Aim

Posttraumatic pelvic-osteomyelitis is one of the most serious complications after pelvic-fractures. The necessary extensive surgical debridement as part of interdisciplinary treatment is complicated by the possible persistence of pelvic instability. The aim of this study was to determine the outcome and outline the course of treatment after early posttraumatic pelvic bone infections due to type-C pelvic ring injuries.

Aim

The pathogenesis of non-union is multifactorial. Path biological factors, mechanical factors, and low-grade-infection contribute to impaired bone healing. Aim of this study was to determine the rate of low-grade-infection in patients with long bone non-union of the lower extremity without signs of acute infection, the influence of CRP (C-reactive protein), and the outcome.

Introduction

Proximal tibial fractures frequently present in combination with other injuries which also have to be treated surgically. Recent publications do not consider isolated proximal tibial fracture (mono-injury) and combined injuries which include tibial fractures as two seperate medical entities. We therefore asessed the influence of additional injuries on treatment and outcome of the proximal tibial fractures.

Objectives: Goal of this retrospective study is to evaluate risk factors, which lead to an osteitis of the tibia depending on the fracture location.

Methods: The study was initiated 01/2002. The study population consists of 104 patients including 14 women (13%). All of them suffered from an osteitis of the tibial. All of them are complications after traumatic open or closed fractures of the tibia, treated surgical. The average age of the patients has been 48 (± 18) years. In 28 cases there has been an acute osteitis of the tibia. In the other 76 patients the infection was not noticed before the ninth week after trauma. In all patients the risk factors were analyzed depending on the fracture configuration, the soft tissue situation, and the fracture location.

Results: All infections have been localized at the fracture level. The majority of the patients suffered from open tibial fractures (77.4%). 7.9% have been first, 23.6% second, and 68.5% third degree open fractures. Almost half of the fractures (48.1%) were located at the distal third of the tibia. Equally, 25.9% of the infections were localized in the medial and proximal third of the tibia. The percentage of open fractures leading to an osteitis was significant highest (p < 0.01) at the medial third of the tibia (91.3%), whereas the percentage of open proximal fractures has been 61.1% and open distal fractures 62%. The complexity of the fractures of the proximal, medial, and distal third of the tibia was very similar. The proportion of osteosynthesis with fixateur externe, plating, or naling showed no significant differences. 37.8% of the patients were smoker. The percentage of smoker was significant highest (p < 0.05) in the subgroup osteitis after closed tibial fracture (69.9%). The number of the other risk factors (Diabetes mellitus, hypertension, alcohol consumption, adipositas, PAD) was similar in all subgroups. There have been no differences between the 28 acute versus the 76 chronic osteitis.

Conclusion: The majority of the posttraumatic tibial osteitis is localised in the distal third. The most important risk factor for the development of a posttraumatic tibial osteitis is the dimension of the soft tissue defect. This is particularly true for the medial third of the tibia where the percentage of open fractures is significant highest. Additionally nicotine consumption is a major risk factor for the development of a posttraumatic tibial osteitis, particularly in cases of closed distal tibial fractures.

Objectives: An osteitis of the tibia remains a major problem especially in cases of open tibial fractures. A successful therapy management goes along with a radical bacterial eradication, sufficient soft tissue coverage, and a stable osseous reconstruction.

Methods: The study population consists of 112 patients (53 ± 13 years). All of them suffered from a tibial osteitis after fracture of the tibia. The study population was divided in patients with osteitis after open versus non open tibial fracture. The therapy strategy was the same in both groups. It was done according to a standardised treatment plan including radical surgical eradication of infectious and necrotic tissue, programmed lavage with vacuum sealing in combination with an effective bacterial antibiotic therapy. Surgical stabilization was done in cases of instability. Final osseous reconstruction and soft tissue coverage was performed if necessary after three negative intraoperative smears.

Results: 89 patients of the patients (79%) suffered form open tibial fractures versus 23 (21%) patients with non open fractures (NOF). The average inpatient treatment time was 13 ± 18 weeks in cases of osteitis after open tibial fractures and 8 ± 4 weeks after NOF. The average number of operative procedures after open fractures vs NOF was 10 ± 7 vs 8 ± 4. In 55 patients a muscle flap procedure was performed after open tibial fractures (53%) versus 9 (26%) after NOF. An amputation of the lower leg had to be done in 5 patients after open tibial fractures (5%) versus in 2 patients after NOF (6%). The rate of bacterial eradication with no recurrence of infection for at least one year was 53% in cases of osteitis after open tibial fracture and 65% after NOF.

