major fractures is performed whenever feasible, depending on the clinical condition.
Questions/purposes
We therefore asked whether (1) any preoperative indicators predict major complications after major extremity surgery; (2) perioperative routine parameters other than those indicative of hemorrhagic shock predict postoperative complications; and (3) any postoperative clinical findings can predict major complications in the further course of the patient.
Methods
We prospectively followed patients with femoral midshaft fracture, Injury Severity Score (ISS) > 16 points, or three fractures and Abbreviated Injury Scale (AIS) ≥ 2 points and another injury (AIS ≥ 2 points), and age 18 to 65 years. We recorded multiple clinical parameters. End points were pneumonia, sepsis, acute respiratory distress syndrome, acute lung injury, and multiple organ failure.
Results
Forty-three of 165 patients developed complications. (1) Patients with complications had a decreased initial Glasgow Coma Scale and tended to have a lower ISS. (2) None of the assessed perioperative parameters was able to sufficiently predict postoperative complications. (3) The presence of a lung contusion and ventilation > 48 hours were associated with complications in the further course.
Conclusions
In stable multiply injured patients, none of the individual routine clinical parameters was able to predict complications. Severe head and thoracic injuries seem to be important drivers for the development postoperative complications.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-2924-8
PMCID: PMC3734416  PMID: 23512748
9.  Trauma Care in Germany: An Inclusive System 
Background
Development of trauma systems is a demanding process. The United States and Germany both have sophisticated trauma systems. This manuscript is a summary of political, economic, and medical changes that have led to the development of both trauma systems and the current high-quality standards.
Questions/purposes
We specifically asked three questions: (1) What tasks are involved in developing a modern trauma system? (2) What is the approach to achieve this task? (3) Do these systems work?
Methods
We conducted a systematic review of relevant articles by searching electronic databases (PubMed, Embase, Cochrane library) using the following search terms: “trauma system”, “polytrauma”, “trauma networks”, and “trauma registry”. Of 2573 retrieved manuscripts, the authors made a personal selection of studies. A personal study selection from our experiences was added when their contribution to the topic was judged important.
Results
Worldwide, similar tasks concerning trauma care have to be addressed. In most societies, traffic accidents and firearm-related injuries contribute to a high number of trauma victims. The German approach has been to decrease the number of accidents through injury prevention and to provide better care by establishing an emergency medical system. For in-hospital treatment, clinical care has constantly improved and a close interaction with members from the American Association for the Surgery of Trauma and the Orthopaedic Trauma Association has helped a great deal to achieve these improvements. The German healthcare system was developed as a powerful healthcare tool covering patients from injury to rehabilitation. In addition, trauma and injury research has been strengthened to deal with various questions of trauma care.
Conclusions
Organized injury prevention programs and systematized professional patient care can address the issues associated with the global burden of trauma. These trauma systems require constant monitoring and improvement.
doi:10.1007/s11999-013-2967-x
PMCID: PMC3734420  PMID: 23633181
10.  Unstable Intertrochanteric Femur Fractures: Is There a Consensus on Definition and Treatment in Germany? 
Background
Extramedullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment.
Questions/purposes
We conducted a national survey of practicing chairpersons of German institutions to determine current perspectives and perceptions of practice in the diagnosis, management, and surgical treatment of unstable intertrochanteric fractures.
Methods
Between January and February 2010, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 26-question web-based survey regarding three broad domains: fracture classification and instability criteria, implants and surgical treatment algorithms, and timing of operations. Response rate was 42%.
Results
There was a clear preference for use of the AO/OTA fracture classification with geographic variations. Absence of medial support was considered the main criterion for fracture instability (84%), whereas a broken lateral wall and detached greater trochanter were considered by 4% and 5% of the respondents, respectively, to determine instability. Two percent routinely fixed unstable intertrochanteric fractures with extramedullary devices. Ninety-eight percent of German hospitals reportedly perform surgery within 24 hours after admission. Time to surgery was dependent on hospital level, with more direct surgeries in Level I hospitals.
Conclusions
Despite varying opinions in the literature in recent years, we found some instability criteria (lateral wall breach, a detached greater trochanter) played a minor role in defining an unstable intertrochanteric fracture pattern. Despite recent meta-analyses suggesting clinical equivalence of intra- and extramedullary implants, few respondents routinely treat unstable intertrochanteric fractures with extramedullary plates. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures.
