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: Arthroscopic matrix-associated bone marrow stimulation enables treatment of symptomatic osteochondral lesions of the ankle joint to alleviate pain and improve function.

Indications: Symptomatic osteochondral lesions caused by trauma, osteochondritis dissecans, or isolated degenerative cartilage damage. Unstable lesions with nonrefixable fragments.

Contraindications: Acute infections, ubiquitous advanced osteoarthritis.

Surgical technique: Treatment of intra-articular pathologies and resection of hypertrophic synovia. Unstable cartilage tissue is debrided, and stable margins are created. The subchondral bone is microfractured to promote bleeding and cell migration. For deeper defects, a spongiosa graft can be performed. A tailored collagen matrix is introduced through a mini-arthrotomy and fixed with fibrin glue.

Postoperative management: Partial weightbearing of 10-20 kg, depending on the procedure performed. From week 7, load-bearing is gradually increased; full weight-bearing is possible after 12 weeks. Sports activities can be resumed after 6 months.

Results: In a retrospective analysis of 10.611 inpatient procedures in Germany from 2006-2022, the numbers for arthroscopies and arthrotomies initially increased, whereby the number of arthrotomies peaked in 2020, followed by a decline. Arthroscopic procedures increased steadily, especially from 2014 onward, indicating a preference for the minimally invasive technique.

Rheumatoid arthritis (RA) is a chronic inflammatory, immune-mediated disease of the musculoskeletal system that predominantly affects the hands and feet. The introduction of highly potent biologic disease-modifying drugs (bDMARDs) has led to a reduction in severe joint destruction and surgical interventions over the last two decades. Nevertheless, hand surgery remains an essential component of interdisciplinary therapy. Joint-preserving measures such as selective arthroplasty and partial arthrodesis are increasingly being performed today instead of arthrodesis, which was more common in the past. At the same time, the perioperative management of biologics is individually adapted to minimize the risk of infection. The following article draws on more than 30 years of personal experience in the treatment of patients with underlying rheumatic diseases and discusses current treatment recommendations for the hand and wrist.

Objective: Treatment of symptomatic Achilles tendinopathy.

Indications: Impingement between the calcaneus and the Achilles tendon.

Contraindications: General contraindications. Active soft tissue infection.

Surgical technique: Incision medial and lateral to the distal portion of the Achilles tendon at the level of the lower ankle joint, if necessary under X‑ray control. Blunt preparation of the two portals (laterally, taking into account the course of the sural nerve) towards the posterior process of the calcaneus with a curved clamp. Insertion of the arthroscope into the lateral portal and the shaver into the medial portal. Resection of the bursa and visualization of the insertion area of the tendon. Insertion of the bone acromionizer or a burr to resect the offending bone; changing the portal and removing bone portions on the medial side of the calcaneus. If necessary, additional transachillary incision to remove the bone near the insertion. Wound closure.

Postoperative management: Immobilization of the foot in equinus position for 3-5 days in a dorsal splint. Retention in a walker for a further 2 weeks after the swelling has subsided. Weight bearing after 3 weeks.

Results: A total of 26 patients were retrospectively evaluated with a mean follow-up time of 25 ± 6 months. The Foot Function Index (FFI) improved from 62 preoperatively to 7 points at the last follow-up examination. The final visual analog scale foot and ankle (VAS-FA) score was recorded as 89. Residual symptoms were present in 15% of patients.

Objective: Repair of the cartilage surface to prevent progression of cartilage pathologies that are associated with pain and limited mobility.

Indications: Talar cartilage lesions up to 1 cm².

Contraindications: Joint infection, generalized arthritis, poor compliance.

Surgical technique: If the cartilage layer is arthroscopically intact: retrograde drilling to increase blood flow and decompress a bone marrow edema or cyst. Superficial cartilage damage: chondroplasty and surface smoothing to limit loose bodies or damage progression. Deep cartilage damage down to the subchondral plate: nano- or microfracture with surface growth cell protrusion to gain replacement cartilage.

Postoperative management: For primary smoothing of the cartilage surface, immobilization with partial loading is recommended until proper wound healing. However, if there is cartilage damage that requires replacement cartilage to form, prolonged partial loading for up to 6 weeks, followed by increased loading is required.

Results: Chondroplasty is usually used in combination with other treatment steps, so few results are available for this treatment alone. Retrograde drilling shows good results in young patients with still open growth plates. Furthermore, a recurrence rate of up to 50% can occur. Nano- or microfracture shows good to excellent results for lesions up to 1 cm². For larger lesions this procedure alone appears to be insufficient.

Objective: Correction of a double varus deformity and an increased tibial slope.

Indications: Medial osteoarthritis (OA) and anterior instability in combination with a double varus deformity (MPTA < 84°, JLCA > 2°) and an increased tibial slope (> 12°).

Contraindications: Femoral varus deformity with lateral distal femoral angle of > 91°, severe lateral cartilage damage, lateral OA, lateral loss of the meniscus.

