Unfallchirurgie (Heidelberg, Germany)最新文献

Acetabular fractures with displaced fragments represent a complex intraoperative challenge. This case report describes the successful treatment of an acetabular fracture with native hip dislocation in a 56-year-old man following high-energy trauma. Open reduction and internal fixation using the Kocher-Langenbeck approach was initially unsuccessful due to a posterior wall fragment, necessitating a trochanteric flip osteotomy. The patient developed an avascular necrosis of the femoral head, which is a frequent complication of acetabular fractures associated with hip dislocation. This emphasizes the importance of regular control follow-up. Despite the high-energy mechanism of injury, the patient showed excellent results based on the Harris hip score (HHS).

Polyaxial screw systems are the state of the art in the field of fracture fixation. In contrast to conventional monoaxial systems, the polyaxial constructs enable variable screw angulation, enhancing the adaptability of plate-screw configurations in different surgical scenarios and different anatomical circumstances. This article provides a comprehensive overview of the functional principles, clinical applications and inherent limitations of polyaxial stability. The conventional monaxial technology restricts screw positioning, potentially compromising fixation in some fracture situations or anatomical regions. In contrast, polyaxial systems enable adapted screw placement, addressing specific requirements arising during surgery. Various locking mechanisms based on friction, deformation, thread forms and engagement techniques, play crucial roles in achieving stability. The article discusses the key currently used technologies, their mechanical characteristics and comparative behavior as the biomechanical interaction between screws and plates is crucial for achieving maximum stability and preventing failure modes that could compromise fracture healing. This article emphasizes that while polyaxial systems offer enhanced fragment-specific screw positioning, their successful application relies on careful surgical technique and an understanding of the mechanics involved. By integrating insights from clinical experiences, biomechanics, and the literature, we aim to raise awareness and support decision-making in fracture management using polyaxial systems. Ultimately, the article advocates a balanced understanding of both the benefits and challenges associated with polyaxial fracture fixation in modern orthopedic trauma surgery.

Trauma surgery and emergency medical care are facing growing challenges: rising patient numbers, a shortage of specialists and a high diagnostic workload are leading to diagnostic errors, up to 80% of which relate to overlooked fractures. Systems based on artificial intelligence (AI) for fracture diagnostics offer promising support in this context. Modern deep learning algorithms, in particular convolutional neural networks, achieve high sensitivities and specificities in the detection of frequent fractures in large validation studies. As a "second reader", they increase diagnostic accuracy, reduce diagnostic time and improve patient safety, especially in the case of subtle fractures or limited practitioner experience. Additional applications include automated triage, angle measurements, bone age determination and the detection of other pathologies. Limitations include heterogeneous training data, limited performance in complex fractures and regulatory requirements. The continuous technological development promises increasing performance and broader fields of application for AI in fracture diagnostics. Future systems will also increasingly enable multimodal and 3D analyses as well as deeper integration into the clinical workflow. The use of AI does not replace physicians but acts as an assistive tool to increase quality and efficiency; however, further independent, prospective and patient-orientated studies and integration into clinical guidelines are required for a broad implementation.

The bony consolidation of fractures depends on various factors. Under optimal conditions fracture healing takes place within a few weeks. An essential requirement for fracture healing is the restoration of adequate biomechanical stability with an interfragmentary movement which is as ideal as possible. Distal femoral fractures can be particularly challenging especially in the presence of extensive soft tissue damage, multiple fragmented fractures and involvement of the joint. The currently applied surgical techniques of single lateral plate, double plate and intramedullary nail osteosynthesis as well as combination procedures have a relatively high complication rate. The principle of the biphasic plate is based on the transverse and longitudinal slots placed in the plate, which enables a "controlled instability". This results in a relatively high interfragmentary movement even at low loads (flexible phase) and a low movement at high loads (stiff phase). Therefore, the implant becomes more rigid at higher mechanical demands. In biomechanical tests the stress distribution of the implant, the number of cycles up to failure and the maximum load are superior compared to the locking compression plate distal femur (LCP-DF). Future studies will need to compare and evaluate the potential clinical and economic benefits in direct comparison to the currently established surgical techniques. Preclinical studies have so far demonstrated the safety and applicability of the biphasic plate and the innovative principle of controlled instability in fracture healing.

