Hannover, Germany
Hannover, Germany

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Gansslen A.,Klinik fur Unfallchirurgie | Frink M.,Unfallchirurgische Klinik | Hildebrand F.,Unfallchirurgische Klinik | Krettek C.,Unfallchirurgische Klinik
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca | Year: 2012

PURPOSE OF THE STUDY Both column fractures, defined as an acetabular fracture with no articular fragment in connection with the axial skeleton account for approximately 20% of all acetabular fractures. The typical type of a both column acetabular fracture is the C1.2 fracture with a multifragmentary anterior column fracture extending to the iliac crest and a large posterior column fragment in more than half of the patients. MATERIAL AND METHODS The analysis of 135 surgically treated patients with both column fractures showed that more than half of these patients had associated injuries. The mean age was 40 years, and two thirds of these patients were male. A high energy trauma was the trauma mechanism in 87.4%. The mean ISS was 14.2 points. The mean articular fracture displacement was 14.8 mm. 65.9% of the patients showed a central femoral head dislocation. An associated posterior wall fracture was present in 34.8% and an acetabular roof comminution in 34.1%. 8.9% of patients had a fracture related nerve damage. RESULTS Osteosynthesis was performed 9.6 days after trauma. Several approaches were used for stabilization with a combination of plate and screw fixation in 71.9%. The mean operative time was 287 minutes with a blood loss of 1796 ml. Postoperatively the hip joint was congruent in 94.7% with anatomical or near-anatomical joint reconstruction in 75.6%. Iatrogenic nerve injury occurred in 12 patients (8.9%). 89 patients (66.4%) could be followed after a mean of 54.6 months. The average subjective Visual Analog Scale pain score was 27.6. Mild or no pain was seen in 60.7%. The mean Merle d'Aubigné score was 15 with 60.7% of patients having a functionally perfect or good result. 61.8% had no post-traumatic osteoarthritic changes of their hip joint. A joint failure was diagnosed in 25.8% of the patients. DISCUSSION Analysing only patients with anatomically reconstructed hip joints patients had better results with 69,8% having no or mild pain and a good or excellent functional result. Post-traumatic arthrotic changes occued in only 17.5% of these patients. A joint failure was present in 25.4%. In this group, a joint failure was significantly more likely to be present with an additional lesion of the femoral head and severe primary articular fracture displacement. CONCLUSIONS In contrast to other acetabular fracture types, both column fractures show worser results regarding joint reconstruction, and functional and radiological long-term results. The optimal results can be achieved with anatomic joint recontsruction.


Gansslen A.,Klinik fur Unfallchirurgie | Hildebrand F.,Unfallchirurgische Klinik | Krettek C.,Unfallchirurgische Klinik
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca | Year: 2013

PURPOUSE OF THE STUDY Associated transverse and posterior wall fractures account for approximately 20% of all acetabular fractures. To asses the risk of these concommitant bone injuries on early joint failure despite a high rate of postoperative congruency. MATERIAL The analysis of 104 surgically treated patients with associated transverse and posterior wall fractures showed that more than half of these patients had associated injuries. The mean age was 35 years, and > 75% of these patients were male. A high energy trauma was the trauma mechanism in 94.2%. The mean ISS was 26.3 points. The majority of patients showed a juxta- or transtectal fracture line. The mean articular fracture displacement was 13.5 mm. 87.5% of the patients showed a femoral head dislocation. An acetabular roof comminution was present in 16.3%. 20.2% of patients received a fracture related preoperative nerve injury to the sciatic nerve. METHODS Osteosynthesis was performed 9.9 days after trauma. The Kocher-Langenbeck approach was used in > 90% for stabilization with a combination of plate and screw fixation in 71.1%. The mean operative time was 190 minutes with a blood loss of 855 ml. Postoperatively the hip joint was congruent in 90.3% with anatomical or near-anatomical joint reconstruction in > 90%. latrogenic nerve injury occurred in 12 patients (8.9%). RESULTS 67 patients (67.7%) could be followed after a mean of 42.7 months. The average subjective Visual Analog Scale pain score was 42.7. Mild or no pain was seen in 58.2%. The mean Merle d'Aubigne score was 15.4 with 56.7% of patients having a functionally perfect or good result. 52.2% had no post-traumatic osteoarthritic changes of their hip joint. A joint failure was diagnosed in 32.8% of the patients. Analyzing only patients with anatomically reconstructed hip joints, patients showed comparable results with 61.3% having no or mild pain and 59.2% a good or excellent functional result. Posttraumatic arthrotic changes occur in only 26.5% of these patients. A joint failure was present in 32.7%. In this group, a joint failure was significantly more likely to be present with an additional acetabular comminution zone. CONCLUSION Associated transverse and posterior wall fractures have a significant risk of early joint failure despite a high rate of postoperative congruency.


