Operative Orthopadie Und Traumatologie最新文献

Objective: Long-term stable fixation of the leg to the remaining ilium or sacrum following internal hemipelvectomy including resection of the acetabulum.

Indications: Bone sarcomas, soft tissue sarcomas infiltrating the bone, solitary late metastases, acetabular reconstruction failure.

Contraindications: Palliative treatment goal, mutilating resection (especially when the tumor extends beyond the midline of the sacrum).

Surgical technique: Facilitation of stable fixation of the femoral head or proximal femur replacement to the remaining bone (ilium or sacrum,) following periacetabular pelvic resection. Insertion of 2-3 bone anchors in the ilium or sacrum, depending on the extent of tumor resection, alternatively transosseous sutures and attachment of a partially resorbable mesh, closed at the proximal end. Depending on the muscular coverage, repositioning of the hip or bipolar cup proximally. Attachment of the mesh to the remaining hip capsule or the megaprosthesis and the muscles. The reconstruction length must not compromise sufficient muscle coverage.

Postoperative management: Elastic hip spica. Bed rest for 1-2 weeks, depending on the weight of the leg. Mobilization with a walker or 2 crutches with 20 kg weight bearing for the following 4-6 weeks. Lymphatic drainage/venous foot pump as required. Adjuvant chemo- or radiotherapy as per multidisciplinary tumor board recommendation.

Results: The goal is the development of a stable scar around the neo-joint with minimal dead space. Young patients can often walk for several kilometers, typically using a walking stick on the contralateral side. Sole lift, lengthening of the femur at a later point if desired. There is a risk of wound-healing disorders or deep infections postoperatively in approximately 30% of cases. In case of infection, removal of the mesh and possibly of the proximal femoral replacement, as well as vacuum-assisted closure therapy may be necessary.

Objective: Biological reconstruction of extensive meta-/diaphyseal bone defects using autologous fibular graft. Aim is stable defect bridging with preservation of the limb and restoration of function.

Indications: Intercalary bone defects caused by joint-preserving tumor resection of bone tumors, failed osteosyntheses with pseudarthrosis, chronic osteomyelitis after debridement, posttraumatic or congenital bone loss. Vascularized grafts are particularly indicated in cases of compromised soft tissue, previous radiotherapy, defects > 10-12 cm, or anticipated delayed healing.

Contraindications: Severe peripheral arterial occlusive disease (donor or recipient site); active infections. Relative contraindications for vascularized grafts include short, biologically active defects with intact perfusion.

Surgical technique: Harvesting of the fibula as a vascularized or nonvascularized segment, adaptation to the defect, fixation using plates. In tumor resections possible combination with allografts or extracorporeally irradiated autografts (using Capanna technique)-especially in the lower leg to improve mechanical stability. Microsurgical vascular anastomoses are required for vascularized fibula.

Postoperative management: Early mobilization under unloading conditions, regular radiographic monitoring, and gradual weight-bearing based on consolidation. Physiotherapy to prevent joint stiffness; clinical monitoring of the donor site.

Results: Consolidation rates of 85-95% under appropriate fixation and soft tissue coverage. Fibula grafts show high biological integration, potential for hypertrophy under load, and long-term load capacity. Typical complications include nonunion, graft fracture, infection, vascular complications, and donor-site morbidity.

Surgical objective: Removal of sufficient representative tumor material for tumor classification and initiation of adequate therapy, ensuring complete subsequent sarcoma resection without contamination of other compartments.

Indications: Histological confirmation of musculoskeletal findings suspected to be malignant or of unclear status and adjustment of existing systemic therapies.

Contraindications: Lack of therapeutic use of the biopsy for decision-making or treatment as well as highly palliative situations with greatly reduced prognosis.

Surgical technique: Skin incision, subcutaneous preparation with fasciotomy and sharp severing of the musculature directly on the bone without 'spreading' the scissors. Avoidance of soft tissue barriers, 'direct access' to the tumor, meticulous hemostasis to avoid hematomas. In case of an intraosseous tumor, opening of the bone with an awl or bone marrow biopsy needle. The surgical aim is to collect approximately 1 cm³ sample.

Further management: Immobilization of the affected limb if necessary. Partial weight-bearing/no weight-bearing in case of intraosseous findings to avoid pathological fracture if necessary. Presentation to the interdisciplinary tumor board before planning further therapy.

Results: In the context of a systematic literature review, all primary studies published between January 2014 and December 2024 that compared biopsy techniques (open incisional biopsy and core needle biopsy) were considered. Of the 76 initially identified studies, five met the predefined inclusion criteria. Recent years has shown an increasing trend toward the use of image-guided core needle biopsy.

