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The treatment of scaphoid nonunion can be challenging with increasing defect size. We evaluated the outcome of scaphoid nonunion with a substantial bone defect treated with a multidirectional locking plate combined with cancellous bone grafting only. Thirteen patients with significant osseous defects measuring 6 mm or more suffering from primary nonunion without treatment (n = 6) or recalcitrant nonunion following Herbert screw osteosynthesis (n = 7) were treated and reviewed retrospectively. The stabilization was performed after debridement, autologous cancellous bone grafting and volar locking plate osteosynthesis. After a mean follow-up period of 12 months, 12 of the 13 patients achieved successful unions with a free range of motion and complete remittance of pain in everyday activity. The mean scapholunate angle decreased from 59.7° ± 11 to 43.9° ± 5 (effect strength d:1.7, p < 0.00001), scaphoid humpback deformity angle from 58.9° ± 8 to 45.1° ± 8 (d:1.8, p < 0.0001), whereas strength of the injured hand increased from 36.4 kg ± 10 to 42.4 kg ± 9 (d:1.4, p < 0.0001). One nonunion persisted without fragment dislocation receiving revision after 1 year. Thus, locking plate osteosynthesis with cancellous bone grafting is a valid alternative in scaphoid nonunions with extensive bone defects. Additionally, stable retention of the fragments prevents dislocation even in delayed or persistent nonunion. Further prospective studies are required to confirm these findings.

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Patients with long-segment cervical spinal fusion resulting from spinal ankylosing disorders (SADs) are at high risk for highly unstable cervical spine fractures necessitating surgery as the treatment of choice; however, without an existing gold standard. Specifically, patients without concomitant myelo- pathy, representing a rare entity, may benefit from a minimized surgical approach of a single-stage posterior stabilization without bone grafting for posterolateral fusion. This retrospective monocenter study in a Level I trauma center included all patients treated with navigated posterior stabilization without posterolateral bone grafting between January 2013 and January 2019 for cervical spine fractures in preexisting SADs without myelopathy. The outcomes were analyzed based on complication rates, revision frequency, neurologic deficits, and fusion times and rates. Fusion was evaluated by X-ray and computed tomography. 14 patients (11 male, 3 female) with a mean age of 72.7 ± 17.6 years were included. Five fractures were at the upper and nine at the subaxial cervical spine (predominantly C5-7). There was one surgery-specific complication of postoperative paresthesia. There was no infection, implant loosening, or dislocation, and no revision surgery necessary. All fractures healed after a median time of 4 months and 12 months being the latest time of fusion in one patient. Single-stage posterior stabilization without posterolateral fusion is an alternative for patients with SADs and cervical spine fractures without myelopathy. They can benefit from a minimization of surgical trauma while having equal times of fusion and no increased rate of complications.

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This study presents a detailed documentation of a total endoscopic anterior pelvic approach (TAPA) for plate fixation of a symphyseal disruption. The purpose of this work is to describe a minimally invasive technique as a possible method for reducing complications and hospitalization. Other goals included giving technical recommendations and assessing potential pitfalls and problems of this new surgical approach. Surgery was performed in an interdisciplinary setting by an experienced orthopaedic and general surgeon. The first endoscopic approach used to visualize the injury was the same as is used for endoscopic hernia surgery. The repositioning of the symphysial rupture was achieved either through external fixation or indirectly with traction and a pelvic binder. Plate positioning and fixation were achieved through two additional, minimally invasive incisions. The endoscopic approach shows multiple advantages, such as no detachment of the rectus abdominis muscle and smaller skin incisions. Furthermore, this approach could lessen the incidence of hernia and postoperative pain. We see the presented technique as a simple and innovative surgical method for treating symphyseal disruption.

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BACKGROUND: Cervical spine injuries (CSI) are rare in trauma patients, at about 9.2-16.5/100,000 inhabitants in Scandinavia and Canada, and the annual incidence of CSI surgeries in Norway is around 3.0/100,000 inhabitants. However, despite their rarity, the incidence of CSI has increased, thereby assuming an increasing need for surgery. Outside of Scandinavia, no data about the incidence of CSI and subsequent surgeries exist. Therefore, this study aimed to analyse CSI epidemiology and surgery in a German city with a Level I trauma centre both to understand the injury and improve needs-based planning. METHODS: This retrospective, monocentre study included all patients who presented with CSI from 2012-2017 at a university hospital with a Level I trauma centre in a major German city and had permanent residency within the city. Based on the assumption that the patients represented all CSI injuries in the city, as they were treated at the only available Level I trauma centre, the annual incidence of surgeries and neurologic deficits due to CSI were calculated. RESULTS: A total of 465 patients with 609 CSI were identified. Of these patients, 61 both received surgery and resided in the city (mean age, 68.1 ± 18.3 years; 26 female, 35 male). The incidence of CSI surgeries was calculated as 3.24/100,000 person years (1.75/100,000 in the upper and 1.54/100,000 in the subaxial cervical spine). Neurologic deficits occurred in 0.64/100,000 person years. The incidence of both surgeries and neurologic deficits showed no significant changes over the 6-year study period. CONCLUSIONS: Compared to Scandinavia, an increasing annual incidence for CSI surgeries and neurologic deficits were found. For long-term demand planning with adaptability to demographic changes, cross-regional studies including long-term follow-up are necessary.

