Operative Orthopadie Und Traumatologie最新文献

Objective: Lengthening of the quadriceps tendon for dehiscence in chronic rupture.

Indications: Chronic rupture of the quadriceps tendon with delayed diagnosis or failure of primary refixation with a dehiscence between 1 and 5 cm.

Contraindications: Dehiscence of more than 5 cm.

Surgical technique: Reopen the old incision and lengthen it to about 20-25 cm if necessary. Visualize the rupture. Debridement of the tendon and the insertion. Measurement of the dehiscence. Creation of a V-flap and reinforcement with a holding seam. Gradual mobilization of the V‑flap distally and reinforcement with two strong suture cords (braided suture size 5). Drilling of three obliquely ascending drill holes through the patella. Transosseous threading of the two reinforcement cords through the three drill holes. Knotting the reinforcement cords on the patella. Closure of the gap between the patella and the superficial tendon leaflet with a #2 braided suture. Closure of the gap between the V‑flap and the quadriceps tendon.

Postoperative management: Six weeks of partial weight-bearing with 20 kg in a straight orthosis. Mobility: weeks 1-4 E/F 0-0-60, weeks 5 and 6 E/F 0-0-90.

Results: We were able to follow-up 8 patients (mean age: 63.1 ± 4.5 years), who underwent this surgery in the manner described. All patients were able to perform an active extension postoperatively. The Lysholm score increased from 46.4 (± 5.4) points preoperatively to 81.6 (± 6.5) points postoperatively. No further rupture was detectable in the ultrasound examination at latest follow-up after an average of 27 (18-36) months.

Objective: We present the two-incision minimally invasive (TIMI) approach for the treatment of anterior acetabular fractures.

Indications: Displaced fractures of the anterior column of the acetabulum; complex fractures of the acetabulum in combination with the posterior approach (Kocher-Langenbeck); periprosthetic fractures of the acetabulum with or without additional revision of the cup.

Contraindications: Possibly previous extended surgery in the anatomical region of the approach.

Surgical technique: The first TIMI incision is performed by an alternate cut through at the level of the proximal third of the pelvic brim. After transection of the abdominal wall, the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held using a retraction system. After fracture reduction and fixation by isolated screws, a reconstruction plate is inserted for fracture neutralization.

Postoperative management: Depending on the fracture type and the severity of the damage to the acetabular dome, the involved extremity is allowed partial weight bearing for 6 weeks to 3 months.

Results: In our experience, a relatively short operation time of approximately 1.5-2 h for acetabular osteosynthesis. Wound infections and revisions are very rare. Radiological follow-up shows an anatomical result in over 75% of cases. The 24-month follow-up examination shows a Harris Hip Score of over 85 points. The quality of life measured by the EQ 5D is comparable to the quality of life of a normal collective of the same age.

Objective: Minimally invasive percutaneous techniques are used to stabilize fractures of the anterior pelvic ring. Stabilization of the fracture facilitates early mobilization and rehabilitation, while percutaneous techniques reduce complications such as infection and bleeding.

Indications: Indicated for patients with non- or minimally displaced fractures of the anterior pelvic ring, or if fracture displacement can be reduced using minimally invasive techniques.

Contraindications: Contraindications include infection at the surgical site, anatomical inability to place screws, or patients unfit for surgery due to health risks.

Surgical technique: The technique involves the insertion of ante- and retrograde transpubic screws and lateral compression (LC) II screws in supine position. Precise reduction of fractures is achieved using minimally invasive techniques.

Postoperative management: In younger patients, partial weight bearing for 6 weeks is recommended, with full weight bearing in older patients.

Results: Literature reports a high union rate of up to 95% for these procedures, with low rates of nonunion and infection (around 2%). Screw loosening or loss of reduction occurs in 8-18% of cases, with better outcomes using bicortical screws.

Objective: To maximize local tumor control, stabilize affected bones, and preserve or replace joints with minimal interventional burden, thereby enhancing quality of life for empowered living.

Indications: Suitable for patients with bone metastases, particularly those with severe pain and/or fractures and appropriate life expectancy.

Contraindications: In primary bone tumors, refer to the sarcoma surgery team for evaluation of wide resection. For patients with poor general condition and/or limited life expectancy (< 6 weeks), consider best supportive care.

Surgical technique: Radiological interventions involve angiography and embolization for hypervascularized metastases, followed by precise biopsy and local tumor control through radiofrequency ablation or cryoablation using navigated imaging. The surgical treatment aims to create a durable, minimally invasive construct for stability, considering various options from percutaneous screws with cement augmentation to joint replacement. Intraoperative imaging and 3D scans guide the procedure, ensuring accurate placement of implants and confirming optimal results.

Postoperative management: Postoperative care involves immediate mobilization with pain-adapted full weightbearing and daily physiotherapy. The goal is to regain preoperative mobility. Follow-up with regular clinical and radiographic assessments and CT in the case of tumor progression and complications.

Results: Since introducing the combined surgical and interventional therapy in October 2021, 16 patients have undergone successful procedures. Complications included material failure, component loosening, and surgical site infection. Five patients (31%) died during observation, while surviving patients surpassed their estimated survival, emphasizing the advantages of minimally invasive treatment with durable constructs.

Objective: Presentation and description of percutaneous sacroiliac (SI) screw fixation with the use of a 3D robot-assisted image-guided navigation system and the clinical outcome of this technique.