Surgical technique: Skin incision medial to the tibial tuberosity of approximately 8-10 cm. Insertion of two converging guide wires directly above the pes anserinus, ascending obliquely above the fibula tip. Check the position of the wires with the image intensifier. Incomplete osteotomy below the guide wires with the oscillating saw. Complete osteotomy of the posterior tibial cortex with a chisel to move the hinge anterolateral. Insertion of two Schanz screws in the proximal and distal fragments from anterior. Ascending osteotomy and removal of a small anterior wedge. Careful opening of the osteotomy with chisels at the level of the posterior tibial cortex. Correction of the tibial reclination with the help of the Schanz screws ("joystick"). Check the correction with the image intensifier in two planes. Osteosynthesis with medial angle-stable plate.

Postoperative management: Partial weight bearing with 10 kg for 2-6 weeks, then gradually increase the load. Range of motion: free.

Results: Using the described surgical technique, 28 patients (7 women, 21 men, age: 36.8 years) with chronic anterior instability or recurrent instability were treated. All patients had a double varus deformity (MPTA < 84°, JLCA > 2°) and a posterior tibial reclination of > 12°. The mean postoperative tibial reclination was 9.1°. The postoperative hip-knee-ankle angle was -0.4°. The Lysholm score increased from an average of 75.2 points to 90.3 points.

Objective: The goal of the fluoroscopically controlled tunnel positioning in anterior cruciate ligament (ACL) revision surgery is the prevention of malpositioning of femoral and tibial tunnel resulting in a reduced risk of rerupture of the ACL graft.

Indications: Remaining instability of the ACL after performed surgery, either after tunnel filling or as a single-stage surgery.

Contraindications: Relative: minor instability, contraindications against performing intraoperative x‑rays, advanced osteoarthrosis. Absolute: general contraindications against surgery.

Surgical technique: Supine position with tourniquet in place and lateral thigh support. Creation of the portals analogous to ACL surgery. Positioning of the drill wires using a targeting device, first femoral, then tibial. Now use of the C‑arm to fluoroscopically check the wire position using the ACL X‑app; correct it if necessary. If the position is adequate, use the quadrant method according to Bernard and Hertel (femoral) or according to Stäubli (tibial) to drill over to the target size of the drill channel. Subsequently, the transplant is drawn in and fixed. If necessary, add additional peripheral stabilization.

Postoperative management: Knee brace for 6 weeks postoperatively, limited flexion at 90° for 2-3 weeks, partial weight bearing (20 kg) for 2-3 weeks.

Results: In the 51 performed ACL revisions performed, there was a postoperative difference of 1 mm in Rolimeter measurement after 6 months.

Objective: The aim of this surgical technique is fracture healing with anatomical alignment and less implant irritation due to smaller, low-profile plates. Equal to superior stability is provided compared to single superior- or anterior-based plates.

Indications: The same general indications for surgical stabilization of clavicle fractures apply for low-profile double plating and include fracture displacement of one or more shaft width, shortening of more than 1 cm in length, and patients with high physical activity levels. Double plating is especially suitable for fractures in the midportion of the clavicle.

Contraindications: Fractures in the far lateral portion of the clavicle due to physiological thinning of the clavicle potentially causing problems with screw purchase of screws fitted in the anterior plate.

Surgical technique: A 2.0 mm low-profile mini plate is used on the superior and a 2.4 or 2.7 mm on the anterior surface of the clavicle. The plates are fixated with a minimum of two cortical or locking screws on each side of the fracture in each plate. A lag screw can be used if absolute stability can be obtained in simple fractures.

Postoperative management: A standard functional postoperative regime can be followed after plate fixation with free mobilization up to 90° without weight bearing for 6 weeks. Afterwards free range of motion and weight bearing are allowed.

Results: A biomechanical study, meta-analysis, and retrospective analysis have shown that low profile double plating offers equal to superior stability, lower rates of implant irritation and subsequent removal compared to conventional single plating with equal healing potential.

Objective: Treatment of pain and hypaesthesia caused by radial tunnel syndrome and functional deficits caused by supinator lodge syndrome. The objective for chronic nerve compression is containment to prevent further damage.

Indications: Radial tunnel syndrome, supinator lodge syndrome, tumour compressing the nerve, unsuccessful conservative therapy for at least 6 weeks and up to 4-6 months.

Contraindications: Infection or skin disease at the surgical area, severe scarring from previous surgery, systemic diseases that prevent anaesthesia, and nerve entrapment outside the radial tunnel and supinator tunnel.

Surgical technique: Decompression of the radial nerve both by addressing the entrapments within the radial tunnel and incising the supinator tunnel facilitating the anterolateral approach via the internerval plane between the brachioradialis and brachialis muscles.

Postoperative management: Compressive dressing around the complete arm for 3 weeks.

Results: Radial tunnel syndrome (RTS) and supinator lodge syndrome are nerve compression syndromes of the radial nerve. Proximal compression may cause mixed symptoms with pain, sensory, and motor deficits, while distal compression may cause either sensory or motor deficits. If symptoms persist for 4-6 months, surgical decompression is recommended, whereby the anterolateral approach is preferred due to better healing results and extensibility. The success rate after surgical decompression averages between 67 and 92%.