Level of Evidence
Level V, expert opinion. See the Instructions for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-013-2834-9) contains supplementary material, which is available to authorized users.
doi:10.1007/s11999-013-2834-9
PMCID: PMC3734428  PMID: 23389806
11.  Can a Modified Anterior External Fixator Provide Posterior Compression of AP Compression Type III Pelvic Injuries? 
Background
Current anterior fixators can close a disrupted anterior pelvic ring. However, these anterior constructs cannot create posterior compressive forces across the sacroiliac joint. We explored whether a modified fixator could create such forces.
Questions/purposes
We determined whether (1) an anterior external fixator with a second anterior articulation (X-frame) would provide posterior pelvic compression and (2) full pin insertion would deliver higher posterior compressive forces than half pin insertion.
Methods
We simulated AP compression Type III instability with plastic pelvis models and tested the following conditions: (1) single-pin supraacetabular external fixator (SAEF) using half pin insertion (60 mm); (2) SAEF using full pin insertion (120 mm); (3) modified fixator with X-frame using half pin insertion; (4) modified fixator using full pin insertion; and (5) C-clamp. Standardized fracture compression in the anterior and posterior compartment was performed as in previous studies by Gardner. A force-sensitive sensor was placed in the symphysis and posterior pelvic ring before fracture reduction and the fractures were reduced. The symphyseal and sacroiliac compression loads of each application were measured.
Results
The SAEF exerted mean compressions of 13 N and 14 N to the posterior pelvic ring using half and full pin insertions, respectively. The modified fixator had mean posterior compressions of 174 N and 222 N with half and full pin insertions, respectively. C-clamp application exerted a mean posterior load of 407 N.
Conclusions
Posterior compression on the pelvis was improved using an X-frame as an anterior fixation device in a synthetic pelvic fracture model.
Clinical Relevance
This additive device may improve the initial anterior and posterior stability in the acute management of unstable and life-threatening pelvic ring injuries.
doi:10.1007/s11999-013-2993-8
PMCID: PMC3734429  PMID: 23604604
12.  Improvement of research quality in the fields of orthopaedics and trauma—a global perspective 
International Orthopaedics  2013;37(7):1205-1212.
The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon’s knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today’s “Cross Check Era”, too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.
doi:10.1007/s00264-013-1897-2
PMCID: PMC3685675  PMID: 23689761
13.  Selective Roles for Toll-Like Receptors 2, 4 and 9 in the Systemic Inflammation and Immune Dysfunction Following Peripheral Tissue Injury 
Background
Toll-like receptors (TLRs) detect endogenous ligands released after trauma and contribute to the proinflammatory response to injury. Post-traumatic mortality correlates with the extent of the immuno-inflammatory response to injury which is comprised of a complex regulation of innate and adaptive immune responses. Although TLRs are known to modulate innate immune responses, their role in the suppression of lymphocyte responses following traumatic tissue injury is unclear.
Methods
This study used a murine model of severe peripheral tissue injury, involving muscle crush injury and injection of fracture components, to evaluate the roles of TLR2, 4 and 9 in the early and delayed immuno-inflammatory phenotype. Post-traumatic immune dysfunction was measured in our trauma model using the following parameters: ex-vivo splenocyte proliferation, Th1 cytokine release and iNOS induction within splenic myeloid-derived suppressor cells (MDSC). Systemic inflammation and liver damage were determined by circulating interleukin-6 levels and hepatocellular injury.
Results
Suppression of splenocyte responses after injury was dependent on TLR4 and 9 signaling as was post-traumatic iNOS upregulation in splenic MDSC. TLR2 was found to have only a partial role through contribution to inhibition of splenocyte proliferation. This study also reveals the involvement of TLR2 and 4 in the initial systemic inflammatory response to traumatic tissue injury, however, this response was found to be TLR9-independent.
Conclusions
These findings demonstrate the previously unidentified role of TLR2, 4 and 9 in the T-cell associated immune dysfunction following traumatic tissue injury. Importantly, this study also illustrates that TLRs play differing and selective roles in both the initial proinflammatory response and adaptive immune response after trauma. Furthermore, the results in the TLR9-deficient mice establishes that the upregulation of early pro-inflammatory markers do not always correlate with the extent of sustained immune dysfunction. This suggests potential for targeted therapies that could limit the immune dysfunction through selective inhibition of receptor function following injury.
doi:10.1097/TA.0b013e3182905ed2
PMCID: PMC3670589  PMID: 23694872
Injury; Toll-like receptor; lymphocyte; MDSC; immune dysfunction
14.  Prolonged operative time increases infection rate in tibial plateau fractures 
Injury  2012;44(2):249-252.
Background
Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as identify other surgical risk factors.
Methods
We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution’s level I trauma center during a recent five year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection.
