Hannover Scoring System Research Articles

Surgical Treatment and Rediscussion of Day’s Classification of Crescent Pelvic Fracture Combined with the Sacral Fracture

Objective: The aim of this study was to summarize the surgical treatment of crescent pelvic fracture combined with the sacral fracture and rediscuss the Day’s classification in the pelvic crescent fractures. Methods: From May 2012 to May 2019, 24 patients of crescent pelvic fracture combined with the sacral fracture were included in this study (15 males, 9 females, mean age: 46.8 years). In this study, there were 8 cases, whose posterior bone mass was large, involving less than 1/2 of the sacroiliac joint. The lateral position was used and the arc incision along the posterior iliac ridge could be taken, the fracture should be first reduced and fixated with lag screw, and then with reconstruction plate. There were another 16 cases, whose posterior bone mass was small, involving more than 1/2 of the sacroiliac joint. For the patients with less injury of sacroiliac joint posterior ligament, the anterior ring of pelvis was fixated first, then the arc-shaped incision along the posterior iliac ridge on both sides was taken in prone position, the fracture could be reduced and fixated with lag screws and then fixated with tension plate. For the patients with server sacroiliac joint complex injury, the open reduction of anterior and posterior rings of the pelvis was taken in the floating position and fixation or arthrodesis of the sacroiliac joint could be taken. For the patients without obvious displacement of the sacroiliac joint, the anterior and posterior approaches could be used at the same time in the supine position to fixate the sacroiliac joint fixation. In addition, the average operation time, the mean blood loss, displacement differences between preoperation and postoperation, fracture union time and Hannover Scoring System were recorded. Results: The average operation time was 75 mins (range from 40 mins to 160 mins), the mean blood loss was 561.7 ml (range from 300 ml to 1100 ml). Meanwhile, no lumbosacral radiculomyelitis was injured in these cases. The mean follow-up period was 16.1 months (range from 12 months to 36 months) and the mean radiographic healing time was 3.6 months (range from 3 months to 6 months) respectively. Due to Hannover Scoring System, 18 patients were in excellent condition and 6 patients were in good condition. Conclusion: The crescent pelvic fracture combined with the sacral fracture was not included in current Day’s classification. We treated 24 cases of crescent pelvic fracture combined with the sacral fracture and obtained good clinical outcome. Therefore, we posed a new type to complement it to the Day’s classification, which was defined as crescent pelvic fracture combined with sacral fracture. It was helpful for the surgeons to choose suitable approach and implants.

Arthroscopic microfracture with atelocollagen augmentation for osteochondral lesion of the talus: a multicenter randomized controlled trial

BackgroundWe aimed to evaluate whether arthroscopic microfracture with atelocollagen augmentation could improve the clinical outcomes and quality of regenerated cartilage in patients with osteochondral lesion of the talus (OLT). We hypothesized that the clinical outcomes and quality of the regenerated cartilage would be superior in patients undergoing arthroscopic microfracture with atelocollagen augmentation compared to those undergoing arthroscopic microfracture alone.MethodsIn this multicenter, randomized controlled trial, 60 patients were randomly allocated to two groups: arthroscopic microfracture with atelocollagen augmentation (group 1, n = 31) and arthroscopic microfracture alone (group 2, n = 29). Mean 100-mm visual analog scale (VAS), Hannover scoring system (HSS), and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed 2 years postoperatively and compared between the groups. The quality of the regenerated cartilage was assessed according to the Magnetic Resonance Observation of CArtilage Repair Tissue (MOCART) score based on magnetic resonance imaging.ResultsForty-six patients (22 in group 1, 23 in group 2) completed the 2-year follow-up. The quality of the regenerated cartilage assessed based on the MOCART score was significantly superior in group 1 compared to group 2 (64.49 ± 18.27 vs 53.01 ± 12.14, p = 0.018). Clinical outcomes in terms of 100-mm VAS (17.25 ± 20.31 vs 19.37 ± 18.58, p = 0.72), HSS (93.09 ± 13.64 vs 86.09 ± 13.36, p = 0.14), and AOFAS (91.23 ± 8.62 vs 86.91 ± 10.68, p = 0.09) scores were superior in group 1 compared to group 2, but the differences were not statistically significant. Both groups showed significant improvements in clinical outcomes compared with the preoperative values.ConclusionThe quality of the regenerated cartilage was superior after arthroscopic microfracture with atelocollagen augmentation compared to that after microfracture alone in patients with OLT. Clinical outcomes assessed 2 years postoperatively were superior in patients who underwent arthroscopic microfracture with atelocollagen augmentation compared to those who underwent arthroscopic microfracture alone, although the differences were not statistically significant. A long-term study of the cohort is required to confirm these findings.Trial registrationClinicalTrials.gov (NCT02519881), August 11, 2015.