Objective: The aim of treating juvenile (UBC) and aneurysmal bone cysts (ABC) is complete defect filling with subsequent bony consolidation, restoration of stability, pain reduction, and minimization of recurrence risk.

Indications: Symptomatic or pathologic fractures due to confirmed UBC or ABC based on imaging and/or histology.

Contraindications: Suspected malignancy based on clinical or radiologic findings.

Surgical technique: After fluoroscopic localization, the lesion is exposed via a tissue-sparing approach. The cyst wall is opened, and complete curettage is performed. The defect is filled with ceramic bone substitute and/or allogeneic cancellous bone soaked in methylprednisolone (UBC) or polidocanol (ABC). In ABC, the cyst lining is completely removed. In UBC, curettage combined with elastic-stable intramedullary nailing (ESIN) for stabilization is frequently sufficient.

Postoperative management: Fractures are managed like nonpathologic fractures. Radiographic follow-up is performed at 4, 12, 26, and 52 weeks. If ABCs fail to respond, repeated percutaneous polidocanol injections are administered.

Results: In a cohort of 44 patients (22 UBC, 23 ABC), after a follow-up of up to 6 years, 82% achieved a favorable radiological outcome (Capanna 1-2). Recurrence with refracture occurred in 4 patients after ESIN removal. The overall complication rate was low.

Objective: Regional neoadjuvant isolated limb perfusion (ILP) with TNF-alpha and melphalan (TM-ILP) for the treatment of primarily unresectable highly malignant soft tissue sarcomas. The goal is to reduce the size and devitalize the tumor in order to convert a primarily unresectable tumor into a resectable state.

Indications: Primarily nonresectable (indication for amputation or higher-grade mutilating resection), highly malignant soft tissue sarcomas of the extremities.

Contraindications: Vascular occlusions, thromboses, acute infections, especially of the affected extremity.

Surgical technique: Vascular access to the artery and vein proximal to the affected limb. Arterial and venous cannulation of the vessels supplying the limb and tumor. Connection to a heart-lung machine. Application of a tourniquet or elastic bandage proximal to the catheter tips. Nuclear medicine leak rate measurement (technetium 99m) to rule out a systemic leak. Perfusion of the limb with 1-2 mg recombinant TNF-alpha (Tasonermin/Beromun, Belpharma SA, Luxembourg) for 15 min, followed by the addition of 11-13 mg melphalan per liter of limb volume and subsequent perfusion for an additional 60 min. Washing out with 2-5 l of crystalloid solution while wrapping the limb several times with elastic Esmarch bandages. Removal of the tourniquet and catheters, reconstruction of the vessels, wound closure.

Postoperative management: Elevate and cool the limb (especially the forearm and lower leg). Close cardiovascular and clinical monitoring for existing risk of TNF-alpha-induced Septic Inflammatory Response Syndrome (SIRS) and compartment syndrome (occurring within the first 24 h after ILP). Full weight-bearing on the limb is possible. Continue elevated positioning therapy depending on the degree of swelling. The hospital stay is approximately 1 week.

Results: Overall treatment response to TM-ILP: 60-70%. Complete remissions observed in just under 20% of cases. Limb preservation is possible in over 80% of cases.

Objective: Improvement of flexion and thereby restoration of function of the knee joint as well as pain reduction by proximalization of the tibial tuberosity in combination with arthrolysis and release of the patellar retinaculum.

Indications: Salvage surgery if conservative or arthroscopic treatment for a patella baja (Canton-Deschamps index < 0.6) has failed, especially in the case of mechanical and pain-related limitation of mobility. The timing for the surgery is crucial; surgery should only be performed after the end of the inflammatory phase and fibrosis of the patella ligament is complete.

Contraindications: Possible conservative and arthroscopic therapy attempts, local infection, pseudarthrosis, bone defects of the patella, fracture in the area of the tuberosity, active inflammatory process.

Surgical technique: Median longitudinal incision. Combined medial and lateral arthrotomy alongside the patellar tendon. Wedge-shaped tuberosity osteotomy over approximately 7 cm. The patella is thereafter reflected proximally to expose the entire knee joint. Extensive open arthrolysis especially of the superior recess and release of the retinaculum. Proximalized refixation of the tuberosity with at least two screws, depending on the preoperative planning and intraoperative movement control. If necessary, lengthening of the medial and lateral retinaculum to completely close the joint.

Postoperative management: Postoperative (post-OP) week 1-6: partial weight bearing 20 kg, knee brace, continuous passive motion (CPM) training, limitation of the range of motion (ROM) to flexion/extension: 90°/0°/0°. Post-OP week 7: additional load of 20 kg per week, free ROM.