Results
Mean operative time in the infection group was 2.8 hours vs. 2.2 hours in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p<0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p<0.001) as independent predictors of surgical site infection.
Conclusions
Operative times approaching three hours and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.
doi:10.1016/j.injury.2012.10.032
PMCID: PMC4034524  PMID: 23200030
Tibia; plateau; infection; operative time; fasciotomy
15.  Dehydroepiandrosterone modulates the inflammatory response in a bilateral femoral shaft fracture model 
Background
Dehydroepiandrosterone (DHEA) has been shown to have immunomodulatory effects after hemorrhage and sepsis. The present study analyzes whether DHEA is also involved in the mediation of inflammatory stimuli induced by bilateral femoral shaft fracture.
Methods
Male C57/BL6 mice (6 per group) were subjected to closed bilateral femoral shaft fracture with intramedullary nailing followed by administration of either 25 mg/kg/24 h DHEA diluted in saline with 0.1% ethanol or saline with 0.1% ethanol. The sham group was treated by isolated intramedullary nailing without fracture. Animals were sacrificed after 6, 24, or 72 h. Serum TNFα, IL-1β, IL-6, IL-10, MCP-1, and KC concentrations were measured by Bio-Plex ProTm analysis. Acute pulmonary inflammation was assessed by histology, pulmonary myeloperoxidase (MPO) activity, and pulmonary IL-6 concentration.
Results
DHEA was associated with a decrease in the systemic inflammatory response induced by bilateral femoral fracture, especially systemic IL-6 (322.2 vs. 62.5 pg/mL; P = 0.01), IL-1β (1,422.6 vs. 754.1 pg/mL; P = 0.05), and MCP-1 (219.4 vs. 44.1 pg/mL; P >0.01) levels. No changes in pulmonary inflammation were measured.
Conclusion
We conclude that DHEA may be a treatment option to reduce systemic inflammation following musculoskeletal injuries although the pulmonary inflammatory reaction was not affected.
doi:10.1186/2047-783X-19-27
PMCID: PMC4040478  PMID: 24886543
Bilateral femur fracture; DHEA; Inflammation
16.  Inducible Nitric Oxide Synthase Contributes to Immune Dysfunction following Trauma 
Shock (Augusta, Ga.)  2012;38(5):499-507.
Trauma results in a persistent depression in adaptive immunity which contributes to patient morbidity and mortality. This state of immune paralysis following trauma is characterized by a change in cell-mediated immunity, specifically a depression in T-cell function and a shift towards Th2 T-cell phenotype. Upregulation of iNOS is well-recognized after injury and contributes to the inflammatory response and organ damage early after trauma. However, it is unknown whether iNOS plays a role in adaptive immune dysfunction after trauma. This study utilized a murine model of severe peripheral tissue injury to show that iNOS is rapidly upregulated in macrophages and a (Gr-1hi-CD11bhi) MDSC subpopulation in the spleen. Through the use of iNOS knockout mice, a specific iNOS inhibitor and an NO scavenger this study demostrates that iNOS-derived NO is required for the depression in T lymphocyte proliferation, interferon-gamma and interleukin-2 production within the spleen at 48hr after trauma. These findings support the hypothesis that iNOS regulates immune suppression following trauma, and suggest that targeting the sustained production of NO by iNOS may attenuate post-traumatic immune depression.
doi:10.1097/SHK.0b013e31826c5afe
PMCID: PMC3475737  PMID: 23042189
Injury; T lymphocyte; Immunosuppression; MDSC; iNOS
17.  Radiographic changes in the operative treatment of acute acromioclavicular joint dislocation – tight rope technique vs. K-wire fixation 
Polish Journal of Radiology  2013;78(4):15-20.
Summary
Background
Operative treatment of higher degree acromioclavicular joint luxation is common. A new option is made available by the tight rope technique. It claims to provide adequate outcome with the use of a minimally invasive technique. First clinical studies justified its medical use, but the equivalence to established surgical methods remains unclear. We therefore analyzed radiographic data from patients that were treated with the tight rope system (TR) and compared them to those treated with K-wires (KW) fixation.
Material/Methods
Retrospective study with inclusion criteria: surgery for acromioclavicular joint luxation between 2004 and 2011, classified as Rockwood type III, no concomitant injury, first event injury. We compared pre- and post-operative X-rays with those taken at the end of treatment. Clinical data from follow-ups and radiographic data were evaluated. The main outcome variable was the remaining distance between the acromion and clavicle (ACD), as well as the coracoid process and clavicle (CCD).
