Operative Orthopadie Und Traumatologie最新文献

Objective: Lengthening of the patellar tendon to normalize patellar height and improve knee flexion deficits.

Indications: Flexion deficits in combination with patella baja (Caton index < 0.6).

Contraindications: Infection.

Surgical technique: Arthroscopy of the knee and resection of adhesions in suprapatellar pouch and additional intraarticular adhesions. Approximately 15 cm long incision from tibial tuberosity up to the patella. Exposition of the patellar tendon. Longitudinal incision in the middle from the tibial tuberosity towards the proximal patella. Division of the tendon into two strands. Detachment of the lateral tendon strand with periosteum from the bone of the patella and detachment of the medial strand with periosteum from the bone of the tibial tuberosity. Resection of fibrotic adhesions within Hoffa's fad pad and detachment of the longitudinal retinacula. Lengthening of the patella tendon of maximal 2.5 cm. Refixation of the medial strand to the upper part of the tibial tuberosity and the lateral strand to the distal patella pole with a soft anchor. Drilling of small transverse bone tunnels in the patella and tibial tuberosity for application of a McLaughlin cerclage for augmentation of the z‑plasty with a thick braided suture cord.

Postoperative management: Six weeks partial weight bearing with 10 kg within a straight leg brace. Free passive range of motion.

Results: Previously published results show that the Z‑plasty technique presented here on the patellar tendon can normalize the Caton index and improve mobility and clinical scores.

Objective: Removal of a transcutaneous osseintegrated endo-fix stem (ESKA Orthopaedic, Lübeck, Germany) following a fatigue fracture of the implant, whilst protecting the residual femur bone to allow transcutaneous osseointegrated prosthesis system (TOPS) reimplantation.

Indications: A patient's request for a further TOPS implantation following a fatigue fracture of a circular osseointegrated implant stem.

Contraindications: Impending destruction of the bone tube through mobilisation of the femoral implant stem with insufficient thickness of the cortical wall (< 2-3 mm). This fact has to be considered before providing the indication for implant replacement.

Surgical technique: A fatigue fracture of a circular osseointegrated implant stem is generally associated with difficult removal of the implant. The longitudinal osteotomy of the tubular femur would lead to massive destruction of the bone due to the osseointegration of the corticalis into the three-dimensional structured surface of the implant and must be excluded as an option for removal. Therefore, the implant must be mobilized from the distal end of the bone. For this approach, tubular cutters and shock wave chisels are available. The procedure itself is time-consuming and is accompanied by a weakening of the corticalis of the femur bone. Intraoperative smear tests to prove a bacteria-free intramedullary space are obligatory.

Postoperative management: After successful removal of an endo-fix stem, reassembling of a new TOPS implant should be considered 4-6 weeks later after ensuring the absence of bacterial colonization of the intramedullary space. If bacteria are detected, surgical revision is necessary.

Results: The authors experience with the described removal of the implant with 4 patients over a period of 17 years must be regarded as anecdotal. All 4 patients could be successfully re-implanted, which emphasizes the value of the described method.

Background: Mechanical anastomoses of blood vessels represent a major advance in modern surgery. Highly specialized instruments ensure the precise connection of blood vessels, enabling the immediate restoration of blood flow. Ring coupler systems for venous anastomoses, in particular, have proven themselves in clinical practice due to their convenience and reliability and are now an indispensable part of surgical routines.

Objectives: Precise and functionally proper anastomosis of blood vessels; shortening of the anastomosis time; minimization of perfusion disorders in the affected tissue; reduction of intraoperative and postoperative complications.

Indications: Replantation of extremities after amputations and injuries; defect reconstruction using free flaps; microsurgical vascular bypass procedures.

Contraindications: Severe vascular pathologies such as vascular aneurysms, arteriosclerosis or severe inflammation in the area of the anastomosis; large differences between the vessel lumina; too small or too large vessels.

Surgical technique: Clamping of both vessel ends; selection of the appropriate ring coupler size based on the vessel diameter; mobilization of at least 1 cm at each vessel end; functional testing of the coupler device; threading the vessels, securely joining the rings and removing the holding device; removing clamps, inspection of the anastomosis.

Postoperative management: Regular blood circulation checks; avoiding pressure on the anastomosis; adequate anticoagulation.

Results: Precise anastomoses; reduction in operating time.

Objective: Peripheral nerve lesions often lead to significant and permanent loss of motor and sensory function. The aim of peripheral nerve grafting is to bridge nerve defects.

Indications: When tension-free nerve repair is not possible, peripheral nerve grafting is indicated.

Contraindications: Local infection, insufficient soft tissue coverage, significant muscle atrophy or joint contraction in case of "motor" nerve grafting, lack of microsurgical instruments or experience, life-threatening injuries.

Surgical technique: Exposure and preparation of the nerve stumps. Choosing and preparation of the donor nerve. Approximation. Nerve repair. Nerve reconstruction must always be tension-free as nerve repair with tension frequently leads to disruption of nerve healing and poor functional outcome. Autologous nerve grafting from various donor sites leads to excellent functional results with little sensory deficits at the donor regions.

Postoperative management: Limited immobilization, physiotherapy, ergotherapy, regular clinical and neurological assessments.