Conclusion: An open fracture of the tibia is a major risk factor for developing a chronic osteitis. The eradication of bacterial infections takes a longer time and more operative procedures are necessary in cases of open tibial fractures versus closed fractures. In cases of open fractures there exists a higher need of soft tissue reconstruction by muscle flaps. After eradication there are no significant differences in the one year recurrence rate.

Background: To improve the primary operative treatment of complex olecranon fractures we searched for new conclusive parameters. We hypothesized that the intermediate fragment plays a critical role for precise restoration of the trochlear notch contour and good outcome of initial operative treatment.

Methods: 58 patients (26 female, 32 male; mean age 55 years) with multi-fragmentary olecranon fracture were identified in a seven-year-period from trauma unit files at two European Level 1 trauma institutions. Retrospective review of all operative reports and radiographs/computed tomography scans identified patients with an intermediate fragment.

Results: 28 patients were treated with stable internal fixation using figure-of-eight tension-band wire fixation and 30 patients using posterior plate osteosynthesis with and without intramedullary screw. An intermediate fragment was seen in 36 patients (62 %). In 17 of these 36 patients (47 %), the intermediate fragment was described in operative report. Twelve of these patients (71 %) were treated with single posterior plate with/without an intramedullary screw, and five patients (29 %) with figure-of-eight tension-band wire fixation.

Conclusion: Fracture analysis identified an intermediate fracture fragment in the majority of patients with complex olecranon fractures. In diagnostic work up a CT scan should be used to assess the fracture pattern and to detect an intermediate fragment. This study suggests that identification, desimpaction and anatomic reduction of the intermediate fragment are critical preconditions for anatomic restoration of the trochlear notch and good functional results. Precise description of the fracture pattern including presence of an intermediate fragment in the operative report is recommended.

Since the introduction of carving skis, the injuries of the tibia is changing from simple fractures of the diaphyse to complex fractures of the epiphyses, according to high energy traumas. There are no studies about results of the treatment and consequences after winter sport accidents.

Method: Prospective documentation of all proximal tibia fractures after winter sport accidents, which were treated between 01.12.2006 and 31.04.2009 in the Trauma Department of the Klinikum Garmisch-Parten-kirchen, Germany. X-Rays and CT scans were classified according to the AO –Classification. Operations, complications, co-injuries and the hospital stay were analysed. We performed the Lysholm score, WOMAC Knee-score and the Tegner-index on the day of injury, 6 months, 12 months, and 2 years after injury.

Results: 78 patients had a proximal tibia fracture following a skiing accident, 36 Male and 42 female. All except two patients had a monotrauma of the proximal tibia. Mean age 46 ± 15 years. 17 types A.1.3, 41 types B and 18 types C3 fractures. 4 patients developed a compartment syndrome, one patient had a lesion of the n. peroneus. 65 patients were operated in our hospital. In 8 patients we performed a conservative treatment. The mean hospital stay was 12 ± 7.5 days. In 15 patients a menisci reconstruction was necessary. 6 patients had a postoperative complication: 3 thromboses, 2 cardiac decompensations, 1 wound healing problems. By now 42 patients were ready for follow-up. So far the mean follow-up time is 13.8 months. The Lysholm score was at 12 months (n= 22) 78 ± 20 points. The Tegner score was pre-injury 6.2 ± 1.1 and 12 months post-injury 4.1 ± 1,8. The results of the WOMAC score show an improvement in the subcategories pain and function in all patients. In the subcategory stiffness only the type A and B fractures show an improvement during the follow-up.

Conclusion: The proximal tibia joint fractures are a serious injury. The most patients’ activity level is tremendously reduced. The major problem after one year seems to be the ligament instability of the knee. A beginning knee arthritis after one year becomes relevant only in the type C fractures. More effort for the prevention of the proximal tibia fractures while skiing is necessary.

Necrotizing fasciitis is a definition of a specific histopathology, the pathogenesis and clinical features vary broadly. Symptomatically is the severe invasive infection of the soft tissues with high rates of patient morbidity and mortality. Beside the most common identified bacteria as A Streptococci (GAS), other bacteria are identified such as gram-positive or-negative bacteria or mixed infections. The aim of the following study was to analyze the specific predisposing risk factors and outcome of patients suffering necrotizing fasciitis.