Results
27 patients (TR: n=16; KW: n=11) with comparable demographics and injury severity were included. Surgery reduced ACD (TR: p=0.002; KW: p<0.001) and CCD (TR: p=0.001; KW: p=0.003). Heterotopic ossification or postoperative osteolysis was not significantly associated with either one of the procedures. Three patients (18.75%) in the TR group showed impaired wound healing, migrating K-wires were recorded in 2 patients (18.2%) and impingement syndrome occurred in 1 patient (9.1%) with K-wires. Posttraumatic arthritis was not seen. There was a loss of reduction in 2 cases within the TR-group (12.51%) and 1 in the KW-group (9.1%). At last follow up, ACD and CCD were wider in both groups compared to the healthy side.
Conclusions
This study shows that the Tight rope system is an effective alternative in the treatment of higher degree acromioclavicular luxation and comparable to the established methods.
doi:10.12659/PJR.889615
PMCID: PMC3908503  PMID: 24505220
radiographic changes; K-wire; tight rope
18.  Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures? 
Background
Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.
Questions/purposes
We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.
Methods
We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24–30 months).
Results
We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.
Conclusions
Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2268-9
PMCID: PMC3392400  PMID: 22311725
19.  Risk stratification by injury distribution in polytrauma patients – does the clavicular fracture play a role? 
Background
Thoracic and extremity injuries are common in polytraumatized patients. The clavicle limits the upper thoracic cage and connects the body and upper extremities. It is easy to examine and is visible on standard emergency room radiographs. We hypothesize that clavicular fracture in polytrauma patients indicates the presence of further injuries of the upper extremities, head, neck and thorax.
Material and methods
Retrospective study including patients admitted between 2008 and 2012 to a level-I trauma center. Inclusion criteria: ISS > 16, two or more injured body regions, clavicular fracture. Control group: patients admitted in 2011, ISS > 16, two or more injured body regions, no clavicular fracture. Patient information was obtained from the patients’ charts; evaluation of radiographic findings was performed; scoring was based on the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) AIS/ISS; data were analyzed using Pearson’s correlation and the Mann–Whitney U-test in SPSS (version 11.5.1); graphs were drawn using EXCEL®.
Results
Thirty-four patients with clavicular fracture (C+) and 40 without (C-) were included; the mean ISS was 25 (range 16–57), m = 70%, f = 30%; age 43.3 years (range 9–88); clavicular fractures were positively correlated with severe thoracic (p = 0.011, OR 4.5: KI 1.3–15.3), external (p < 0.001, OR 9.2: KI 2.7–30.9) and upper extremity injuries (p < 0.001, OR 33.2: KI 6.9–16.04 resp. p = 0.004, OR 12.5: KI 1.5–102.9). C + showed a lower head/neck AIS (p = 0.033), higher thorax AIS (p = 0.04), arm/shoulder AIS (p = 0.001) and external AIS (0.003) than C-. Mean hospital stay and ICU treatment time were longer in the C + group (p = 0.001 and p = 0.025 respectively).
Conclusion
A clavicular fracture can be diagnosed easily and may be used as a pointer for further thoracic and upper extremity injuries in polytrauma patients that might have been otherwise missed. Special attention should be paid on second and tertiary survey.
doi:10.1186/1754-9493-7-23
PMCID: PMC3704959  PMID: 23822875
20.  Operative treatment of acute acromioclavicular joint injuries graded Rockwood III and IV: risks and benefits in tight rope technique vs. k-wire fixation 
Background
Operative treatment of acromioclavicular joint injuries is recommended for higher degree dislocations. Recently a new option has become available with the minimally-invasive tight rope technique. Whereas clinical studies justify the medical use, risks and benefits remain unclear. Therefore, this study analyzed these facts associated with this procedure and compared them to K-wire fixation.
Material and Methods
A retrospective analysis was performed of patients surgically treated either with the TightRope™-technique (TR) or K-wires (KW) for a first event isolated Rockwood type III or higher acromioclavicular joint dislocation between 2004 and 2011. Timing for surgery, surgical duration, length of hospital stay, costs, complications and outpatient visits were recorded.
Results
41 patients were included (TR: n = 18; KW: n = 23) with comparable demographics and injury severity. A trend towards shorter operation time was seen in the TR group (TR: 64.3 ±19.8 min. vs. KW: 80.9 ±33.7 min., n.s.) A tendency for lower total operation theater costs was seen in the TR group (TR: 474 ±436.5€ vs. KW: 749.1 ±31.2€, n.s.). Patients from the TR group left hospital earlier (TR: 2 ±1d vs. KW: 3.6 ±1.8d, p = 0.002). Severe complications (i.e. a fracture of the clavicle or nerve damage) occurred in neither of the groups. Early loss of reduction (n = 1) and impaired wound healing (n = 2) was seen in the TR group. Migrating K-wires (n = 4), loss of reduction (n = 1) and impingement syndrome (n = 1) were recorded in the KW group.
