Due to their immunomodulatory and regenerative capacity, human bone marrow-derived mesenchymal stromal cells (hBMSCs) are promising in the treatment of polytrauma patients. However, few studies evaluated the effects of sera from polytraumatized patients on hBMSCs. The aim of this study was to explore changes in hBMSCs exposed to serum from polytrauma patients from different time points after trauma. Sera from 84 patients on day 1 (D1), 5 (D5) and 10 (D10) after polytrauma (ISS ≥ 16) were pooled respectively to test the differential influence on hBMSC. As a control, sera from three healthy age- and gender-matched donors (HS) were collected. The pooled sera were analyzed by Multicytokine Array for pro-/anti-inflammatory cytokines. For the cell culture experiments, hBMSCs from four healthy donors were used. The influence of the different sera on hBMSC regarding cell proliferation, colony forming unit-fibroblast (CFU-F) assay, cell viability and toxicity, cell migration, as well as osteogenic and chondrogenic differentiation was analyzed. One-Way-ANOVA and LSD-test were used for the parametric, Kruskal-Wallis-test for non-parametric data. p≤0.05 was considered as statistically significant. The results showed that D5 serum reduced hBMSCs cell proliferation capacity by 41.26% (p=0.000) compared with HS and increased the proportion of dead cells by 3.19% (p=0.008) and 2.25% (p=0.020) compared with D1 and D10. The frequency of CFU-F was reduced by 49.08% (p=0.041) in D5 and 53.99% (p=0.027) in D10 compared with HS, whereas the other parameters were not influenced. The serological effect of polytrauma on hBMSCs was related to the time after trauma. It is disadvantageous to use BMSCs in polytraumatized patients five days after the incidence as obvious cytological changes could be found at that time point. However, it is promising to use hBMSCs to treat polytrauma after 10 days, combined with the concept of “Damage Control Orthopaedics” (DCO)

Determine the prevalence, etiologies, and risk factors of unplanned return to the OR (UROR) in adult orthopaedic trauma patients. Retrospective review of a trauma prospective registry from 2014 – 2019 at a Level 1 academic hospital. An UROR was defined as a patient returning to OR unexpectedly following a planned definitive surgery to either readdress the presenting diagnosis or address a complication arising from the index procedure. Univariate and multivariate logistic regression was performed comparing those patients with an UROR versus those without. A total of 1568 patients were reviewed. The rate of UROR was 9.8% (153 patients). Symptomatic implant was the leading cause of UROR (60%). Other significant UROR causes were infection (15%) and implant failure (9%). The median time between index procedure and UROR was 301 days. For the univariate and multivariate analysis, open fracture (p< 0.05), fracture complexity (p<0.01), and weekend procedure (p< 0.01) were all associated with increased risk of UROR. All other variables were not statistically significant for any associations. Those patients with an UROR for reasons other than symptomatic implants were more likely to have polyorthopaedic injuries (p < 0.05), ISS > 15 (p < 0.05), osteoporosis (p < 0.01), ICU status (p < 0.05), psychiatric history (p < 0.05), compartment syndrome (p < 0.05), neurovascular injury (p < 0.01), open fracture (p < 0.05), and fracture complexity (p < 0.05). The rate of UROR in the orthopaedic trauma patient population is 10%. Most of these cases are due to implant-related issues. UROR for reasons other than symptomatic implants tend to be polytraumatized patients with higher-energy injuries, multiple complex fractures, and associated soft tissue injuries. Future focus on improved implant development and treatments for polytraumatized patients with complex fractures is warranted to decrease a relatively high UROR rate in orthopaedic trauma