Methods: The data of patients suffering necrotizing fasciitis were prospective collected since 2004. Criteria were the clinical and histological evidence of a necrotizing fasciitis. The clinical course, concomitant diseases, detectable bacteria and outcome with focus on limb salvage, amputation rates and hospital mortality was analyzed. Primary focus of the therapeutic regimen was the surgical and intensive care therapy. Adjuvant therapy was the hyperbaric oxygen therapy.

Results: 55 patients were prospective enrolled in the study with the clinical and histological diagnosis of a necrotizing fasciitis from 2004–2008. The mean age of the patients was 58 ± 15 years at the timepoint af admission to the hospital. Gender distribution was 68 % male and 32 % female. 87 % of these patients were admitted after interhospital transfer. 82 % were admitted to the intensive care unit and 78 % needed catecholamines. The hospital mortality was 31 %. The ranking list of potential risk factors in descending frequency was: diabetes, obesity, immunosupression of different causes. Affected were in 22 % of the cases the upper extremities, 72 % lower extremities and/or in 12 % the trunk. In 80 % of the deceased patients the pelvic region or the trunk was involved. Almost half of the patients suffered an amputation of one limb.

Summary: The necrotizing fasciitis remains an interdisciplinary challenge for specialized centers providing the logistical infrastructure for the treatment of these patients. Despite the optimal treatment options and additional therapy with hyperbaric oxygen therapy the hospital mortality remains high. Prognostic unfavorable is the involvement of the trunk and pelvic region. Typical risk factors are described above. The analysis of pathogenic bacteria shows a broad variety and gives no clear hints in the diagnosis or prognosis of the fasciitis. Crucial for the surgery and indication for limb amputations as a salvage procedure is the clinical course.

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

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.

Background: Aim of this study was to evaluate and compare clinical and radiological outcome of distal femur fracture stabilization using retrograde nailing or LISS plating.

Materials and Methods: In a retrospective study from 2003–2008 we analyzed 115 patients with distal femur fractures who had been treated by retrograde i.m. nailing (60 patients) or LISS plating (55 patients). Mean age was 55 years in the two cohort groups. Mechanism of injury was high energy impact in 57 % (SCN 53 %; LISS 76 %) and low energy injury in 43 % of all evaluated patients (SCN 47 %; LISS 33 %). Fractures were classified according to AO classification: There were 52 type A fractures (SCN 31; LISS 21) and 63 type C fractures (SCN 28; LISS 35). Interestingly severe articular fractures (type C2 and C3) were found much more often in LISS group (15 patients; 27 %) compared to 5 patients (8 %) in the SCN group.

Results: Fracture healing within 3 months was observed in type A fractures in over 90 % of the cases (SCN 29 patients, 89 %; LISS 20 patients, 95 %). A distinct diffrence was found in type C fractures. Whereas still nearly 90 % consolidation was evaluated in the SCN group (25 patients; 89 %), LISS plate group showed only 41 % (14 patients). Nonunion was found in type A fractures in only one patient per group (SCN and LISS 3 %) and in 2 patients in type C fractures treated with SCN (7 %). As expected 35 % (11 patients) nonunions were found in type C fractures treated with LISS. Both, the nail and the LISS group required additional bone grafting for successful healing (SCN 2; LISS 8). Functional outcome using the KOOS score demonstrated in type A fractures a score of 263 in the nail and 260 in the LISS plate group, and in type C fractures 257 in the nail and 218 in the LISS group. Loosening of screws without disturbing fracture healing (SCN 12 %; LISS 2 %). Deep infection (SCN 2 %; LISS 7 %), axis deviation of more than 10 degrees in the coronal or sagittal plane in 5 % in the nail and 12 % in the plate group were treated.

Conclusion: Both, retrograde i.m. nailing and LISS plating are adequate treatment options for distal femur fractures. No differences in outcome between implants regarding fracture healing, nonunion, and infection were found in type A fractures. A distinct difference occurred in type C fractures. According to high rate of severe articular and open fractures a high rate of nonunions and infections was found in the LISS group. Locked plating can be utilized for all distal femur fractures including complex type C fractures, periprosthetic fractures and osteoporotic fractures. I.m. nailing provides favorable intramedullary stability and can be successfully implanted in bilateral or multisegmental fractures of the distal femur as well as in extraarticular and type C1 to C2 fractures.