4-5 Year Results Following AMIC Procedure with Collagen Matrix in Cartilage Reconstruction of the Talus

Category: Ankle, Arthroscopy Introduction/Purpose: In recent years, the autologous matrix-induced chondrogenesis (AMIC) has established itself in the treatment of cartilage defects of the talus. In this prospective study, the 4-5 year results following arthroscopic AMIC technique at the Talus will be presented. Methods: 97 patients has been treated with this method from August 2009 until September. 48 patients (26 F, 22 M) with a mean age of 36.5 ± 3.9 years (15-69) and a BMI of 24.8 ± 3.9 (19.1 to 39.6) met the inclusion criteria. The Hannover scoring system (HSS) and VAS score for pain, function and satisfaction at baseline and 1 year (FU1), 2 years (FU2) and 4.4 years (FU3) postoperatively have been evaluated. Following arthroscopic exploration to control the inclusion criteria, the cartilage defect was debrided thoroughly. Subsequently, microfracturing has been performed with a special swan neck awls and then PRP was injected over the subchondral plate. Afterwards, covering of the defect area was carried out with the collagen matrix (AMIC) which was impregnated with PRP, which was then fixed with fibrin glue. Results: The HSS improved from 55.6 ± 12.18 baseline to 82.3 FU1 ± 15.64 (p <0.05 compared to baseline.), FU2 88.8 ± 7,43 (p <0,05 see to baseline) and FU3 89.7 ± 8.3 (p <0.05 compared to baseline) with a significant improvement over the entire period of p = 0.008. VAS for pain was 4 ± 2.74 at the Baseline and improved at FU1 to 7.8 ± 2.73 (p <0.05, compared to baseline.), FU2 8.9 ± 1.01 (p <0.05) and FU3 9.3 ± 1.26 (p <0.05) with a significant improvement over the entire period of p = 0.001. Similar results were observed in the VAS scores for function and satisfaction. There were no infections or surgical complications. Conclusion: The arthroscopic AMIC procedure also shows good mid-term results in treatment of cartilage defects of the talus. It is a promising and safe procedure in the cartilage therapy with a low complication rate through an arthroscopic surgery.

T2-mapping at 3 T after microfracture in the treatment of osteochondral defects of the talus at an average follow-up of 8 years

To compare repaired cartilage with native cartilage, and inter-observer reliability, using T2 mapping at 3T for assessing cartilage repair in osteochondral defects of the talus after the microfracture technique. We enrolled eight females and seven males undergoing arthroscopic microfracture for osteochondral defects of the talus at an average follow-up of 7.9±2.2years (range 5-13years). Cartilage tissue was assessed using a 3-T magnetic resonance imaging unit with an 8-channel phased array foot and ankle coil (gradient strength, 50mT/m; slew rate, 200T/m/s). T2 maps were then calculated. Three independent boarded specialists evaluated the images, and magnetic resonance observation of cartilage repair tissue scores was used to assess the cartilage and joint status. Clinical results were assessed using the Hannover Scoring System (HSS) for the ankle and the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot score. No significant mean differences were found between the T2 properties of the repair tissue and those of the native reference cartilage (T2=38.6±5.3ms, range 30.2-55.8ms vs. 40.3±8.5ms, range 31.4-59.8ms, respectively; intra-class correlation coefficient=0.94; confidence interval 0.84-0.99, P≤0.001). Despite ≥50% defect filling in all patients, subchondral bone changes were considerable. The HSS at the follow-up revealed a mean score of 87±12 (range 51-97), and the AOFAS-Score was 90±13 (range 59-100). 3T T2 maps were similar in repaired and native cartilage with good inter-observer reliability. IV.