Pelvicring disruption (PRD) requires considerable forces and usually occurs in polytraumatized patients(pt). The purpose of this study is to analyze radiologic results and functional outcome of PRD in polytraumatized pt. Material and Methods: Of 226 pt with PRD, 78% (176) were polytraumatized, and they are the subject of this study. Mean age was 38.8 years (11.4–85.8). There were 102 men and 74 women. The cause of injury in 69% was traffic accident; fall from a great height in 16.4%; accident at work in 8.6% and miscellaneous in 6%. The incidence of involvement of other systems was: musculosceletal-78%; respiratory-58%; CNS-51%, intestinal-32%, urinary-14%; cardiovascular-8%. The average ISS was 34; 56 pt (32%) were haemodynamically unstable. According to M. Tile’s classification, 101 were found type B (B1-48; B2-30; B3-23) and 75 type C (C1-49; C2-18; C3-8). Perioperative mortality was 6% in B-type and 15% in C-type fractures. Immediate resuscitation started at admission and was followed by staged treatment. Life-saving surgery and provisional stabilization of pelvis were performed as a top priority (first stage). Management of associated lesions (second priority) was the next stage. The last stage was open reduction and internal fixation of PRD in 102 pt, external fixation in 46 pt and combined fixation in 28 pt. Results: X-ray follow-up results were excellent in 66%, good in 16%, fair in 10% and poor in 8%. The best X-rays results were in type B1-94%; B2/B3-76% and C-63%. Functional results were excellent in 48%, good in 32%, fair in 12% and poor in 8%. The best functional results were in type B2/B3 -90%; B1-73% and C-70%. Conclusion:. Determination of priorities of surgery is essential in the management in polytraumatized patients with PRD especially in the early period. Reconstruction of PRD requires a staged approach. These findings are not only related to the stability and symmetry of pelvic ring, but also depend on the severity of soft tissue injury around the pelvis

Introduction: The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable patients with head, chest, abdomen or pelvic injuries with blood loss) followed by an immediate fracture fixation (“Early Total Care”) may be associated with a secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). We present our experience experience in the treatment strategy of polytraumatized patients with femoral shaft fracture. Patients and Methods: From 1995 to 2008 there were 137 polytraumatized patients with femoral shaft fracture treated in our hospital. The outcomes of their treatment were retrospectively analyzed in this study. Patients were grouped according the treatment strategies for stabilization of the femoral shaft fracture: Group A – 99 patients treated with early total care (ETC) - intramedullary nailing (IMN) within 24 h of injury Group B- 38 patients treated with temporary external fixation as a bridge to IMN (DCO surgery starting at 2005). Results: The groups were comparable regarding age, gender distribution and mechanism of injury. ISS was higher in group B (DCO) – 32,2 compared to group A (ETC) – 22,6. The patients in DCO group required significantly more fluids (14,2 L) then those in ETC (8,2 L) and blood (2,2 vs 1,3 L) in the initial 24 hours. Thoracic, abdominal or head injuries were accounted significantly higher number of patients submitted to DCO group from 2005 (24,2%) compared to ETC group (12,4%). Mean operative time for External Fixators was 40 minutes, 110 minutes for IMN. There was a significantly higher incidence of ARDS in ETC group −18,2% compared to DCO group – 8,6%. The incidence of multiple organ failure (MOF) was significantly lower in DCO group – 7,4% than in ETC group – 12,1 %. There were 3 unexpected deaths and 2 cases with conscious worsening in patients with head injury in ETC group. No significant differences in the incidence of local complications were found. Conclusions: Based on this study it seems that a significant reduction in incidence of general systemic complications (ARDS, MOF) was found in DCO group in comparison with ETC group, Changing of the treatment protocol from ETC to DCO is not associated with increased rate of local complications (pin-tract infections, delayed unions or nonunions). There is a lower complication rate in DCO Group despite higher ISS compared with the ETC Group, DCO surgery appears to be an viable alternative for polytraumatized patients with femoral shaft fracture

Aims: Evaluation of: 1/ type and incidence of pelvic ring injuries, 2/ type and incidence of associated injuries, 3/ type of pelvic ring injuries pathomechanism, 4/ influence of pelvic ring injuries on trauma severity score, 5/ analysis of clinical long term results. Material and methods: Retrospective evaluation of 257 patients with pelvic ring injuries treated between 1989–2003 had been made. Mean patients age was: 65 y.o. (Range: 32–61 y.o.). Mean follow-up time: 57,5 months (range: 18–192 m.). All patients were treated no operatively: bed-rest, hamaque suspension, and skeletal traction. Analysis of pelvic injuries was made by Tiles classification. Evaluation of pelvic injuries pathomechanism was made by Young-Burgess classification. Clinical end results were evaluated by Iowa Pelvic Score. In polytraumatized patients trauma severity was evaluated by AIS and ISS. Results: Incidence of pelvic injury in hospitalized patients was 1,3%. In study group there were following pelvic injury types: type A – 14 %, type B – 77 % and type C – 9%. Pathomechanisms of pelvic injuries in study group were following: type LC – 61%, type APC – 30%, type VS – 2%, type CMI – 7%. Long term clinical results in Iowa pelvic Score were for pelvic ring injuries: type A – 92 p., type B – 86 p., type C – 67 p. Mean value of ISS index in patients with pelvic ring injuries was 23p, mean value of ISS index in patients without pelvic ring injuries was 19p. Conclusions: 1/ pelvic ring injuries in standard orthopedic and traumatic department are rare, 2/ pelvic ring injuries are frequent in polytraumatized patients, 3/ type C according to Tile’s classification is the most frequent type of pelvic ring injury, 4/ type LC according to Young-Burgess classification is the most frequent type of pelvic ring injury pathomechanism, 5/ incidence of pelvic ring injury in polytraumatized patient increases ISS index, 6/ long term clinical results suggested that most pelvic ring injuries can be successfully treated nonoperatively

