Der Orthopäde
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Locked plating is one of the most modern plating techniques, the aim of which is to achieve the smallest possible surgical trauma, small incisions, preserve blood supply to the bone and adjacent soft tissues, and to ensure a minimal bone-implant interface.
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Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. ⋯ The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.
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The stabilization of long bone fractures through reaming the medullary cavity and insertion of an intramedullary nail, with or without locking bolts, was a standard procedure in fracture treatment for a long time. With the development of nails, which can be applied without reaming, the procedure lost importance. This publication presents the mechanical principles and impact of reaming on the bone. ⋯ Today nevertheless unreamed nailing is favoured especially in German-speaking countries. This is maybe due to the necessary classic procedure of planning, positioning on the fracture table and reaming in steps, which make the operation slightly more complex, requiring a certain amount of armamentarium and technical understanding. In any case reamed intramedullary nailing offers an alternative procedure for many indications; to treat a hypertrophic non-union of the shaft of the long bones it remains the method of first choice.
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Bone tissue possesses a unique regeneration ability, translating mechanical and metabolic stimuli into a biological response. The perpetual regeneration processes allow continuous self-renewal and adaptation to prevailing mechanical forces. The complex regulation of osteoblastic differentiation during fracture repair has not been completely defined. ⋯ Moreover, correct WNT signalling is also required for BMP2-induced bone formation. There is increasing evidence that patients who develop recalcitrant fracture nonunions exhibit not only reduced numbers and differentiation capacity of osteogenic progenitors but also a significant downregulation of numerous factors in the WNT pathway. Therefore, better understanding of the WNT regulatory mechanisms could reveal new strategies for the treatment of delayed fracture healing and for the tissue engineering of bone.
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The efficacy of intensive interdisciplinary pain management programs for patients with chronic low back pain has been repeatedly demonstrated. A controversial issue in previous studies is the cost-effectiveness of this treatment. Between 2001 and 2006, a total of 575 patients with chronic nonspecific back pain took part in an outpatient pain management program at the German Red Cross Pain Center (DRK Schmerz-Zentrum Mainz) in Mainz, Germany. ⋯ For employed patients, the number of absent days decreased to almost one-quarter. On the basis of the study by Wenig, who calculated pain-related costs as a function of Von Korff pain grades, the treatment resulted in a savings of euro 3,329.50 per year per patient. Intensive multidisciplinary treatment of chronic back pain is highly effective and, at least for patients with high levels of disability, is also cost-effective.