Missed foot fractures in polytrauma patients: a retrospective cohort study

BackgroundMissed foot fractures are a known problem in the care of the traumatized patient. They do not usually have an influence on the survival, but on the long-term result and the quality of the patient’s life. The aim of this study is to find out how many of these fractures are overlooked in a Level I trauma center and what the consequences for the patients are hypothesing that patients with a delayed diagnosis will have worse clinical results.MethodsForty-seven patients (7.3%) with foot fractures could be identified in 642 polytrauma patients, retrospectively. All patients were divided into two groups: early diagnosed fractures and delayed diagnosed fractures, the latter defined as diagnosed after Secondary Survey. Patients were evaluated according to the Hannover Outcome Score, the Short Form-36 Health Survey, the AOFAS Score and the Hannover Scoring System. The average follow-up was 5 years and 8 months. Reasons for overlooking a foot fracture were analyzed.ResultsThe foot fracture was early diagnosed in 26 (55.3%) patients, but delayed in 21 (44.7%). There were no significant differences in the mean stay in the hospital or in the ICU. The fractures that were most often missed were those of the cuboid or the metarsalia. The highest risk factor for a delayed diagnosis was a fracture already diagnosed on the same foot. In 52.4% of the delayed diagosed fractures, an operative therapy was necessary. There were no significant differences between the two groups in the clinical results.ConclusionsIn summary, the results of this study show that foot injuries can be a safety problem for the patient and the examination of the feet in the trauma room has to be a compulsory part of the algorithm. Although the majority of delayed diagnosed foot fractures demonstrated comparable results to the immediately diagnosed fractures, approximately 10% might have benefited from an earlier diagnosis. Even if there were no significant differences in the clinical results, we have to be aware that missing a fracture in the foot can lead to worse results in the complete polytrauma care.

Posterior fixation of thoracolumbar burst fractures: Is it possible to protect one segment in the lumbar region?

BackgroundThe treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures.MethodsIS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation.ResultsThe measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)].ConclusionsThe radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.

Operative treatment of crescent fracture of the pelvis by posterior approach

Objective To explore the efficacy of posterior approach in treatment of crescent pelvicfracture. Methods Between April 2007 and January 2010, 12 patients with crescent pelvic fracture were treated via posterior approach at our department. They were 8 men and 4 women, aged from 21 to 55 years （average, 31.3 years）. Six left and 6 right sides were affected. The fractures were caused by a traffic accident in 8 cases, high falling in 3 cases and heavy weight crushing in one. By Tile classification, there were 8 cases of type B2. 1 and 4 cases of B2.2. The time from injury to operation was 3 to 9 days, with an average of 6.2 days. They were treated with open reduction and internal fixation via the posterior approach. Operation time, intraoperative blood loss, postoperative loss of pelvic ring reduction, fracture healing time and Hannover pelvic outcome scoring were documented. Results The average operation time was 172.5 ±34. 1 minutes（from 120 to 240 minutes） . The average blood loss was 412.5±128. 1 mL（from 250 to 700 mE） . The average reduction gained was 11.7±4.6 mm（from 6 to 21 mm）, Ten patients obtained an average follow-up of 16.3 months （from 12 to 20 munths）. The X-ray films showed bony healing in all patients after an average of 3. 1 ±0.3 months（from 3 to 4 months）. There was no postoperative loss of pelvic, ring reduction or implant failure. By the Hannover scoring system, 7 patients were rated as excellent and 3 as good in clinic symptoms, and complete social reintegration was obtained in 8 cases and incomplete one in 2 cases. Conclusion Operation via posterior approach is a good choice for treatment of crescent pelvic fracture. Key words: Pelvis; Fractures; Sacroiliac joint; Fracture fixation, internal

Microfracture for chondral defects of the talus: maintenance of early results at midterm follow-up