Results: Outcome of peripheral nerve grafting may, for example, depend on defect length, caliber and quality of the injured nerve, quality of the donor nerve, microsurgical expertise of the surgeon, time of reconstruction, and age of the patient.

Substantial nerve lesions almost always lead to persistent functional deficits, even with ideal treatment. Nerve lesions commonly occur in young patients, are often part of complex injuries, and are repeatedly diagnosed and treated with delay. Functional outcome crucially depends on early and adequate treatment. The aim of surgical treatment is a precise and tension-free microsurgical restoration of nerve continuity in a vital and healthy tissue environment. Adequate microsurgical treatment with differentiated postoperative treatment can result in an excellent clinical outcome, even after a delayed diagnosis.

Objective: Anastomosis of two vessels by end-to-end or end-to-side suturing to create an uninterrupted blood flow between the two vessels.

Indications: Transplantations; replantations; vascular trauma.

Contraindications: Active infections in the area to be vascularized or surgical site; large differences in caliber between the vessels; hypercoagulability; extensive tissue damage.

Surgical technique: First, clamping, cleaning and flushing of the vessel ends; adaptation of the vessel ends using end-to-end or end-to-side anastomosis, using an end-to-side anastomosis if an existing vessel axis should not be interrupted; creation of the anastomosis using a single button suture or continuous suture technique; careful avoidance of puncturing the posterior wall and exact adaptation of the vessel ends without leaks; release of the blood flow and examination of the anastomosis.

Postoperative management: Postoperative avoidance of traction, tension, pressure and shear forces on the anastomosis; regular blood flow checks of the revascularized tissue or flap; sufficient anticoagulation.

Results: An atraumatic and gentle suturing technique is a basic requirement for a successful anastomosis. Special suturing techniques can improve the anastomosis of fragile vessels.

Objective: Replacement of superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with an allograft.

Indications: Chronic 3° isolated medial instability and combined anteromedial or posteromedial instability.

Contraindications: Infection, open growth plates, restricted range of motion (less than E/F 0-0-90°).

Surgical technique: Longitudinal incision from medial epicondyle to superficial pes anserinus and exposure of the medial collateral ligament complex. Thawing of the allogeneic semitendinosus tendon graft at room temperature, reinforcement of the tendon ends with sutures and preparation of a two-stranded graft. Placement of guidewires in the sMCL and POL insertions and control with image intensifier. Tunnel drilling. Pulling the graft loop into the femoral bone tunnel and fixation with a flip button. Pulling the two graft ends into the tibial tunnels. Tibial fixation by knotting the suture ends in a 20° flexion on the lateral cortex. Suture the tendon bundles to the remaining remnants of the medial collateral ligament complex to adopt the flat structure of the natural medial collateral ligament complex.

Postoperative management: Six weeks partial weight-bearing, immediately postoperatively splint in the extended position, after 2 weeks movable knee brace for another 4-6 weeks. Mobility: 4 weeks 0-0-60, 5th and 6th weeks 0-0-90.

Results: From 2015-2021, this surgical procedure was performed in 19 patients (5 women, 14 men, age 34 years). Mean Lysholm score at follow-up after at least 2 years was 89 (76-99) points. In 6 patients, there was restricted range of motion 3 months postoperatively, which resulted in further therapy (3 × systemic cortisone therapy, 3 × arthroscopically supported manipulations under anesthesia).

Objective: Patellar dislocations are a common occurrence in orthopedic practice, often accompanied by osteochondral fractures of the retropatellar cartilage surface, known as flake fractures, in up to 58% of cases. The parachute technique represents a simple and cost-effective surgical option aimed at restoring osteochondral integration and preserving native cartilage.

Indications: Flake fracture of the patella with osteochondral fragments.

Contraindications: Patella fracture.

Surgical technique: By utilizing transpatellar, absorbable sutures, a stable osteochondral interface is achieved without penetrating the fragment itself.

Postoperative management: Postoperative treatment involves partial weight-bearing with a maximum of 20 kg for 6 weeks in full knee extension. In addition, the range of motion of knee flexion is limited to 30° and is increased by 30° every 2 weeks.

Results: To examine the short- to medium-term clinical outcomes, all patients with acute patellar dislocation treated using the parachute technique between 01/2012 and 11/2022 were included. Clinical outcomes were assessed using the visual analog scale (VAS), Tegner Activity Scale (TAS), Kujala Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC). Out of 20 patients, 19 (10 men, 11 right-sided, 95% follow-up rate) could be recruited for postoperative evaluation. The average follow-up period was 62.5 ± 20.5 months. The clinical outcome scores yielded the following results: VAS 0.5 ± 1.6, TAS 5.8 ± 2.2, Kujala 89.4 ± 12.5, KOOS 87.8 ± 14.1, and IKDC 86.7 ± 14.3. Overall, 18 patients (90.0%) expressed willingness to undergo the procedure again. At the time of follow-up, 19 patients (95.0%) were satisfied with the surgical outcome. One patient (23-year-old man) required revision. None of the included patients suffered from the recurrence of patellar dislocation. In summary, the parachute technique demonstrated excellent clinical function in the short- to medium-term follow-up for acute patellar dislocation.