Pelvic x-ray is a routine part of the primary survey of Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard in the diagnosis of pelvic fractures. This study aims to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis, in favour of later pelvic CT scan. A retrospective analysis of polytraumatized patients in our emergency room was conducted between 2005 and 2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and clinically stable pelvis. We excluded patients requiring immediate intervention. We reviewed the records of 452 patients. 91 fulfilled inclusion criteria (56% male, mean age 45 years). 43% were road traffic accidents and 47% falls. In 68/91 (75%) patients, both pelvic x-ray and CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None false positive pelvic x-ray was detected. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23). In hemodynamically stable patients with clinically stable pelvis, x-ray sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination. The results support the safety and utility of our modified ATLS algorithm

Background. The suicidal jumper's fracture of the pelvis is a special form of sacrum fractures associated with high energy trauma. The typical H-type fracture pattern runs transforaminal on both sides with a connecting transverse component between S1 and S3. Due to the high-grade instability operative treatment is imperative. Aim of this study was to compare iliosacral double screwing (2×7,3mm canulated screw with 16mm thread) with spinopelvic internal fixation. Methods. Both methods were tested on 6 synthetic and 6 anatomical pelvises. After osteotomy and alternating osteosynthesis stability was tested with a universal testing machine (Zwick) in a simulated two-leg stand. Data were generated by a 3-dimensional computer-assisted ultrasoundsystem (Zebris©) (3 translational datasets x,y,z and 3 ankles). Testing was performed after preload of 50N and two setting cycles of 100N followed by a full load cycle of 150N. ASCII-data were then transferred to SPSS for statistical analysis. Results. Both experimental series showed similar results. There was a tendancy of less displacement when iliosacral screwing was performed. However, no statistical significance could be observed between both techniques. Discussion. Although the spinopelvic internal fixation is a more rigid system, the double screwing may compensate this as it interacts in the center of the fracture. We therefore think that iliosacral double screwing is an appropriate technique for stabilisation of this special fracture type. The possibility of percutaneous osteosynthesis and of its performance in a supine position, this procedure provides essential advantages for the operative treatment of polytraumatized patients

Introduction. Isolated U-shaped sacral fractures are rare entities, mostly seen in polytraumatized patients, and hence, they are difficult to diagnose. While the pelvic ring remains intact across S2/S3, the U-shaped fracture around S1 leads to marked instability between the base of the spine and the pelvis. As severe neurological deficits can occur, timely treatment of these fractures is crucial. We present a novel technique of percutaneous reduction and trans-sacral screw fixation in U-shaped fractures. Material and Methods. 3 multiply injured patients with u-shaped sacral fractures (female, age 21.7±7.23). Two underwent immediate fracture fixation. In the third case delayed reduction and fixation was performed after referral 6 weeks following open decompression. In prone position, a pair of Schanz pins was inserted into pelvis at the PSIS. A second pair of Schanz pins was inserted into S1 or L5. All pins were inserted percutaneously. The fracture was reduced indirectly, using the Schanz pins as levers. After image intensifier control of the reduction result, two trans-sacral screws were inserted for finite fixation. Results. In all three cases, this novel method of percutaneous reduction allowed an anatomical sacral alignment and stabilization with trans-sacral screws was initially sufficient. At 1 year follow-up, both immediately fixed fractures showed an anatomical sacral alignment. Both had no neurological deficits, no signs of screw-loosening and were pain free. Unfortunately the delayed fixation showed a new tilt and hence loss of sacral alignment. This might be due to posterior structural integrity loss after decompression. Conclusion. U-shaped sacral fractures are rare, but correct and immediate treatment is paramount to achieve good outcome. Percutaneous reduction and screw fixation offers a less invasive treatment method. Anatomical alignment and stabilisation is possible and time of surgery can be reduced significantly