Conclusion
Usage of the tight rope technique offered advantages, such as being a safe minimally-invasive technique and showed a tendency towards shorter operation time, and lower physician- and total operation and theater costs. Material costs were significantly higher for this device but patients were discharged earlier. The influence of different clinical long-term results on the financial outcome needs to be evaluated in further studies.
doi:10.1186/1754-9493-7-18
PMCID: PMC3681720  PMID: 23721404
Tight rope technique; K-wires; Costs; Acromioclavicular joint dislocation; Reconstruction; Surgery; Comparison; Analysis
21.  Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial 
European Spine Journal  2012;21(5):992-998.
Purpose
To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students.
Methods
In 2007–2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE).
Results
Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts.
Conclusions
The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.
doi:10.1007/s00586-011-2140-8
PMCID: PMC3337919  PMID: 22223196
Peer teaching; Gender differences; Randomised controlled trial; Complex motor skills; Spinal manipulative therapy
22.  Predictors of poor outcome after both column acetabular fractures: a 30-year retrospective cohort study 
Background and Purpose
Acetabular fractures are often combined with associated injuries to the hip joint. Some of these associated injuries seem to be responsible for poor long-term results and these injuries seem to affect the outcome independent of the quality of the acetabular reduction. The aim of our study was to analyze the outcome of both column acetabular fractures and the influence of osseous cofactors such as initial fracture displacement, hip dislocation, femoral head lesions and injuries of the acetabular joint surface.
Methods
A retrospective cohort study in patients with both column acetabular fractures treated over a 30 year period was performed. Patients with a follow-up of more than two years were invited for a clinical and radiological examination. Displacement was analyzed on initial and postoperative radiographs. Contusion and impaction of the femoral head was grouped. Injuries of the acetabular joint surface consisting of impaction, contusion and comminution were recorded. The Merle d’Aubigné Score was documented and radiographs were analysed for arthritis (Helfet classification), femoral head avascular necrosis (Ficat/Arlet classification) and heterotopic ossifications (Brooker classification).
Results
115 patients were included in the follow up examination. Anatomic reduction (malreduction ≤ 1mm) was associated with a significantly better clinical outcome than nonanatomical reduction (p = 0.001). Initial displacement of more than 10mm (p = 0.031) and initial intraarticular fragments (p = 0.041) were associated with worse outcome. Other associated injuries, such as the presence of a femoral head dislocation, femoral head injuries and injuries to the acetabular joint surface showed no significant difference in outcome individually, but in fractures with more than two associated local injuries the risk for joint degeneration was significant higher (p < 0.001) than in cases with less than two of them.
In the subgroup of anatomically reconstructed fractures no significant influence of the analyzed cofactors could be observed.
Conclusion
Anatomical reduction appears to be an important parameter for a good clinical outcome in patients with both column acetabular fractures. Additional fracture characteristics such as the initial displacement and intraarticular fragments seem to influence the results. Patients should also be advised that both column acetabular fractures with more than two additional associated factors have a significantly higher risk of joint degeneration.
doi:10.1186/1754-9493-7-9
PMCID: PMC3606597  PMID: 23510122
Both column acetabular fractures; Outcome prediction; Long term results
23.  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.
doi:10.1007/s00264-011-1338-z
PMCID: PMC3193959  PMID: 21863226
24.  Outcome after thoracoscopic ventral stabilisation of thoracic and lumbar spine fractures 
Background and Purpose
Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery.
Methods
We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI).
Results
Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups.
Interpretation
The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.
doi:10.1186/1752-2897-6-10
PMCID: PMC3489793  PMID: 23072274
Spine; Thoracoscopic surgery; Thoracolumbar fractures; Outcome
25.  Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial 
BMC Medical Education  2012;12:85.
Background
The exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake.
Methods
Second-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student’s perceptions were evaluated using Likert scale-based items.
Results
The ASK-group (n = 70, age 23.4 (20–36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20–53) yrs.) and the CON-group (n = 88, 22.8 (20–33) yrs.; p = 0.019). After an additional arthroscopy teaching 1% of students failed the MC exam, in contrast to 10% in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001).
Conclusions
The additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery.
doi:10.1186/1472-6920-12-85
PMCID: PMC3473305  PMID: 22958784
Arthroscopy; Education, Anatomic competence, Randomized controlled trial, Knee joint, Shoulder joint, Students; Medical, Musculoskeletal ultrasound

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