Aims: Aim of this prospective clinical study was to prove whether there are clinical differences between ms VTS with interposition of an autogenic tricortical bone graft alone and a consecutive dorso-ventral procedure for A 1.2 and A 3.1 fractures of the thoracic and lumbar spine.

Materials und Methods: From 01/2002 to 12/2003 298 pat. with traumatic fractures of the thoracic and lumbar spine were treated and had a prospective clinical and radiological follow-up according to the mc-study of the DGU. For 29 pat. (14 m, 15 f; mean age 33 y) ms VTS was performed either isolated (10) or consecutive after dorsal instrumentation (19). Over the post-OP course with a follow-up of 18 mo. the pat. underwent a questionnaire concerning the morbidity at the surgical approaches, the subjective back function and the Odom-score. The osseous integration of the graft and the resulting loss of correction were investigated within the follow-ups 3, 6, 12 and 18 mo. post-OP.

Results: Concerning the anterior column 83% of the pat. had type A 3.1.1 fractures. All pat. with type B and C injuries underwent consecutive dorso-ventral instrumentation in 2 sessions. In one case revision surgery with bisegmental replacement of the affected vertebral body by a distractible cage was performed due to osteolysis of the bone graft. The other 28 pat. had no intra- or post-OP complications associated with the autogenic bone graft. At the 12 mo. follow-up osseous integration of the bone graft was observed in 28/29 in the CT-scans. The dorsal instrumentation could be removed in 8 of the 19 pat. with a dorso-ventral procedure after a mean of 12,6 mo. The measurements of the CT-scans at 18 mo. showed an average loss of correction (bisegmental) of 1,5° in the isolated ventral group and of 2,7° in the dorso-ventral group (p < 0,05). After 18 mo. Odom-score and subjective back function increased by 49% respectively 57% compared to the post-OP values (p< 0,05). Concerning the morbidity at the surgical approaches the pat. stated a pain relief of up to 73%.

Conclusions: Ms VTS with interposition of an autogenic bone graft of the iliac crest is an appropriate and meanwhile standardized minimal-invasive procedure with a low morbidity at the surgical approach. In this study a high potential for graft integration with a low amount of loss of correction could be detected in both groups (p < 0,05). For the mentioned indications the isolated ventral technique can be seen equal to the dorso-ventral procedure in 2 sessions. However the indication for an isolated ventral procedure has to be reconsidered carefully concerning increasing age and level of osteoporosis.

Objectives: This study evaluates the number of recurrence of acute infection following total knee arthroplasty treated with a concept of implant salvage using programmed revision surgery and specific long-term antibiotic therapy with and without additional application of antibiotics penetrating bacterial biofilms like rifampicin.

Methods: In a retrospective study, 24 patients with early infection of unconstrained total knee arthroplasty were treated according to our protocol and were followed up for a period of 4 years [range 1,2–6,2]

using a questionnaire to investigate course of disease and health-related quality of life (VAS). 7 patients were treated with and 17 patients without additional application of antibiotics penetrating bacterial biofilms.

Results: In the group of patients treated without additional application of antibiotics penetrating bacterial biofilms 11 of 17 (65%) implants were salvaged. In 5 cases revision arthroplasty and 1 arthrodesis were necessary to eradicate infection. Health-related quality of life and function of the arthroplasy were superior in the group of salvaged implants.

In the group of patients treated with additional application of antibiotics penetrating bacterial biofilms 6 of 7 (86%) implants were salvaged and reduced number of revison surgery was needed.

Conclusion: Treatment of infection with implant salvage may be one therapeutic option if the implant is not loose. Therapy with retention of the prosthesis may be indicated: in the case of early infection (< 3 weeks of ongoing symptoms), with unconstrained implants, in the case of infection by a single organism that is susceptible to antibiotic therapy, if soft tissue envelope is not affected, and if the immune system is not compromised. Early and consequent therapy with operative debridements and specific long-term antibiotic therapy are necessary to achieve implant salvage. Additional application of antibiotics penetrating bacterial biofilms such as rifampicin contribute to improve prognosis.

Due to the fact that revision arthroplasty is often associated with limited function after infection of total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.