In Germany 427.500 persons per year were injured in traffic accidents. Because of faster cars the number of seriously injured persons increased. In a retrospective study we analysed the outcome and the posttraumatic quality of life (POLO Chart) of patients suffering from a severe trauma (ISS ≥ 50). Highlight of interest were:. pattern of injury. injured part of the body. days in ICU/days of external ventilation. outcome. actual state of health. mental health. changes in the social environment. Between 1/2000 and 12/2005 1435 patients with multiple trauma were hospitalized in our Trauma Center, 88 (6,5%) suffered from a severe trauma with ISS ≥ 50. A total of 29 patients answered the POLO Chart. The most important pattern of injury were caused by traffic accidents (62%),. Thoracic injury was the most common injury (94%) with an average AIS of 4,1. The patients with an ISS ≥ 50 spent significant more days in ICU and had significant more days of external ventilation than polytraumatized patients with an ISS < 50. 23% of the patients had a good outcome, 15% were severe physically handicapped and 36% died. Actually, more than half of the patients were more or less physically handicapped. 62% suffered from pain. 41% showed characteristics typically for a posttraumatic stress disorder. Only 15% were able to go back to work - on average two years after trauma. In conclusion the patients with severe trauma had a good survival rate, but they showed a poor posttraumatic quality of life, predominantly because of pain and mental ill like posttraumatic stress disorder. So in the time after trauma it is important to treat the whole patient and not only the physical lesions

Purpose: To analyze the validity of the Ottawa Ankle Rules in our environment as a basis for ordering emergency radiographs after angle and/or mid-foot lesions. Materials and methods: In this observational study we applied the Ottawa Ankle Rules and prospectively measured the result obtained in patients treated in our emergency department for ankle and/or mid-foot lesions from 1 July 2003 to 1 February 2004. The study excluded polytraumatized and multicontused patients as well as pregnant women and patients who had had the lesion for over 7 days. Radiographs were obtained for all the patients in the study regardless of the result produced by the Ottawa Rules. Results: 687 patients were included in the study; 111 presented with a fracture. The Ottawa Rules showed a sensitivity of 97.2% (95% CI, mean: 96.0–98.4%). Negative predictive value was 98.5.% (95% CI, range: 96.4–98.7%). Specificity was 35 % (95% CI, range: 31.4–38.6%). Positive predictive value was 22.2% (95% CI, range: 19,1–25.3%). Discussion and conclusions: The Ottawa Rules are valid in our environment as a decision-making aid when ordering radiographs of patients with angle and midfoot trauma. Applying these rules, savings of up to 30% can be made on radiographs ordered unnecessarily

Purpose: Open reduction and internal fixation (ORIF) is considered the treatment of choice in dislocated acetabular fractures. However ORIF has several drawbacks, such as intra operative blood loss, operative trauma and septic complications. To overcome these problems we applied percutaneous cannulated screw fixation in some cases. Methods: 198 acetabular fractures were treated between 1996 and 2003 in our department. According to the AO classification there were: 74 type A, 99 type B and 25 type C cases. The causes of the trauma were fall from high at 29, traffic accident at 112 and simple drop with osteoporosis in 57 patients. There were 29 polytraumatized and 46 multitraumatized patients. The 89 non-displaced fractures were treated conservatively: 8–12 weeks non-weight bearing were applied. The other cases were treated surgically: the simple wall fractures with screws, the column fractures with plates. The ilioinguinal approach was used in 11 and the Kocher-Langenbeck in 92 patients. Recently we have started to apply a percutaneous technique with cannulated screws. We used them at the fractures of the roof of the acetabulum and at elderly patients who had moderately dislocated anterior column fracture. We applied this technique in 6 cases. Results: In the cannulated screw group there was no intra- or postoperative complication, and the functional results have been excellent or good. In those cases, where the fracture involved the posterior wall or the posterior column, and percutaneous reduction could not have been achieved; we made open reduction, and ORIF. Conclusions: Percutaneous cannulated screw technique can be useful in the treatment of the fractures of the anterior column and the dome of the acetabulum