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BACKGROUND: Video consultations could support patient care in hand surgery during social distancing in the COVID-19 era. According to the literature, images of hand and fingers can support telediagnosis in hand emergencies. We present this feasibility study on online video consultation in hand surgery. METHODS: A structured examination was designed to query the medical history and examine motor skills, sensitivity, strength and function tests of the hand. Thirty examinations on both hands were carried out by online video consultation, then in direct contact and compared with each other. RESULTS: With 4560 evaluated range of movement of the hand and finger joints, there was a high correlation between the measurement methods of R = 0.995 (p < 0.0001, confidence interval 0.9946 - 0.9954). In the video-based examination, 84.6% of the measured values showed a deviation of less than 5° compared to the direct examination, 92.8% less than 10° deviation. Good accordance was also found in the patient's medical history. An estimating examination of sensitivity, function and strength during video examination is feasible with simple auxiliary aids. Deficits are evident in the detection of scars, in function tests and the absence of haptic findings. CONCLUSION: Online video consultation allows hand examination with sufficient documentation of hand and finger movements (range of motion) and proper evaluation of symptoms. It cannot replace direct examination but complement patient care in hand surgery even beyond the current COVID-19 pandemic.

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Achilles tendon ruptures are among the most common ruptures of large tendons. Due to the vulnerable soft tissue there is a high risk of soft tissue defects. The combination of Achilles tendon ruptures and soft-tissue defects remains a challenge for the surgeon. Despite different treatment options there is a lack of structured treatment recommendation. By means of a systematic literature review and experience from our own clinic standard, an overview of the stepwise treatment options is presented. A treatment algorithm for reconstructive measures of Achilles tendon ruptures accompanied by soft-tissue defects according to the length of defect of the Achilles tendon, the size of the soft-tissue defect and patient-individual factors is developed. This is intended to serve the surgeon as a basis for decision making prior to application of therapy.

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BACKGROUND: Tumor prostheses are established as a standard procedure in tumors of the lower extremities. Septic and aseptic loosening remains the main reason for the failure of tumor prostheses. Due to bone defects, the possibilities of anchoring revision prostheses are limited. Trabecular metal cones are established in prosthetic revision surgery. However, the use of segmental trabecular metal cones in a custom-made tumor revision prosthesis has not yet been described. OBJECTIVE: A 58-year-old patient, who initially received a resection of the distal femur and reconstruction with a tumor prosthesis due to chondrosarcoma, attended our clinic. Because of aseptic loosening of this tumor prosthesis, revision surgery was indicated. METHODS: On account of huge bone defects, a reconstruction using a modular standard prosthesis was not possible. In order to prevent further resection of the bone and not replace the total femur, a custom-made revision tumor prosthesis was implanted. RESULTS: After preoperative planning and explantation of the loosened prosthesis, a partially cemented custom-made revision tumor prosthesis was successfully implanted using a Revitan® Curved revision stem with a custom-made Revitan® -Taperadapter and a custom-made segmental trabecular metal cone connected to a custom-made titanium segmental distal femur and a Zimmer® NexGen® RH Knee Tibia with a straight stem (Zimmer, Inc., USA). CONCLUSIONS: The application of segmental trabecular metal in a custom-made revision tumor prosthesis offers a new option to the previously existing treatment strategies.

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We report the case of a 62-year-old patient with lower back pain radiating into the right leg accompanied by numbness. The pain had an acute onset and was resistant to conservative pain treatment. A magnetic resonance imaging (MRI) scan of the lumbar spine showed no degenerative discovertebral lesions, but a swelling of the nerve root supplying the affected dermatome. For pain treatment the patient received lumbar epidural infiltrations. During this treatment the patient suddenly developed a skin rash with grouped vesicular blisters on an erythematous ground. After the diagnosis of a lumbar herpes zoster and an acyclovir treatment, the patient could be discharged in an ameliorated condition. This case demonstrates the importance to consider rare causes of lumbosciatic pain and disorders and to acknowledge unspecific changes in a MRI scan.