Study Design:Expert opinion.Objectives:Osteoporotic vertebral fractures are of increasing medical importance. For an adequate treatment strategy, an easy and reliable classification is needed.Methods:The working group “Osteoporotic Fractures” of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) has developed a classification system (OF classification) for osteoporotic thoracolumbar fractures. The consensus decision followed an established pathway including review of the current literature.Results:The OF classification consists of 5 groups: OF 1, no vertebral deformation (vertebral edema); OF 2, deformation with no or minor (<1/5) involvement of the posterior wall; OF 3, deformation with distinct involvement (>1/5) of the posterior wall; OF 4, loss of integrity of the vertebral frame or vertebral body collapse or pincer-type fracture; OF 5, injuries with distraction or rotation. The interobserver reliability was substantial (κ = .63).Conclusions:The proposed OF classification is easy to use and provides superior clinical differentiation of the typical osteoporotic fracture morphologies.
Background Postoperative C-reactive protein (CRP) levels in serum appear to reflect surgical trauma. We examined CRP levels after different types of surgery in hip fractures.Methods We studied the CRP response after 349 operative procedures in proximal femur fractures with a normal postoperative course. 5 different operative techniques were used: 3-4 percutaneous cancellous screws, dynamic hip screw (DHS), proximal femur nail (PFN), hemiarthroplasty (HA), and total hip arthroplasty (THA).Results Peak CRP levels were reached on the second postoperative day in each group (medians: screws 8.7, DHS 12, PFN 14, HA 16, THA 16 mg/dL). Significant differences were found between screws and all others, and between DHS and arthroplasties.Interpretation CRP levels following surgical trauma can be used to quantify the degree of tissue damage and invasiveness of a procedure and reflect the perioperative stress experienced by the patient.
Study Design:Prospective clinical cohort study (data collection); expert opinion (recommendation development).Objectives:Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures are widely differing. Based on current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification) the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations.Methods:a total of 707 clinical cases from 16 hospitals were evaluated. An OF classification–based score was developed to guide in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X-rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scan. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score.Results:A score of less than 6 points advocates nonsurgical management; more than 6 points recommend surgical management. The primary goal of treatment is fast and painless mobilization. Because of expected comorbidities in this age group, minimally invasive procedures are being preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. Instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment; necessity to fuse; multiple level fractures; consecutive and adjacent fractures; fractures in ankylosing spondylitis are being addressed separately.Conclusions:The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for treatment choices available. However, intermediate clinical situations remain with a score of 6 points allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the next step, the recommendations presented will be further evaluated in a multicenter controlled clinical trial.
Indications for liver surgery to treat primary and secondary hepatic malignancies are broadening. Utilizing data from B-mode or 2-dimensional intraoperative ultrasound, it is often challenging to replicate the findings from preoperative CT or MRI scans. Additional data from more recently developed image-guidance technology, which registers preoperative axial imaging to a 3-dimensional real-time model, may be used to improve operative planning, locate difficult to find hepatic tumors, and guide ablations. Laparoscopic liver procedures are often more challenging than their open counterparts. Image-guidance technology can assist in overcoming some of the obstacles to minimally invasive liver procedures by enhancing ultrasound findings and ablation guidance. This manuscript describes a protocol that evaluated an open image-guidance system, and a subsequent protocol that directly compared, for validation, a laparoscopic with an open image-guidance system. Both protocols were limited to ablations within the liver. The laparoscopic image-guidance system successfully creates a 3-D model at both 7 and 14 mm Hg that is similar to the open 3-D model. Ultimately, improving intraoperative image guidance can help expand the ability to perform both laparoscopic and open liver surgeries.
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