We determined whether the early improvement in symptoms and function after microfracture in the management of articular cartilage defects of the talus is maintained at mid term follow-up. Factors influencing outcome and postoperative magnetic resonance imaging were also evaluated. We performed data collection prospectively using the Hannover Scoring System for the ankle (HSS) and a Visual Analog Scale (VAS) for pain and function preoperatively, at 1 +/- 0.1 year (45 ankles), 2 +/- 0.4 years (45 ankles), and at an average of 5.8 +/- 2.0 years (39 ankles) postoperatively. MRI was used to assess cartilage repair tissue based on the following variables: degree of defect repair and filling of the defect, integration to border zone, surface of the repair tissue, structure of the repair tissue and subchondral bone alterations. Comparing the outcome scores of the last follow-up to the previous follow-up points, the HSS and the VAS (pain, function and satisfaction) showed no deterioration. Four ankles, however, underwent further surgery to address the chondral defect and were regarded as failures. A body mass index greater than 25 kg/m(2) and having severe post-traumatic cartilage damage appeared to be negative prognostic factors. Results for patients older than 50 years were not inferior to those in younger patients. Microfracture arthroplasty induces repair of localized articular cartilage defects of the talus maintaining the encouraging early results at mid term follow-up.

Die autologe Knorpelzelltransplantation zur Behandlung von Knorpelläsionen am Talus

In contrast to the knee joint, autologous chondrocyte transplantation (ACT) is rarely used for treating articular cartilage lesions in the ankle joint. Matrix-associated autologous chondrocyte transplantation (MACT) with the use of biomaterials as cell carriers has facilitated operative application and fixation within the lesion. We have gained experience in the use of two different MACT techniques. According to the Hannover scoring system for the ankle and visual analog scores, results improved significantly (p<or=0.001) after MACT with the Hyalograft C in nine ankles at a mean follow-up of 3.7 years (range 2.6-4.8 years). All patients had undergone prior operative treatment for the cartilage lesion. Two patients were rated as excellent and seven as good. According to the ICRS cartilage repair assessment score, the transplanted areas were rated nearly normal (grade II) in seven patients who underwent undergone repeat arthroscopy. Magnetic resonance imaging revealed that in the majority of cases, filling of the defect was accomplished with a nonhomogeneous surface and structure of the graft. The use of a purely arthroscopically applicable three-dimensional MACT (ARTROcell 3D) with chondrospheres further facilitates the process and reduces operative morbidity. We have included eight patients in a prospective study so far. Six patients had undergone prior operative treatment for the cartilage lesion. In two cases, culturing of the cells failed for unexplained reasons; therefore, only six patients finally received the MACT with chondrospheres, and only four patients were evaluated at a 6-month follow-up examination. Thus, valid results cannot be reported. In revision cases, MACT is suggested to be a reliable alternative for treating articular cartilage lesions of the talus, but longer-term results in more patients remain to be evaluated.

Die Technik der Mikrofrakturierung zur operativen Therapie von Knorpelläsionen am Talus

The microfracture technique is an established method for treating articular cartilage lesions of the talus. Symptomatic chondral or osteochondral lesions of grade II or higher with softening or fraying of the chondral surface or an unstable rim are indications for débridement of the lesion and use of the microfracture technique. In advanced degenerative lesions, the indication must be determined critically. In a prospective study, significant (p<0.001) improvement was observed at a mean follow-up of 5.2 years (range 3.8-6.6 years) in 23 ankles. According to the Hannover scoring system, 87% of the patients were rated as excellent or good. Results for patients older than 50 years were not inferior to those for younger patients. Results for overweight patients were significantly (p=0.03) worse compared with patients of normal weight. Magnetic resonance imaging findings revealed that filling of the defect is accomplished in the majority of cases with an inhomogeneous structure of the cartilage repair tissue and a high incidence of subchondral alterations. The microfracture technique appears to be a reliable method for treating chondral and osteochondral lesions of the talus, with good outcomes in a mid-term follow-up.