Introduction: A multiplicity of factors can increase the risk of nosocomial infection in polytraumatized patients. Infections in the hospital environment are still a serious public health hazard. Nonetheless, only a few studies have been published on nosocomial infections in poly-traumatized pediatric patients. Materials and methods: A 4-month prospective study was carried out of patients admitted to the traumatology department and to the pediatric intensive-care unit between July and November 2003 in order to assess all the procedures the patients were subjected to. Infections were considered to be nosocomial when they appeared 72 hours after admission. Results: 121 patients were included in the study. 77% (93) were boys and 23% (28) girls, with a mean age of 10.6 years. The number of infected patients was 6 (5%) and the number of episodes of nosocomial infection diagnosed was 12. 33% of infected patients had a single episode and 67% had two or more infections. When considering the intrinsic risk factors considered in the study one should mention that 10% of patients who were admitted were in a coma, 4,1% had a respiratory syndrome and 2% were diagnosed as obese. The most frequently isolated micro-organisms in this group of patients were Gram positive bacteria (50%), while the most common pathogen was coagulase-negative staphylococcus (85,7%). Conclusions: The paper reveals the profile of nosocomial infections in ploytraumatized pediatric patients in our hospital environment and defines their connection with the use of invasive measures as well as with the length of the patient’s hospital stay

Introduction: Percutaneous iliosacral screws are commonly used for the fixation of the posterior pelvis. The procedure is technically demanding because of the limitations of radiological visualisation of the relevant landmarks. There have been several reports of misplaced screws and other complications, occasionally with serious consequences. To achieve a secure surgical procedure we routinely use a CT-guided technique for percutaneous pelvic screw fixation since 2004. Methods: Between September 2004 and January 2009, 39 patients were treated using CT-guided screw fixation. Under general anaesthesia patients were placed on a vacuum mattress in a stable lateral position within the CT gantry (Siemens SOMATOM definition; i-Fluoro: 20mAs; Hand CARE mode). The scanner bed was on a calibrated track so the same images could be used and repeated throughout the procedure. Gantry and patient were draped under sterile conditions. The laser sights of the CT indicated the cutaneous site which corresponded to the underlying osseous level (first or second sacral pedicle). At this the CT scan trajectory in the CT-fluoro mode indicated the extrapolated position of the guide-wire. A 3.2mm guide-wire was inserted using battery-powered equipment or hammer blows. When the guide-wire was in a correct position a self-drilling cannulated lag screw was placed (6.5mm DePuy). Two screws were inserted in sacral fractures, one screw in sacroiliac ligament ruptures. Results: 19 of 39 patients were polytraumatized. In 10 cases there were both side injures. Overall 71 screws were placed. Median time for the procedure was 36 minutes in unilateral lesions and 48 min in bilateral lesions. There were no cases of infection, non-union or neurological deficit. Postoperative CT revealed correct screw positions in all cases. Screw removal was done routinely in the patients younger than sixty years to resolve the blocked sacroiliac joint. Conclusions: CT-guided is a safe and feasible treatment option in patient with instable pelvic ring lesions. A close collaboration between interventional radiologist and surgeon is essential. Compared to other procedures g.e. internal plate fixation or fluoroscopic guided procedures CT-guided screw insertion seems to be more secure and could strongly be advocated

Intro: Traumatic atlanto-occipital dislocation (AOD) remains a seldom and severe injury which function-ally separates the head from the upper cervical spine and thus can lead to neurological compromise or death. We report on a survivor after AOD, who came back to sportive activity after operative sta-bilization C0–C2. Case Report: The 32 year old polytraumatized racing-bicyclist was addmitted to our insitution after a crash. Initially, due to the lack of hard diagnostic signs the diagnosis AOD was missed. Thoroughly reevaluation and craniocervical diagnostics particluar dynamic roentgenogramms revealed the atlanto-occipital instability. Thus the patient underwent posterior fusion C0–C2 using a pedicular-rod-based cranio-cervical hardware-system (CerviFix). The patient gained full recovery and after 2 years of active physiotherapy he showed a favourable functional outcome and came back to sportive-cycling. Discussion: Missing atlanto-occipital dislocation as well as secondary dislocation with conservative treatment of this rare entity can cause serious sequelae or lead to death. Thus a thorough diagnostic scheme has to be installed for cervical spine fractures including dynamic roentgenogramms contrary to fear of neu-rological compromise in this technique as well as CT and MRI. The knowledge based in literature suggest that any concomittant ligamentous instability in case of C0–C1 injury has to be stabilized by operative fusion as there is unsure clinical course, if treated in conservative manner predisposing for secondary hits, epecially in sportive individuals. Conclusion: Actually due to the lack of large single institution series, theres no evidence or proper guidelines concerning diagnostics and treatment of AOD. We recommend CT and dynamic roentgenogramms of the cervical spine in case of a suspected AOD. Dynamic x-rays clearify masked cervical spine in-stabilities including AOD and thus should be performed to reveal AOD prefering to MRI. The treatment of AOD utilizing anchor stable posterior rod-based systems enable early postoperative physiotherapy, rehabilitation and secure healing