Results: The authors followed a series of 7 patients with proximalization of the tibial tuberosity in symptomatic patella baja. The authors recorded pre- and postoperative patient-reported outcome measures with an average follow-up of 3.0 ± 2.6 years (range 0.6-7.6 years). The patients were 43 ± 11 years old (6 women, 1 men). There was a significant improvement in the 2000 International Knee Documentation Committee (IKDC)-subjective score (pre-OP: 40 ± 17 vs. post-OP: 72 ± 10; p = 0.011) and in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscore for activities of daily living (pre-OP: 20 ± 23 vs. post-OP: 60 ± 20; p = 0.014). The authors were also able to identify a trend towards improvement, particularly in the Kujala score and the KOOS subscores for pain and physical activity; however no significant improvements were observed. These results make it clear that the proximalization of the patellar tuberosity can improve the subjective outcome in symptomatic patella baja.

Surgical objective: Wide 'en bloc' extra-articular resection of the knee joint while maintaining the necessary safety margins for adequate oncological therapy and reconstruction using a knee joint endoprosthesis with the aim of preserving good extensibility of the knee joint.

Indications: Infiltration of the knee joint by soft tissue or bone sarcomas, pathological intra-articular fractures, (potential) contamination of the knee joint due to inappropriate biopsy approach.

Contraindications: Advanced tumour manifestation with no possibility of wide tumour resection with preservation of the extremity, progressive multiple metastatic tumour disease with a short prognosis, florid infections.

Surgical technique: Lateral approach, circular incision of the biopsy approach, patella osteotomy in the frontal plane with prior K‑wire marking, careful separation of the retinaculum from the fascia, osteotomy of the distal femur corresponding preoperative planning, distal separation of the gastrocnemius origins for dorsal capsular reconstruction, flexion of the knee joint for better medial separation of the retinaculum from the fascia, marking of the proximal osteotomy of the tibia proximal to the tibial tuberosity to protect the patellar tendon, reconstruction using a modular tumour endoprosthesis after tumour resection.

Postoperative management: Axial 20 kg partial weight-bearing for 6 weeks postoperatively in an extension brace and then gradually increasing flexion 30° every 2 weeks in a flexion-limiting knee joint brace. Oncological therapy and aftercare as determined by the tumour board.

Objective: Complete tumor resection while maintaining oncologically required safety margins. The focus is on functional limb preservation, taking into account tumor spread in the individual compartments and the positional relationship to vascular and nerve courses.

Indications: Localized tumor disease and complete resection possible. No to acceptable postoperative functional restrictions. Palliative tumor resection in the case of imminent or existing exulceration, for pain reduction or in the case of solitary metastases.

Contraindications: Tumors that are not surgically accessible. Advanced or progressive tumors with extensive metastases and short life expectancy. Complete postoperative loss of function of the extremity.

Surgical technique: Interdisciplinary planning in the tumor board. Access with consideration of the compartments, whereby the biopsy tract is resected. Dissection taking into account high quality (fascia/adventitia/perineurium/periosteum) and low quality (muscle/fat) resection margins. If necessary: muscular refixation, plastic reconstruction. Multilayer wound closure to reduce the dead space volume with drainage insertion.

Postoperative management: Compression therapy using thigh compression stockings or single-leg compression tights compression class 2 with pad. Lymphatic drainage. Physiotherapeutic mobilization taking functional restrictions into account. Oncological therapy/follow-up taking into account grading, resection margins and regression.

Results: The outcomes of soft tissue sarcoma resection in the thigh are generally favorable, both oncologically and functionally. Early diagnosis and treatment in specialized centers can improve survival and reduce the amputation rate.

Objective: Addressing all injured structures and medial stabilization against both valgus stress and rotation.

Indications: Acute, isolated medial collateral ligament (MCL) rupture grade III (especially distal and midsubstance rupture) and combined injuries/multiligamentary injury.

Contraindications: Contraindications are chronic medial instability or rotational instability with indication for medial reconstruction as well as intolerance/allergy to material or other injuries requiring soft tissue consolidation/other operations (open wounds in the surgical area, fracture especially in the area of fixation). Relative contraindications are open growth plates.

Surgical technique: Recommendation for combination of arthroscopy and (mini) open procedure with refixation of superficial MCL (sMCL), if necessary deep MCL (dMCL) and posterior oblique ligament (POL), using suture anchors in anatomical position and under X‑ray control. Additional brace augmentation of the sMCL using tape.

Postoperative management: Weeks 1-6 partial weight bearing with 20 kg on crutches. Regardless of the leg axis, the range of motion is gradually increased every 2 weeks in a stabilizing hard-frame orthosis (extension/flexion): week 1-2: 0-20-60°, week 3-4: 0-10-90°, week 5-6: 0-0-90°, From the 7th week onwards, free range of motion, training off orthosis.