Etiology, treatment and long-term results of isolated midfoot fractures

Abstract Purpose Etiology, treatment and long-term results of patients with isolated midfoot fractures were evaluated to create a basis for treatment optimization. Method Injury cause, type and extent, treatment and long-term results (American Association of Foot and Ankle Surgery-Midfoot-Score (AOFAS-M), Hannover Scoring System (HSS), own Questionnaire (Q)) of isolated midfoot fractures (avulsions and Chopart/Lisfranc fracture dislocations excluded) were determined. Results Fifty-eight patients with isolated midfoot fractures were included. Injury causes were vehicular trauma ( n =40), falls ( n =13), contusions ( n =3) and others ( n =2). The fractures were located as follows: cuboid, n =28; naviculare, n =23; cuneiforme I, n =19; cuneiforme II, n =11; and cuneiforme III, n =9. 91.4% ( n =53) of cases were treated operatively, 15 times with closed and 38 times with open reduction. Five patients were treated conservatively. Forty-seven (81.0%) patients had follow-up after 9 (1–22) years. The mean follow-up scores of the entire group were AOFAS-M=66.7, HSS=62.8, and Q=62.2. No significant score differences were determined with regard to age, sex, and time or type of treatment. The highest scores were observed in non-displaced fractures or after early anatomic reduction. Conclusion Isolated midfoot fractures without Chopart's or Lisfranc's joint fracture dislocation are uncommon. The long-term results are mostly characterized by minimal functional restrictions. In cases with poor results, the initial restoration of anatomic conditions have been unsatisfactory. Therefore, we recommend the early reduction and internal fixation in all displaced fractures. The reduction should be open if the closed reduction does not achieve anatomic conditions.

Results of Microfracture in the Treatment of Articular Cartilage Defects of the Talus

The microfracture technique has been used successfully for the treatment of cartilage defects in the knee. The purpose of this study was to evaluate the microfracture technique in the treatment of osteochondral and degenerative chondral defects of the talus. In a prospective study, 30 ankles in 30 consecutive patients (17 men and 13 women; average age, 41 years; range 20 to 74 years were treated with arthroscopic microfracture. Twenty patients had osteochondral defects and 10 had degenerative chondral defects. Patients were evaluated with clinical examination and MRI preoperatively and at 3, 6, 12, and 24 months postoperatively. At a mean followup of 2 years (range 22 to 27 months), 29 patients were available for follow-up. The results for all ankles according to the Hannover Scoring System were 45% excellent, 38% good, and 17% satisfactory. Results in patients older than 50 years were not inferior to those in younger patients. Visual Analog Score revealed an average of 8 +/- 2 for pain (preoperatively 3 +/- 2; p < or = 0.001), 8 +/- 2 for function (preoperatively 3 +/- 2; p < or = 0.001) and 8 +/- 2 for satisfaction (preoperatively 2 +/- 2; p < or = 0.001). MRI and arthroscopic assessment suggested the presence of cartilage in the microfractured area. At short-term followup, the microfracture technique appeared to repair severe cartilage damage with a good functional outcome. Age was not shown to be a limiting factor.

Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction.

Injury cause, treatment, and long-term results [American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score, Hannover Scoring System, Hannover Outcome Questionnaire] of patients with Chopart joint dislocations or fracture-dislocations were evaluated. Between 1972 and 1997, 100 patients with 110 Chopart joint dislocations were treated in the authors' institution. Pure Chopart joint dislocations were observed in 28 (25%) feet, fracture-dislocations in 60 (55%) feet, and combined Chopart-Lisfranc joint fracture-dislocations in 22 (20%) feet. The primary treatment was operative in 91 (83%) feet and nonoperative in 19 (17%) feet. Sixty-five (65%) patients had follow-up after an average of 9 years (range, 2-25 years). The mean scores of the entire follow-up group were: AOFAS score, 75 points; Hannover Scoring System, 69 points (maximium possible score = 100 points); Hannover Outcome Questionnaire, 68 points (maximium possible score = 100 points). There were no differences between the scores for pure dislocations or fracture-dislocations of the Chopart joint, but significantly lower scores were noted with combined Chopart-Lisfranc joint fracture-dislocations. In all three injury pattern groups, an initial anatomic reduction was essential for good results. The high functional restrictions in Chopart dislocations can most likely be minimized with initial open reduction, especially in fracture-dislocations. A closed reduction yielded good results only with pure dislocations, when anatomic conditions could be restored, or if there were contraindications to surgery.

