Operative Orthopadie Und Traumatologie最新文献

Objective: Minimally invasive stabilization of osteoporotic fractures of the posterior pelvic ring to ensure rapid and low-pain mobilization and timely fracture healing while avoiding progressive fracture instability.

Indications: Primarily unstable osteoporotic fractures of the posterior pelvic ring, in particular sacroiliac fracture dislocations (OF 5) and bilateral sacral fractures (OF 4), unilateral sacral fractures (OF 3) in constellations indicating a higher degree of instability. In addition to the type of fracture, important clinical parameters and modifiers that indicate greater instability should be taken into account when deciding on treatment options. An important aid for decision-making is the OF Pelvis Score, in which a score above 8 indicates surgical treatment.

Contraindications: Major soft tissue damage, decubital ulcers or infections at the surgical site; voluminous implants or defect zones/osteolysis in the transiliac screw corridor; sacroiliac dislocation fractures with a large crescent fragment, which are treated similarly to iliac fractures; high degree of vertical instability with the need for spinopelvic support.

Surgical technique: Fluoroscopically assisted minimally invasive implantation of long large-caliber polyaxial screws in both transiliac screw corridors, subfascial insertion of a connecting rod, fixation on both sides with set screws.

Postoperative management: Rapid mobilization with weight-bearing as tolerated (WBAT).

Results: Between 5/2024 and 3/2025, 10 patients underwent transiliac internal fixation (TIFI) surgery for unstable fractures of the posterior pelvic ring: in 8 cases alone and in the remaining 2 cases in combination with osteosynthesis of the anterior pelvic ring. In 1 patient, the wound had to be revised due to a suture granuloma, otherwise there were no complications requiring revision. In all cases, postoperative computed tomography (CT) imaging confirmed the correct position of the implant. Stabilization of the posterior pelvic ring using TIFI is a minimally invasive, safe and highly stable osteosynthesis with a relatively simple surgical technique.

Objective: Refixation of anterior cruciate ligament (ACL) tears and augmentation using an Internal Brace® (Arthrex Inc., Naples, FL, USA) has become increasingly popular in recent years. The aim is to preserve the native ligament structure and, thus, improve clinical outcomes.

Indications: Indications are proximal ACL tears of Sherman type I and II in the acute phase postinjury. For multiligament injuries, internal brace augmentation can contribute to increased joint stability.

Contraindications: ACL refixation is not recommended for distal or middle segment tears and should not be delayed for more than 4 weeks posttrauma to ensure adequate healing.

Surgical technique: The rupture is bridged by an ultrahigh-molecular-weight polyethylene tape to reattach the ACL to the femoral footprint.

Postoperative management: Functional postoperative treatment involves partial weight-bearing of 15 kg on crutches within 3 weeks postoperatively. High-impact activities should be avoided for the first 6 months postoperatively.

Results: The clinical results of ACL augmentation with an Internal Brace® show a slightly increased re-rupture rate compared to ACL replacement, with good to excellent functional outcomes.

Objective: Restoration of passive medial stability of the patella by reconstruction/augmentation of the medial patellofemoral ligament complex.

Indications: Treatment of first-time patellar dislocation requiring surgery and recurrent dislocation as an isolated procedure or in combination with concomitant osseous intervention.

Contraindications: Patellofemoral pain without objective instability/dislocation of the patella; known material intolerance.

Surgical technique: A synthetic ligament is inserted in a V-shaped fashion into the second layer of the medial retinaculum via a 2-incision technique after soft tissue fixation in the area of the patellar medial patellofemoral complex (MPFC) and fixed at the femoral insertion using an interference screw.

Postoperative management: Partial weight-bearing for 2-3 weeks as tolerated; active and passive exercises without restriction of range of motion; immediate exercises for quadriceps muscle control, and coordinative exercises as well as stabilization of the functional pelvis-leg axis after full weight-bearing is achieved.

Results: The clinical results in the literature consistently show significant improvements in the patient-reported outcome measures and are so far-along with the biomechanical data-comparable with those of autologous tendon reconstruction.

Objective: Stabilization of the distal fibula and tibia to enable elongation-free healing of the ruptured syndesmotic ligaments.