Indications: Pelvic fractures involving the posterior pelvis.

Contraindications: Patients not suited for surgery.

Surgical technique: Planning the screws on the diagnostic computer tomogram (CT). Matching with a low-dose CT in the operating room. Lateral incision. Verify the guidewire position with the personalized inlet and outlet views. After correct positioning, place a cannulated screw over the guidewire. For fragility fractures, augmentation is recommended. Finish the surgery with a final 3D scan to confirm correct placement of the screws and cement.

Postoperative management: Direct postoperative mobilization with pain-adapted full weight-bearing.

Results: Data of 141 patients between January 2018 and August 2022 were analyzed (average age 82 ± 10 years, 89% female). Most of the fractures were type II fragility fractures of the pelvis (FFP; 75%). The median hospital stay was 12 ± 7 days and the median surgery duration for a unilateral SI screw was 26 min. In total 221 S1 screws and 17 S2 screws were applied. No screws showed signs of loosening or migration. Of the five suboptimally placed screws, one screw was removed due to sensory impairment. All patients with cement leakage remained without symptoms.

Conclusion: The surgical technique with the use of a 3D robot-assisted image-guided navigation system is a technique for safe fixation of dorsal fragility fractures of the pelvis and is associated with fewer complications.

Objective: Extraction of cancellous bone from the distal radius for reconstructive procedures on the hand.

Indications: All reconstructive procedures on the hand for which a corticocancellous and/or vascularized bone graft or a large amount of cancellous bone is not required.

Contraindications: Acute distal radius fracture, osteosynthesis material embedded in the distal radius, e.g., after palmar plate osteosynthesis of a distal radius fracture, tumor in the distal radius.

Surgical technique: Removal of cancellous bone from the distal radius radially from the dorsal radial tuberosity via a small bone window at the base of the second extensor tendon compartment.

Postoperative management: Wound dressing on the distal radius, elevation of the arm above heart level until swelling has subsided, first dressing change on postoperative day 1 or 2, depending on the primary procedure on the hand, dressing until wound healing is complete, removal of the skin sutures around postoperative day 14.

Results: In 2023, cancellous bone was harvested from the distal radius of 17 patients for reconstructive procedures on the hand (6 mediocarpal partial arthrodeses, 3 acute fractures, 5 delayed bone healings, 1 pseudarthrosis, 2 bone tumors). In all cases, the available amount of radius cancellous bone was sufficient, resulting in satisfactory healing. All patients complained of short-term, slight discomfort at the donor site for the first few days after surgery, which resolved completely. There were no complications at the donor site on the distal radius.

Objective: Minimally invasive stabilization of non- and minimally displaced acetabular fractures using intraoperative, robot-assisted three-dimensional (3D) imaging and a navigation system.

Indications: Nondisplaced or only minimally displaced fractures of the acetabulum.

Contraindications: Comminuted and highly displaced fractures of the acetabulum, protrusion of the femoral head into the pelvis with the need for open reduction, lack of possibility of intraoperative navigation.

Surgical technique: After supine positioning the patient, the patient-side navigation reference is attached to the anterior superior iliac spine using a Schanz screw. The 3D scan and registration of the dataset in the navigation system can then be performed. This allows the 7.3 mm screws to be planned using 3D imaging and then implanted through minimally invasive incisions.

Postoperative management: After successfully implanting the screws using the minimally invasive surgical technique, the patient can be mobilized the following day with pain-adapted physiotherapy exercises. Full weight bearing is usually possible.

Results: Between 2015 and 2023, 101 patients were treated using minimally invasive and navigation-assisted screw osteosynthesis for acetabular fractures. In 2 patients, a secondary screw dislocation occurred in the hip joint after mobilization, which required revision surgery with repositioning of the screw osteosynthesis and a hip arthroplasty, respectively. Minimally invasive navigated screw osteosynthesis, thus, offers adequate treatment of nondisplaced and minimally displaced acetabular fractures. Attention must be paid to the correct indication and surgical technique.

Objective: Treatment with transcutaneous osseointegrated prosthesis systems (TOPS) for short femoral amputation stumps aims to restore independent walking ability after proximal femoral amputation by direct bone-guided prosthesis anchorage. This cannot be safely achieved with conventional socket prostheses due to the mechanically inadequate socket contact surface.

Indications: Treatment of patients with short transfemoral stumps who cannot be mobilized sufficiently with conventional socket prostheses.

Contraindications: Known contraindications as with standard TOPS fittings.

Surgical technique: Special features already arise during positioning with correct orthograde adjustment of the short femoral stump under X‑ray fluoroscopy. The prosthesis is anchored using the specified technique, taking into account the central insertion of the femoral neck screw with the aid of the aiming arm under X‑ray fluoroscopy in two planes.

Postoperative management: In most cases, step 1 and 2 treatment is primarily possible, i.e., insertion of the double-cone adapter and passing through the skin by the intraoperatively created stoma (skin opening on the amputation stump). This requires patient compliance and hygiene with twice daily showering of the stoma and dressing. After the exoprosthesis components have been fitted by the patient's orthopedic technician, weight-bearing with the new adapted prosthesis is possible.

Results: A total of 14 TOPS procedures were performed at Rostock University Medical Center between 2022 and 2024, including 9 patients with short femoral stumps. A prolonged rehabilitation phase compared to patients with "standard" TOPS restorations is not recognizable, but a significant gain in quality of life is evident.