Aetiology, treatment and outcome in Lisfranc joint dislocations and fracture dislocations

The aetiology, treatment and outcome of Lisfranc joint dislocations and fracture dislocations (L) were analysed. From 1972–97, 101 L were treated (right: n = 52, left: n = 49, bilateral: n = 8). Pure joint dislocations (LD) were observed in 24 cases, fracture dislocations (LFD) in 55 cases and Chopart-Lisfranc fracture dislocations (CLFD) in 22 cases. A total of 85 L were operatively treated; 15 times with closed reduction and 70 times with open reduction. A total of 85 (84%) feet received internal fixation, and in 15 (15%) cases, an external fixator was utilized additionally. In total, 10 primary and 20 secondary arthrodeses were performed and 16 feet were treated non-operatively. A total of 62 patients had follow-up after 9 (1–25) years. The mean scores were: AOFAS-Midfoot = 72 (29–100), Hannover Scoring System = 66 (26–100). Under consideration of age, sex, injury cause, time and type of treatment, no significant score differences occurred. CLFD showed lower scores than LD and LFD. In LFD and CLFD, an initial and maintained anatomic reduction with internal fixation or added external fixation was essential for good results. The long-term results of L are characterized by high functional restrictions, which can most likely be minimized with early open reduction and internal fixation, especially in fracture dislocations.

Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients.

An osteochondral defect (OCD) is known as a symptomatic lesion causing pain, recurrent synovitis, and altered joint mechanics most commonly in a weight-bearing joint. Loose bodies may develop, which may then cause joint destruction and/or locking. The damage to the articular surface is most likely a precursor of ankle osteoarthritis. With the recent advances in diagnostic imaging, such as MRI, as well as the development of ankle arthroscopy, the identification and classification of these lesions has become much more precise. This allows more accurate staging and improves treatment recommendations. The assessment of a particular treatment is also improved. A variety of treatment alternatives are now available. These include arthroscopic procedures including debridement, retrograde drilling, and bone grafting. Compared to open treatment, arthroscopic procedures may be particularly advantageous in the treatment of small defects and stable OCD lesions. Until recently, however, favorable results have been less predictable for large or unstable osteochondral defects. We treat these more difficult lesions with a mosaic autogenous osteochondral transplantation. In our hands, this appears to provide an optimal treatment result. The present report evaluates the clinical outcome of 36 patients followed for two to seven years after a mosaicplasty autogenous osteochondral transplantation from a non or less weight bearing portion of the knee to the ipsilateral talus. Ankle function was measured by the Hannover scoring system and showed good to excellent results in 34 cases (94%) with no long term donor site morbidity. The encouraging clinical results are supplemented with radiographs and histology, which support the premise of lasting relief of symptoms and prevention of ankle arthrosis.

Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results

Etiology and outcome of 155 patients with midfoot fractures between 1972 and 1997 were analyzed to create a basis for treatment optimization. Cause of injuries were traffic accidents (72.2%), falls (11.6%), blunt injuries (7.7%) and others (5.8%). Isolated midfoot fractures (I) were found in 55 (35.5%) cases, Lisfranc fracture dislocations (L) in 49 (31.2%), Chopart-Lisfranc fracture dislocations (CL) in 26 (16.8%) and Chopart fracture dislocations (C) in 25 (16%). One hundred and forty eight (95%) of the midfoot fractures were treated operatively; 30 with closed reduction, 115 with open reduction, 3 patients had a primary amputation. Seven (5%) patients were treated non-operatively. Ninety seven (63%) patients had follow-up at an average of 9 (1.3-25, median 8.5) years. The average scores of the entire follow-up group were as follows: AOFAS - sum of all four sections (AOFAS-ET): 296, AOFAS-Midfoot (AOFAS-M): 71, Hannover Scoring System (HSS): 65, and Hannover Questionnaire (Q): 63. Regarding age, gender, cause, time from injury to treatment and method of treatment no score differences were noted (t-test: p>0.05). L, C or I showed similar scores and CL significantly lower scores (AOFAS-ET, AOFAS-M, HSS, Q). The highest scores in all groups were achieved in those fractures treated with early open reduction and operative fixation. Midfoot fractures, particularly fracture dislocation injuries, effect the function of the entire foot in the long-term outcome. But even in these complex injuries, an early anatomic (open) reduction and stable (internal) fixation can minimize the percentage of long-term impairment.