Introduction: Hemorrhage in pelvic trauma may be life treatening. Emergent treatment obtaine the haemostasis and stop the bleading. The deþnitive treatment depend on the type of fractures and general state of patient. The purpose: of this study is to present our experiance in emergent and deþnitive treatment of pelvic disruption. Materials and methods: From 1982 to 2000, 212 pt. were treated with pelvic disruption. Of all pt. 186 were surgicaly treated with deþnitive stabilization. The other 26 pt. died. Of all pt. 72% were polytraumatized and 30% haemodinamically unstable. The average of ISS was 31. Assessment of pelvic instability was made by protocol which included: physical examination; radiographic assessment and CT of the pelvis. Classiþcation of the pelvic disruption was done according M. Tile. There were found 104 pt. with type B (B1-44; B2-37; B3-23) and 82 pt. with type C (C1-58; C2-14; C3-10). Emergent treatment of hemodynamic unstable pt. included: Intial resuscitation by polytrauma protocol, minimum diagnostic procedures, provisional stabilization of pelvis (Ex.Fx or pelvic stabilizator). Deþnitive stabilization was done by internal þxation in 87 pt., external þxation in 62 and combined þxation in 37 pt. X-rays follow-up results by Slatis were as excellent in 123 (66%); good in 33 pt. (18%); fair in 19 pt. (10%) and poor in 11 pt. (8%). Functional outcome results by DÔAubigne-Postel Scoring System were excellent in 89 pt. (48%); good in 60 pt. (32%); fair in 22 pt. (12%); poor in 15 pt. (8%). There were complication as a persistent sacroiliac pain in 12 pt.; impaired gait in 10 pt.; deep infection in 4 pt. and pin tract infection in 14 pt. Conclusion: Provisional stabilization of pelvic disruption should be viewed as part of pt. resuscitation. The results supports the deþnitive treatment of internal þxation in all type C pelvic fractures and pt. with severely type B injury

Introduction: Bilateral and transverse fractures of the first two sacral vertebrae with intrapelvic intrusion of the lumbo-sacral spine are very rare injuries. In most cases the lesion occurs after a fall from great height in a kyphotic position when landing. Today’s CT-scans in these mostly polytraumatized patients enable a clear diagnosis. In contrast conventional radiographs have a high risk to ignore these fractures. Operative treatment requires proper reduction and secure fixation which so far is not unrestricted possible using recommended techniques. For reduction lumbo-sacral distraction followed by lordotic extension is essential but difficult to obtain. Therefore we modified the lumbo-pelvic instrumentation to facilitate these requirements. Methods: In the last four years we treated three female patients (aged 27–68 years) as follows: Variable axis screws (VAS – Synthes®) were inserted in the L4 and L5 pedicles and connected with two connecting rods. An additional variable axis screw was inserted in each posterior iliac spine. These both screws were connected with a transverse connecting rod situated over the transverse fracture line. This rod was connected with the two upright rods using a rod-to-rod connector and forming a hinged joint. Due to the not tightened nut of the pedicle screws at that time it was possible to spread the lumbo-sacral fracture line. After tightening of the lumbar screws the upper part of the body was slightly elevated resulting in a lordotic extension in the hinged joint. Subsequently the hinged joint was locked (Video). Results: Postoperative CT scans revealed anatomic reduction and properly inserted implants in all cases. Follow-up was uneventful but a heparin related thrombopenia in one patient. Two patients were mobilized under full weight bearing within 4 and 10 days, respectively. In one cases this was not possible because of relevant foot fractures. Neurological deficits completely resolved in one patient within fourteen days and markedly diminished in another patient within months (persistent neuralgia). In one patient no neurological deficit existed. In all cases a complete hardware removal was done in 8 to 11 months. Conclusions: The presented procedure is suitable for the so-called jumper’s fractures and results in anatomic reduction of the displaced fractures and a secure stabilization. The described hinged joint offers effective lordotic extension which is the key point for reduction. Thus this configuration is a reduction as well a fixation device. Full weight bearing in an erect posture is immediately possible and clearly shorten the rehabilitation period