Indications: Unstable syndesmotic injuries. Unstable syndesmotic injuries in combination with an ankle fracture. Subacute or chronic syndesmotic injury in combination with another procedure (debridement, fibular osteotomy, new osteosynthesis, ligament reconstruction).

Contraindications: Soft tissue infection.

Surgical technique: Stabilization of the distance between the fibula and tibia after repositioning using a strong suture cord, which is fixed to the cortex of the tibia and fibula via two buttons. The cord-button construct is inserted minimally invasively under image intensifier control.

Postoperative management: Two weeks of partial weight bearing with 15 kg weight, rigid ankle joint orthosis (walker) for 6 weeks, accompanied by physical therapy.

Results: The results published to date demonstrate with strong evidence that cord-and-button fixation is superior to screw fixation in terms of clinical scores, correct reduction, and reoperation rates. This applies both to isolated unstable syndesmotic injuries and to syndesmotic injuries combined with fibula fractures. Another advantage of this surgical technique is that implant removal is not necessary in most cases. The disadvantage of this procedure is the high implant cost.

Objective: Improving the overall function of the hand by resection of the second ray applying the palmar approach in order to achieve an aesthetically pleasing postoperative result.

Indications: Mechanically disturbing proximal limb stump, high degree of instability of the index finger, chronic infection/osteomyelitis of the index finger, dystrophic index finger with impaired circulation, degloving injury, malformations, malignant tumours of the index finger, aesthetic improvement after index finger amputation.

Contraindications: Loss of grip strength that cannot be tolerated.

Surgical technique: Dissection of the index finger with resection of the second metacarpal at the proximal diametaphyseal region, mobilisation of the neurovascular bundles, and transposition of the first dorsal interosseus muscle onto the second dorsal interosseus muscle, reconstruction of the thumb-middle finger commissur.

Postoperative management: Sufficient dressing of the thumb-middle finger commissur with immobilisation for 2-5 days, then mobilisation for 8 weeks without forceful pinch grip between thumb tip und middle finger tip, mobilisation without limits after 3 months.

Results: After resection of the second ray, studies showed very pleasing aesthetic results with high patient satisfaction despite a decrease in grip strength.

Objective: Anatomical reconstruction of the posterior cruciate ligament (PCL) with suture tape augmentation to enhance primary stability.

Indications: Acute or chronic PCL ruptures, either isolated or as part of multiligamentous injuries, in cases of symptomatic instability or failure of conservative treatment.

Contraindications: Fixed posterior drawer, active infection, bony avulsion.

Surgical technique: Supine positioning, use of standard portals for arthroscopic PCL reconstruction. Femoral and tibial tunnels are created using a targeting device following preparation of the insertion sites. The hamstring graft is augmented with nonresorbable suture tape. The augmentation suture is fixed separately using a suture anchor under continuous anterior drawer stress. Graft fixation is performed via extracortical device at the femur and with an interference screw at the tibia.

Postoperative management: Six weeks of extension bracing with posterior tibial support, worn 24 h/day, and 20 kg partial weight-bearing. This is followed by 6 weeks of continued mobile bracing with posterior tibial support and progressive mobilization and load increase, accompanied by physiotherapy.

Results: Biomechanical and early clinical studies suggest promising benefits of augmentation for stability and function, though robust long-term data are still lacking.

Objective: To obtain a pain-free, fully weight-bearing ankle joint in a functional position through minimally invasive arthrodesis.

Indications: Symptomatic osteoarthritis of the upper ankle joint, which is no longer treatable conservatively or by joint-preserving surgical procedures.

Contraindications: Revision arthrodesis, infections in the surgical area, circulatory disorders; extensive malalignment, large bony defects (relative contraindications).

Surgical technique: Anteromedial and anterolateral standard portal to the upper ankle joint. Soft tissue debridement and, if necessary, removal of large ventral osteophytes and free joint bodies. Removal of the remaining tibiotalar articular cartilage using curettes, sharp spoons, chisels, or reamers. Opening of the subchondral bone with bone awls or chisels to expose the former joint surfaces. Anatomical adjustment of the joint, transfixation with 2 to 3 Kirschner wires for percutaneous stabilization with cannulated double-threaded screws or cancellous bone screws with short threads under X‑ray control.

Postoperative management: Postoperative immobilization in an orthosis or plaster cast with unloading for 6 weeks; after X‑ray control, gradual increase in weight-bearing over a further 2-6 weeks.

