Polytrauma mit Beckenfraktur und schwerem Thoraxtrauma

Background

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

Methods

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

Results

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

Conclusions

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.     

Therapiestrategien bei Talusfrakturen

Background

The talus distributes the load from the leg to the foot. Talar fractures are rare injuries.

Diagnostics and therapy

Fractures of the talar neck and body are typical high energy injuries and especially seen in multiple trauma patients with accompanying injuries. Because of the high risk of soft tissue damage, fractures with posterior dislocation of the talar body are surgical emergencies and have to be immediately reduced. The definitive fixation should be performed by an experienced team. Fractures of the lateral process are typical injuries related to an ankle sprain, needing a subtle examination for detection. Misdiagnosis can lead to persisting ankle pain.     

Verzögert diagnostizierte Capitulum-humeri-Frakturen beidseits

Fractures of the capitulum of the humerus are rare and difficult to recognize. At present conservative therapy is only indicated in a few cases with no dislocation of the fracture. Otherwise an anatomical reduction and internal fixation should be done as early as possible. This article reports the case of a 51-year-old female patient with bilateral fractures of the capitulum of the humerus which were diagnosed 6 weeks after trauma. In spite of the extra risk of fragment necrosis, a reduction and internal fixation were performed. After rehabilitation, the patient was free of complaints except for a minimal limited range of motion.     

Komplikationen und Komplikationsvermeidung beim Abdominaltrauma

Trauma und Berufskrankheit - Algorithmen können durch eindeutig festgelegte Schritte zur Komplikationsvermeidung beitragen, auch wenn das gerade beim Polytrauma besonders schwierig ist. Eine...     

Percutaneous navigated screw fixation of glenoid fractures

Background

Open or percutaneous arthroscopic-based procedures are reported to fix unstable or displaced intra-articular glenoid fractures. Approach related morbidity has to be considered for open procedures, and arthroscopic-based procedures are demanding. Therefore an alternative percutaneous navigated approach is described.

Technical procedure

In an experimental setting an operative workflow was simulated to evaluate the best position of the patient on the operation table, the operating room set up and the fixation technique for the dynamic reference base of the navigation system. Based on two clinical cases, screw fixation of glenoid fractures via a posterior percutaneous approach is described, using a 2D-fluoroscopic based navigation system. Compared to the common approaches, the advantages and disadvantages of this procedure are discussed.

Conclusion

The described technique of percutaneous navigated screw fixation of glenoid fractures is an alternative minimal invasive procedure. A reduction of approach related morbidity and more rapid return to function could be expected. The intraoperative results and postoperative functional outcome of both cases are promising.     

Navigation of vertebro-pelvic fixations based on CT-fluoro matching

Different navigation procedures (based on 2D-, 3D-fluoroscopy or CT modalities) with their respective limitations are established in orthopedic surgery. The hypothesis is that intraoperative matching of different modalities (fluoro and CT) increases the precision of navigated screw placement and reduces the fluoroscopy time. Vertical unstable pelvic ring fractures of 12 patients were treated with vertebro-pelvic fixations (6 in the standard technique and 6 using the fluoro-CT navigation). An optimal osseous corridor could be determined by the navigation procedure increasing the overall precision of screw placement (no misplacement in the second group as compared to one malplaced pedicle screw in the standard group). The achieved screw lengths were [(mean ± SE) 78 ± 5 vs. 53 ± 4 mm, p < 0.001). Less invasive open approaches and a reduction of fluoroscopy time (time per screw in seconds: 121 vs. 62 s) were observed. CT-fluoro-matched navigation improves the intraoperative visualization of osseous structures and increases the precision of screw placement with less radiation exposure.     

Navigation in femoral-shaft fractures--from lab tests to clinical routine

Introduction

This study evaluates the use of a navigation system (BrainLAB, Feldkirchen, Germany) to intra-operatively check for correct length, axis and rotation in intramedullary nailing of femoral-shaft fractures in an experimental setting and in clinical routine.

Materials and methods

We tested the navigation system in two experimental settings before introducing it into clinical routine. In the first experiment, 10 osteotomised model femora were fixed with intramedullary nails by using a navigation system. The goal was a locking fixation in predefined values for length and rotation.In the second experiment, eight examiners assessed values for rotation and length of one femur 10 times to examine the accuracy and reproducibility of that determination.Following this, we navigated 40 femoral nailing procedures in our department. Preoperatively, we assessed values of femur geometry on the contralateral side in a computed tomography (CT) scan and reproduced these values intra-operatively on the fractured side, guided by the navigation system. During the intervention, we recorded the length of the procedure steps and the fluoroscopy time.We verified the intra-operative values achieved with the navigation system in a postoperative CT scan and documented differences in rotation and length.After the assessment, we analysed the data for different findings on femur geometry, fluoroscopy time and procedure duration.

Results

The experimental evaluation showed a range of ±5° for anteversion differences and ±2.3 mm for length differences. We estimated this accuracy as sufficient to use the system in clinical routine. The navigation system was used for 40 fracture fixations. All our criteria for restoring femoral geometry could be achieved by navigation guidance in these procedures.Setting up the system took on average 33 ± 11.5 min. An additional fluoroscopy time of 36 ± 22 s was needed to acquire the reference X-rays and to verify pin placement.The differences between anteversion values assessed in intra-operative planning steps on the navigation system and values assessed with a postoperative CT were on average 5.4 ± 3.5°, whilst femur length differed on average by 4 ± 4 mm.

Discussion

Many authors judge intra-operative control of anteversion in femoral-shaft fracture fixation as problematic.Neither our experimental navigation assessment nor our clinical navigated evaluation showed relevant anteversion differences to a postoperative CT assessment of femur geometry. After initial training, guidance by a navigation system achieves consistent results in a clinical situation.

Conclusions

The use of a navigation system to align axis, length and rotation led to a secure way of avoiding any relevant malalignment in complex femur-shaft fractures whilst exposing patients to an acceptable amount of additional procedure sequences.Malalignment can be avoided by using a navigation system in the operative treatment of femoral-shaft fractures and may be integrated into clinical routine in specialised centres.     

Entwicklung der navigierten Versorgung von Kahnbeinfrakturen

Percutaneous screw fixation of nondisplaced scaphoid fractures has gained popularity but remains technically demanding. Internal fixation has been advocated in young active individuals with nondisplaced scaphoid fractures to accelerate healing, allow early wrist motion, and avoid the disadvantages with prolonged immobilization. Central placement of the screw in the proximal fragment of the scaphoid is associated with decreased time to union. The newly developed universal scaphoid splint results in complete immobilization of the wrist and allows either a dorsal or palmar surgical approach. The universal scaphoid splint offers adequate reference marker stability and successful 2D/3D-navigated fluoroscopic K-wire drilling and screw placement in the scaphoid bone. Biomechanic studies, cadaver investigations, and early clinical results support the advantages of computer-assisted surgery (CAS) compared to percutaneous screw placement.