Subtalar fusion after conservative or operative treatment of intraarticular calcaneus fracture

In a long-term follow-up we evaluated 40 patients out of 55 (73 %) with a subtalar fusion. The operations took place from 5/84 to 5/91. In all cases the indication for the fusion was a post-traumatic arthritis after an intra-articular os calcis fracture. The evaluation of the overall results was carried out with three different scoring systems: a. The Hannover Scoring System. b. The Outcome-questionnaire, rating patient's complaints and the functional status based on the severity-symptom scale and functional status described for Carpaltunnel-syndrome by Levine et al. c. The clinical rating system (CRS) described by Kitaoka et al. The statistical evaluation was performed by analysis of variance (ANOVA). Level of significance was based on P = 0.05 and calculation of Pearson's correlation coefficient. The Os calcis fracture was the cause for the subtalar arthritis in all 40 patients (33 males and 7 females). The primary treatment of the calcaneal fracture was conservative (cons.) using a plaster in 23 patients (57.5 %), while 17 patients (42.5 %) underwent open reduction and plate fixation (op.). The interval between trauma and subtalar fusion averaged 3.5 years (3 months to 20 years). The interval between subtalar fusion and follow-up averaged 5.2 years (4–14 years). The mean age at the time of reexamination was 47 years (26–61 years). In the present study, complete pain relief could be achieved in 21 (52.5 %; 58 % op., 50 % cons.) patients. A relevant restriction in the range of motion in the ankle joint was found in 26 (65 %; 76 % op., 58 % cons.). In 23 patients (62 %; 65 % op., 59 % cons.) the radiological evaluation revealed a grade 1 ° arthritis of the ankle joint, in the talonavicular joint in 17 patients (42.5 %; 41 % op., 45 % cons.), and in the calcaneo-cuboid joint in 14 patients (35 %; 47 %., 27 % cons.). The statistical analysis revealed a better outcome in the operative group compared with the conservative group, although the operated os calcis fractures in the majority were the more severe fracture types. In all evaluation systems a score between 61 and 69 points could be achieved with no significant difference between the operatively and conservatively treated groups and between the newly developed questionaire and the clinical-radiological scoring systems. For the questionaire this fulfills the requirements for a reliable outcome evaluation.

Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique--a preliminary report.

A one-stage autogenous osteochondral grafting technique for the treatment of talar dome osteochondritis dissecans is described. Eleven patients with osteochondritis dissecans lesions, 10 mm or greater in diameter, were operated on using the mosaicplasty autogenous osteochondral transplantation technique. Osteochondral cylindrical grafts from the ipsilateral knee were delivered into the talar defect using specially designed tube chisels. These procedures were done by arthrotomy. With follow-up of 12 to 28 months (mean, 16 months), the patients returned to full activities and the results, using the Hannover scoring system, have been excellent.

Comparison of scoring systems in primary myelodysplastic syndromes

To compare the prognostic value of scoring systems in primary myelodysplastic syndromes (pMDS), four clinicohematological systems (Rennes, Bournemouth, Düsseldorf, Pavia) and the histopathological Hannover Scoring System were applied to 415 MDS patients from the Bone Marrow Registry of Hannover Medical School. According to the FAB classification, 180 patients (43%) were diagnosed as RA, 33 (8%) as RARS, 99 (24%) as RAEB, 36 (9%) as RAEBt, and 48 (12%) as CMMOL; 19 patients (4%) were not further classified (MDS.UC). All scoring systems revealed three or four groups of patients with significantly different survival times. The ranges and standard deviations in these groups were similar but high in all scoring systems. A good differentiation between short-term survivors (< 1 year survival time) and intermediate-term survivors (1-4 years) was possible with all tested scoring systems, but the differentiation between intermediate- and long-term survivors (> 4 years) was not distinctive enough. The problem of risk assessment in the single patient is furthermore elucidated by the values of specificity and sensitivity, which were relatively low in all scoring systems tested. Best results were yielded by the Bournemouth Score for long-term survivors and the Düsseldorf and Hannover Score for intermediate- and short-term survivors. Multivariate analysis of all parameters used in the scoring systems showed the highest negative impact on survival for increase of myeloblasts, anemia, myelofibrosis, high age of the patient, and abnormal localization of immature precursors (ALIPs). Therefore, the histopathological Hannover Scoring System is not only equal to clinicohematological risk assessment in pMDS, but also includes important independent prognostic parameters. Risk assessment for the individual low-risk MDS patient using only initial parameters may be rendered impossible due to the biological nature of pMDS. Therefore, sequential analysis is needed to elucidate random events which alter the prognosis.