Gansslen A.,Klinik fur Unfallchirurgie | Hildebrand F.,Unfallchirurgische Klinik | Krettek C.,Unfallchirurgische Klinik
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca | Year: 2012

Complete separation of all bony fragments around the acetabulum in both column fractures can lead to extra-anatomical orientation of these fragments around the femoral head with the potential of a "secondary congruence". No long-term data are known in the literature. We could follow 35 patients were a both column fracture was treated non-operatively due to different reasons. Demographics, fracture type, additional fracture lesions (comminution, marginal impaction), the clinical and radiological result and joint failure (severe arthrosis, FHN, esc. THR) were analyzed. The mean age was 38 years, 27 patients were male, eight female. All but four were multiply injured with a mean ISS of 22 points. 16 patients had additional pelvic ring injuries the majority of patients showed a C1-fracture of the acetabulum (anterior column multifragmentary, posterior column simple). 31 patients healed in secondary congruence (88%). Primary displacement was half (11,4 mm, 3-27 mm) compared to patients without secondary congruence (20 mm, 17-22 mm). 80% of the patients had none or only slight pain and 77% had an excellent or good functional result (Merle d'Aubigne Score). The rate of joint failure due to non-union, femoral head necrosis, posttraumatic degenerative changes or pain was relatively low with 17% after a mean of 5 years following trauma. In selected patients, conservative treatment of both column fractures can lead to acceptable long-term results with a high rate of secondary congruence.


Gansslen A.,Klinik fur Unfallchirurgie | Hildebrand F.,Unfallchirurgische Klinik | Pohlemann T.,Universitatskliniken des Saarlandes
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca | Year: 2012

The hemodynamic status in patients with pelvic ring injuries is amajor prognostic factor of an immediate mortality risk. Especially, patients "in extremis" are of high risk to die. This patient group is characterized by absent vital signs or being in severe shock with initial systolic blood pressure <70 mm Hg and/or requiring mechanical resuscitation or catecholamines despite >12 blood transfusions within the first two hours after admission. The sources of pelvic bleeding is in approximately 80-90% of venous origin and relevant arterial bleeding accounts for 10-20%. Important parts of the initial treatment treatment concept include mechanical pelvic ring stabilization combined with hemorrhage control concepts. Mechanical stabilization is performed non-invasively by pelvic binder application or invasively by classical anterior pelvic fixation or posterior pelvic C-clamp, depending on the local available resources. In patients "in extremis" the concept of direct extraperitoneal pelvic packing is recommended, whereas in moderately unstable patients or in patients where persistant hemodynamic instability occurs despite shock therapy and mechanical stabilization and pelvic packing, arterial injury is ruled out by angiography followed by selected embolization of pelvic vessels. © Česká společnost pro ortopedii a traumatologii 2006.


Panzica M.,Unfallchirurgische Klinik | Krettek C.,Unfallchirurgische Klinik | Cartes M.,Strategisches Risikomanagement
Unfallchirurg | Year: 2011

The probability that an inpatient will be harmed by a medical procedure is at least 3% of all patients. As a consequence, hospital risk management has become a central management task in the health care sector. The critical incident reporting system (CIRS) as a voluntary instrument for reporting (near) incidents plays a key role in the implementation of a risk management system. The goal of the CIRS is to register system errors without assigning guilt or meting out punishment and at the same time increasing the number of voluntary reports. © Springer-Verlag 2011.