Results: In all, 30 arthroscopically assisted arthrodeses of the ankle joint performed between 2014 and 2017 were retrospectively evaluated. Of these, 22 patients were very satisfied, 5 patients were satisfied, and only 2 patients were not satisfied with the surgical outcome. The evaluation using postoperative scores (American Orthopaedic Foot and Ankle Society Score [AOFAS], Foot and Ankle Outcome Score [FAOS], Visual Analogue Scale Foot and Ankle [VAS-FA]) also yielded good results on average. The complication rates were comparable to those in the literature, with 2 pseudarthroses, 3 superficial wound healing disorders, and 2 irritations caused by the osteosynthesis material.

Surgical objective: Arthroscopy of the ankle joint is one of the standard procedures for treating many pathologies of the ankle joint. Ventral and posterior arthroscopy can be performed. The aim is to gain an overview of the joint using minimal incisions. There are many indications to perform ankle arthroscopy.

Indications: Arthroscopy can be used diagnostically to check the cartilage status or the ligamentous apparatus. In traumatology, arthroscopy can be used to check for intra-articular damage or step formation following osteosynthesis. Arthroscopy can also be performed for cartilage therapy, ligament reconstruction or to support arthrodesis of the ankle joint.

Contraindications: Absolute contraindications are rare. The most important contraindication is noncompliance. Relative contraindications include acute infection, severe vascular disorders, complex regional pain syndrome (CRPS), osteopenia or coagulation disorders. Nicotine consumption and obesity should be discussed critically with the patient.

Postoperative management: Postoperative treatment depends on the addressed concomitant pathology. Suture material can be removed 14 days postoperatively. If an isolated arthroscopy is performed (e.g., diagnostic, arthrolysis, exclusion of infection), the authors recommend pain-adapted full weight-bearing, possibly in a lower leg orthosis until the wound has healed properly.

Results: The results of arthroscopy depend on the pathology addressed. The primary advantage is a significantly reduced risk of wound healing disorders due to small incisions.

Objective: Identification and treatment of concomitant intra-articular pathologies, verification of syndesmotic instability, debridement of syndesmotic structures in chronic injuries, reduction, and retention of the fibula in the distal tibiofibular joint.

Indications: Acute and chronic two- or three-ligamentous syndesmotic ruptures in active patients.

Contraindications: Soft tissue injuries, general risk factors, e.g., circulatory disorders, diabetic foot syndrome, complex regional pain syndrome.

Surgical technique: Diagnostic arthroscopy of the ankle joint using anterolateral and -medial portals; identify and treat concomitant intra-articular pathologies; verify syndesmotic instability by inserting an instrument > 4 mm into the incisura fibularis; in case of chronic syndesmotic injuries, debridement of syndesmotic structures, and if necessary debridement of the deltoid ligament complex; reduction of the fibula in the incisura fibularis; retention of the fibula using a screw or flexible implant.

Postoperative management: Partial weight-bearing with 20 kg for 6 weeks, no immobilization, exercise for the mobility of the ankle joint, X‑ray after 6 weeks, then increase of weight-bearing.

Results: Acute syndesmotic injuries: 19 patients (37 ± 13 years) were examined 38 ± 17 months after arthroscopically assisted treatment of an acute syndesmotic injury. 53% suffered a two-ligament injury, 16% a three-ligament injury, and in 32% a bony syndesmotic injury. Grade II cartilage damage was observed in 35%, grade IV damage in 20%, and loose bodies were removed in 16%. 94% of patients achieved a treatment outcome in line with the healthy reference population for the Olerud and Molander Ankle Score (OMAS; primary outcome parameter) and Foot and Ankle Ability Measure (FAAM). Type of syndesmotic injury and severity of cartilage damage had no significant influence on treatment outcomes. Chronic syndesmotic injuries: a systematic literature search identified 17 studies with 196 patients following surgically treated chronic syndesmotic injuries, 16 of which were retrospective case series and one prospective case series. Arthroscopically assisted surgery was performed in 13 studies. Regardless of the surgical technique, surgery resulted in an improvement in the American Orthopaedic Foot and Ankle Society (AOFAS) score in 10 studies. Overall, the study quality was low and the information on complications, secondary diastasis, treatment results, etc. was very limited.