Introduciton Diagnosis of cranio-cervical dissociaton is frequently delayed, and neurological consequences may be severe. Our purpose was to identify problems with the diagnosis and treatment of craniocervical dissociation, while reporting the results of early craniocervical fusion with posterior segmental fixation. Methods We present a retrospective review of 17 survivors of cranio-cervical dissociation identified through institutional spine and trauma registries. Medical records, radiographs, and prospectively collected data were used to identify the timing and method of diagnosis, and the effect of delayed diagnosis. Radiographic and clinical results of treatment were evaluated. Emphasis was placed on identifying missed or delayed diagnoses, decline in neurologic function, potential clinical or radiographic warning signs, and response to treatment. Results Despite an abnormal Basion-Dens relationship in all but one patient, cranio-cervical dissociation was identified or suspected on the initial lateral cervical spine radiograph in only two patients (12%), and was diagnosed in only four patients (24%) following initial trauma evaluation (lateral radiograph and CT of cervical spine). The two day average delay in diagnosis was associated with profound neurologic deterioration in five patients. One patient had post-operative neurologic worsening. No patients developed craniocervical pseudarthrosis or hardware failure after a 15-month average follow-up period. The mean ASIA motor score of 50 improved to seven, and the number of patients with useful motor function (ASIA D or E) increased from seven patients (41%) pre-operatively to 13 (76%) post-operatively. The typical patient profile was of a polytraumatized patient with associated head injuriy, cranio-facial trauma, and asymmetric motor deficits extending above the C5 level. Conclusions Better clinician awareness and disciplined review of screening C-spine radiographs are important for prompt diagnosis and stabilization of craniocervical instability. Of 17 patients with CCD necessitating internal fixation (stage two and three), 13 had a delay in diagnosis either at our institution or the transferring hospital, with severe neurological consequences in five patients. Significant recovery of neurologic function was a consistent post-operative finding, confirming the importance of prompt diagnosis and operative stabilization of these devastating injuries

Introduction: Proximal tibial fractures continue to be problematic for orthopaedic surgeons. Continued problems in their managment include infection, soft tissue problems, failure of fixation and joint stiffness. Combining the concept of “biological plating” and locked internal fixators, the LISS (Less Invasive Stabilization System) has been developed. Material and methods: The Lis-system is an extramedullary internal fixator that proposes the advantage of indirect reduction and percutaneous, submuscular implant placement. The Lis-system is indicated for fractures of the proximal tibia that involve both the medial and lateral columns. They include AO/OTA Type A2, A3, C1, C2, C3 and type B in selected cases. For the reduction, we put the lower limb in the calcaneal-traction. For intra-articular fractures the prime objective is to achieve anatomic reconstruction of the joint. This study is a prospective evluation of the Lis-System for the treatment of high-energy tibial plateau and proximal tibial fractures treated between October 2002 and Febrary 2004. Twenty-five patient (18 male and 7 female) were treated. The fracture were classified according to the AO classification. The follow-up period between 3 months and 16 months (mean 8.9 months). Results: The fractures treated were 10 intrarticular (AO 41C or 41B) and 15 metaphyseal (AO 41 A); two of these fractures presented with open soft tissue damage. The average age of the patients was 43 years. There were five cases of polytraumatized and four patinetsa with multiple fractures. The mean range of motion was 2 degree (R= 0–13) to 110 degree (R= 80–150). The mean time to full weight-bearing was 16.2 weeks (R= 10–19). There where no non-union. In one case, there was a valgus malunion of about 5 degree, in 2 case a valgus malunion of less of 5 degree and anyone of more of 5 degree. The tecnique of osteosyntesis with the LISS allows a minimally invasive approach, minimizing additional trauma to the soft tissue. There were no cases of varus malunion, of failure or of loss of reduction. One patient developed superficial infection that we treat with antibiotics terapy. No syndrome compartiment were see. Conclusion: In conclusion with the new methods of percutaneus plate osteosyntesis we see decreased soft tissue complication and the time of healing. The Less Invasive Stabilizzation System in our opinion is the goal standard for multisegmentary or comminnuted fractures of the proximal tibia with distal long extensions in patients with politrauma. The early clinical result optain in our experiance indicate that the Less invasive Stabilizzation System combine efficent bone stabilization with the advantage of minimally invasive operative technique