For the stabilization of the ruptured pubic symphysis, rigid forms of fixation such as plate osteosynthesis and flexible fixations such as wire loops or PDS banding have been recommended. All methods have only been tested by static unidirectional loading until failure of the system. By this experimental arrangement Ecke and Hofmann found comparable results for flexible and rigid methods of internal stabilization of the pubic symphysis. They preferred flexible methods to maintain mobility of the symphysis and to prevent symphyseal fusion. We tested dynamic compression plate osteosynthesis, reconstruction plate osteosynthesis, wire loops and PDS banding for internal fixation of injured pubic symphysis in a dynamic multidirectional experimental arrangement simulating gait conditions. The specimens were loaded with 85 N in vertical (y-) direction and 34 N in sagittal (z-) direction, which represent 50% of the forces acting at the pubic symphysis during walking and with a frequency of 1.5 Hz over 55,500 loads simulating the conditions over a 6-week mobilization period. Loading with 100% of the acting forces (corresponding to full weight bearing mobilization) led to early failure of the system. Our experimental analysis showed that neither wire loops nor PDS banding is able to stabilize the ruptured pubic symphysis, even immediately after fixation before loading. During the tests instability increased until failure of the system due to cutting of the bone or breaking of the wires or PDS banding. Success of plate osteosynthesis was dependent on the initial stability of the fixation. Overwinding of the screws, as in osteoporotic bone, lead to increasing loosening during repeated loading, whereas primary stable fixation of the screws was almost completely maintained during the test. In consequence, neither wire loops nor PDS banding should be used for stabilization of injured pubic symphysis if early mobilization with partial weight bearing is desired. Plate osteosynthesis (DC or reconstruction plate) tolerates early half weight bearing in patients with "open-book" injury only if safe screw fixation is guaranteed.

Purpose: C-reactive protein (CRP) and white blood cell (WBC) count are routine blood chemistry parameters in monitoring infection. Little is known about the natural history of their serum levels in conservative and operative spondylodiscitis treatment. Methods: Pre- and postoperative serum levels of CRP and WBC count in 145 patients with spondylodiscitis were retrospectively assessed. One hundred and four patients were treated by debridement, spondylodesis, and an antibiotic regime, 41 only with a brace and antibiotics. The results of the surgical group were compared to 156 patients fused for degenerative disc disease (DDD). Results: Surgery had a significant effect on peak postoperative CRP levels. In surgically managed patients, CRP peaked at 2–3 days after surgery (spondylodiscitis: pre-OP: 90 mg/dl vs. post-OP days 2–3: 146 mg/dl; DDD: 9 mg/dl vs. 141 mg/dl; p < 0.001), followed by a sharp decline. Although values were higher for spondylodiscitis patients, dynamics of CRP values were similar in both groups. Nonoperative treatment showed a slower decline. Surgically managed spondylodiscitis showed a higher success rate in identifying bacteria. Specific antibiotic treatment led to a more predictable decline of CRP values. WBC did not show an interpretable profile. Conclusion: CRP is a predictable serum parameter in patients with spondylodiscitis. WBC count is unspecific. Initial CRP increase after surgery is of little value in monitoring infection. A preoperative CRP value, and control once during the first 3 days after surgery is sufficient. Closer monitoring should then be continued. Should a decline not be observed, therapy needs to be scrutinized, antibiotic treatment reassessed, and concomitant infection contemplated.

In our society every second polytraumatized patient is a chronic alcoholic. A patient's alcohol-related history is often unavailable and laboratory markers are not sensitive or specific enough to detect alcohol-dependent patients who are at risk of developing alcohol withdrawal syndrome (AWS) during their post-traumatic intensive care unit (ICU) stay. Previously, it has been found that plasma levels of norharman are elevated in chronic alcoholics. We investigated whether beta-carbolines, i.e. harman and norharman levels, could identify chronic alcoholics following trauma and whether possible changes during ICU stay could serve as a predictor of deterioration of clinical status. Sixty polytraumatized patients were transferred to the ICU following admission to the emergency room and subsequent surgery. Chronic alcoholics were included only if they met the DSM-III-R and ICD-10 criteria for alcohol dependence or chronic alcohol abuse/harmful use and their daily ethanol intake was > or =60 g. Harman and norharman levels were assayed on admission and on days 2, 4, 7 and 14 in the ICU. Harman and norharman levels were determined by high pressure liquid chromatography. Elevated norharman levels were found in chronic alcoholics (n = 35) on admission to the hospital and remained significantly elevated during their ICU stay. The area under the curves (AUC) showed that norharman was comparable to carbohydrate-deficient transferrin (CDT) and superior to conventional laboratory markers in detecting chronic alcoholics. Seventeen chronic alcoholics developed AWS; 16 of these patients experienced hallucinations or delirium. Norharman levels were significantly increased on days 2 and 4 in the ICU in patients who developed AWS compared with those who did not. An increase in norharman levels preceded hallucinations or delirium with a median period of approximately 3 days. The findings that elevated norharman levels are found in chronic alcoholics, that the AUC was in the range of CDT on admission and that norharman levels remained elevated during the ICU stay, support the view that norharman is a specific marker for alcoholism in traumatized patients. Since norharman levels increased prior to the onset of hallucinations and delirium it seems reasonable to investigate further the potential role of norharman as a possible substance which triggers AWS.

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Due to a significant increase in spinal interventions and in particular spinal fusion procedures, also in elderly and immunocompromised patients, spinal surgeons are increasingly confronted with deep wound infections and/or spondylodiscitis with in situ instrumentation. This occasionally life-threatening complication can be a challenge for even the most experienced physician, not only in the initial diagnosis but also when determining the operative treatment strategy. It is not uncommon that patients must undergo several operations before a deep infection is finally under control. The aim of this article is to suggest an algorithm for the diagnostics and management of this very troubling complication.