The postoperative assessment of fracture healing remains a clinical challenge despite established treatment standards. The lack of reliable information on the mechanical stability of the fracture complicates individualized follow-up care. This increases the risk of delayed mobilization, implant overload or late detection of healing complications.Sensor-based implants, such as the AO Fracture Monitor enable objective, continuous measurement of implant load, offering a novel approach to evaluating the healing process. Preclinical studies demonstrate a significant correlation between mechanical load and radiological healing parameters, confirming the potential of instrumented implants for diagnostic and preventive applications. Initial clinical data are currently being collected as part of a multicenter study. Additional application areas, such as spinal fusion and hip fracture treatment are the focus of ongoing research and commercial development efforts.Continuous data acquisition enables uninterrupted remote monitoring, independent of scheduled follow-up examinations. This opens new possibilities for dynamic adjustment of treatment protocols, early detection of complications and targeted rehabilitation management; however, integrating such systems into routine clinical practice poses substantial regulatory and procedural challenges. Current studies therefore provide an essential foundation for the gradual establishment of personalized follow-up strategies in routine clinical care.

Reduction of acetabular fractures places high demands on the treating surgeon due to the complex three-dimensional anatomy of the hemipelvis. Knowledge of various reduction instruments, step by step reduction techniques and approach-related intraoperative visualization are the basis for the as optimal as possible anatomical reduction. Marginal impactions are particularly challenging for the treating surgeon as often only an indirect approach to address these concomitant injuries is possible as these fragments are difficult to visualize intraoperatively.

Vertebral body metastases represent one of the most frequent manifestations of skeletal tumor dissemination and must be considered in the differential diagnosis of unexplained back pain, particularly in patients with a known history of oncological diseases. The associated morbidity, including spinal instability, deformity, pathological fractures and severe pain, is substantial. Healthcare professionals are regularly confronted with this complex clinical scenario in both outpatient and inpatient settings. A thorough medical history, especially the identification of red flags (e.g., prior trauma and/or malignancy) is critical. Early initiation of appropriate imaging studies, timely evaluation of the clinical urgency and expedited referral to specialized spine centers constitute the foundation for effective interdisciplinary treatment planning. This article outlines the key diagnostic and organizational principles required for the evaluation and further management of patients with vertebral metastases.

Severe trauma is a frequent cause of death worldwide, especially among younger patients and predominantly due to blunt abdominal trauma. While the liver is often affected, pancreatic injuries are rare. The initial diagnostics include the medical history, physical examination, laboratory tests and the focused assessment with sonography for trauma (FAST). The estimation of hemodynamic stability is decisive. Emergency laparotomy is indicated for critically ill patients and those with an accumulation of free intraabdominal fluid detected by sonography. Stable or stabilizable patients should undergo triphasic contrast-enhanced computed tomography. This enables classification of the injury pattern according to the injury scoring scale of the American Association for the Surgery of Trauma (AAST) and explicit detection of active bleeding and helps to estimate the extent of the injuries. Nonoperative management (NOM) has become established as the standard treatment. In addition to pure monitoring, special interventions are also used. A surgical approach is necessary in cases of instability, extensive injuries or failure of the NOM. The surgical approach depends on the pattern of injury and is similar to that of elective surgery. In addition to local hemostasis resections are possible. Both NOM and complex surgical treatment should be performed at specialized centers.

Background: Despite new working time regulations, the workload in orthopedics and trauma surgery remains high. Balancing work, family and leisure is difficult and can lead to frustration, health problems, and potential risks to patient safety, which can diminish the attractiveness of this surgical specialty. A current survey analyzes the present situation and identifies the needs of clinically active colleagues in the field of orthopedics and trauma surgery.

Material and methods: An electronic questionnaire (Microsoft Forms, Microsoft Inc., Redmond, WA, USA) was distributed to collect demographic data as well as information on current and desired working time and duty models. Additional questions addressed the work-life balance, opportunities for remote work (home office) and career goals. Data analysis and graphical presentation were carried out using Excel (Microsoft Inc) and statistical analyses were performed with SPSS Version 25.0 (IBM Corp., Armonk, NY, USA).

Results: A total of 549 individuals participated. Most participants were residents in training (n = 231) or senior physicians (n = 161). The established working time models were recognized but rated as below average in terms of satisfaction. Of the respondents 84% worked full-time with an average working time of 59.5 h per week. Both full-time and part-time employees expressed a significant desire to reduce their working hours, 54% reported the presence of an objective electronic or other time-tracking system and in 47% of cases a time-tracking account was in place. Of the respondents 84% indicated that remote work was not available, although 75% would like to make use of this option and 90% were interested in a continued employment in the hospital provided that their preferences could be implemented.

Conclusion: The workload of clinically active physicians in orthopedics and trauma surgery is high. Concepts that include a reduction in working hours, an improvement in duty-related strain, greater flexibility in working time models and the possibility of partial remote work could have a sustainable impact and offer a significant competitive advantage in view of increasingly scarce human resources.