Despite the fact that proximal humerus fractures represent one of the most frequent types of all fractures, the quality of evidence is poor although it has improved in recent years. It is widely agreed in the literature that nondisplaced fractures can be treated conservatively with good outcome. Two recent prospective randomized studies have shown that this also applies to displaced three- and four-part fractures. The results of fixed-angle plate osteosynthesis are also not superior to conservative management in complex displaced fractures in the elderly and in many aspects are even worse. Fixed-angle plate osteosynthesis has not fulfilled expectations. High rates of complications and revision surgeries as well as moderate functional results have been demonstrated in numerous studies. Conventional fracture prostheses or inverse prostheses are solutions fo complex not reducible and/or retainable. Also for the dislocated 4-part fracture of the patient above 60ears no general advantages of the joint replacement compared to conservative treatment could be shown in a recent scandinavian prospective randomized clinical trial. © 2011 Springer-Verlag.


We present a literature review about implant removal after intramedullary stabilization of femoral or tibial shaft fractures, upper extremity fractures, and pediatric fractures.A special focus is the difficult implant removal. Implant removal of nails gets difficult when implants are bent or broken. Other difficulties include broken interfaces between nail and removal instrument or when bone ingrowth hinders extraction.A special difficulty is posed by broken solid nails. Implant failure shows typical failure patterns regarding the location of the fatigue fracture.Based on well-documented clinical cases, we describe in detail surgical techniques as well as tips and tricks which help in the difficult circumstances of bent or broken implants in proximal, midshaft, or distal nail segments for a large variety of implants (solid, cannulated, slotted). We also describe an elegant technique for the safe removal of an infected cemented arthrodesis nail.The time required to perform a nail removal can easily exceed the planned amount. Nail removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the nail should be made with great care. Therefore, good communication with the patient and thorough information about risks and benefits are essential. © 2012 Springer-Verlag.


The management of complex pilon fractures with soft tissue injuries has seen many trends, with changes toward staged protocols of temporary external fixation followed by delayed open reduction and internal fixation (ORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques and special implants, the benefits of negative pressure wound sealing and early „fix and flap“ efforts to reconstruct soft tissue defects. Reduction and fixation must involve cautious management and careful handling of soft tissue in order to minimize the well-known complications of this difficult fracture. With these changes, the rate of soft tissue complications, infections and non-unions has decreased. The target remains the anatomical reconstruction of the articular surface as well as the geometric integrity of the distal tibia and fibula. Currently it is still unclear how much articular anatomy and perfection in reduction is needed as the radiographic results do not always correlate with the clinical results. © 2015, Springer-Verlag Berlin Heidelberg.


Krettek C.,Unfallchirurgische Klinik | Bachmann S.,Unfallchirurgische Klinik
Chirurg | Year: 2015

Intraarticular fractures of the distal tibia (pilon fractures) are caused by axial forces, usually in combination with torsional moments. Routine diagnostics include plain films and three dimensional (3D) imaging with computed tomography (CT). Treatment is often impaired by complex fracture configurations and thin soft tissue layers. The management of complex pilon fractures with soft tissue injuries has seen many trends, with changes toward staged protocols of temporary external fixation followed by delayed open reduction and internal fixation (ORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques and special implants, the benefits of negative pressure wound sealing and early „fix and flap“ efforts to reconstruct soft tissue defects. Reduction and fixation must involve respectful management and careful handling of soft tissues in order to minimize the well-known complications of this difficult fracture. The proper approach is one of the keys to success. Approach planning is based on the careful and thorough analysis of the fracture pattern in the 3D data set, which is the basis for a successful strategy for articular reconstruction. © 2015, Springer-Verlag Berlin Heidelberg.


Meller R.,Unfallchirurgische Klinik | Krettek C.,Unfallchirurgische Klinik
Unfallchirurg | Year: 2012

Fractures of the lateral clavicle and the acromion are uncommon and represent a separate entity. Fractures of the lateral clavicle demonstrate a high rate of problems, such as non-union, malunion and functional impairment when treated nonoperatively. The aim of any treatment option is full restoration of shoulder function by achieving fracture healing without significant malpositioning. Unstable fracture patterns have to be identified and should be fixed using an appropriate technique, which include plating, K-wire fixation and arthroscopic techniques which bring the dislocated fragments into contact. Dislocated fractures of the acromion can usually be treated by plating. © 2012 Springer-Verlag Berlin Heidelberg.

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