Operative Orthopadie Und Traumatologie最新文献

Objective: Osteosynthesis in dislocated diametaphyseal forearm fractures is intended to restore anatomy and function. Antegrade intramedullary nailing in the radius is used to restore length, rotation, and axis within the age-specific correction limits. Sufficient stability ensures early functional postoperative treatment without load.

Indications: Dislocated diametaphyseal forearm or radius fractures that cannot be closed, stably reduced, or remain outside the age-specific correction limits.

Contraindications: Radius or forearm fractures located distal or proximal to the defined area. Soft tissue defects, contamination or infections located in the access path.

Surgical technique: In the course of the Thompson approach, the soft spot between the extensor digitorum and extensor carpi radialis brevis muscles is located and an approx. 3-4 cm skin incision is made. Then blunt preparation down to the bone, sparing the profundus and superficial radial nerve. Retraction of the musculature with two Langenbeck hooks. Opening of the cortex with an awl. If necessary, a 2.5 mm drill with tissue protection can be used beforehand if the cortex is very hard. A titanium elastic nail (TEN) diameter is selected so that it fills approximately 2/3 of the medullary canal. It is recommended to flatten the TEN runner with parallel flattening forceps. After closed reduction, the TEN is then brought up in front of the growth plate with slightly rotating movements. The TEN is bent over at the proximal end and pinched off above the muscle bellies. Alternative procedures include Kirschner wire osteosynthesis or retrograde TEN from radial or dorsal, with or without bending.

Postoperative management: The aim of osteosynthesis is early functional follow-up without load. Sports abstinence is recommended for 8 weeks. Metal removal can be performed after consolidation between 3 and 6 months.

Results: Clearly dislocated or outside the correction limits infantile radius and forearm fractures show very good treatment results with a low risk profile after the described osteosynthesis technique. Pseudarthrosis and nerve damage were not observed. Secondary dislocation has not occurred.

Objective: Simultaneous implantation of a TOPS (transcutaneous osseointegrated prosthetic system) and THA (total hip arthroplasty) or staged approach.

Indications: Patients with a TOPS who have coxarthrosis. Patients with an existing THA who have required above-knee amputation and need a TOPS. Patients with an existing TOPS who sustain a medial femoral neck fracture and are not stabilizable with osteosynthesis.

Contraindications: Atypical anatomy, osteomyelitis, radiation or chemotherapy to the affected limb in the last 18 months, peripheral occlusive arterial disease with critical ischemia, diabetes mellitus with polyneuropathy, local dermal or systemic infection, immunocompromised state or use of immunosuppressants, cognitive impairment or lack of compliance for the system, other significant physical impairments.

Surgical technique: Individualized preoperative planning based on CT data. Access similar to conventional THA for existing TOPS. Implantation of an artificial acetabulum with a matching inlay. Similar approach for medial femoral neck fractures without reconstructive options. For existing THA and prior above-knee amputation, removal of existing shaft and potentially neck component for modular prosthesis. Subsequent implantation of TOPS stem in conventional manner.

Postoperative management: Additional THA requires appropriate rehabilitation following endoprosthesis guidelines, tailored to the TOPS situation. For simultaneous implantation of TOPS and THA the patients' load-bearing capacity and mobilization depend on the duration of the implanted stem.

Results: Only 4 patients have been treated at BGU Murnau making statistical analysis not feasible. Three of the 4 patients experienced significant pain relief and improved mobility shortly after surgery. One patient remained as immobile postoperatively as preoperatively due to inability to achieve pain-free full weight-bearing.

Objective: Realignment of the hindfoot by talonavicular arthrodesis.

Indications: Idiopathic and posttraumatic arthritis of the talonavicular joint with or without malalignment. Optional in flatfoot reconstruction.

Contraindications: General medical contraindications to surgical interventions.

Infection:

Surgical technique: Medial, dorsomedial, or dorsal skin incision. Exposure of the talonavicular joint and cartilage removal. Decortication. Reposition of the joint if malaligned. Optional transplantation of corticocancellous bone. Temporary stabilization with Kirschner wires and stabilization with screws, optional with cramps or plates.

Postoperative management: Six weeks nonweightbearing in a long walker boot. Afterwards 2 weeks of progressively weight bearing in a long walker boot. Then full weightbearing in walking shoes with stiff soles. Physiotherapy.

Results: A total of 18 feet in 18 patients with isolated talonavicular arthritis were treated with isolated talonavicular fusion and corticocancellous bone thorough a midline incision. For postoperative management, patients had nonweightbearing for 6 weeks in a long walker boot. Mean follow-up was 14.5 months (range 8-35 months). Mean age was 63.2 years (range 54-72 years). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 65.3 (± 5.2); postoperative MOXFQ score was 28.5 (± 7.0). One revision surgery performed due to pseudarthrosis.

Objective: To treat instability caused by a genu recurvatum using ventral open wedge osteotomy of the distal femur.

Indications: Knee instability caused by Genu recurvatum with femoral extension deformity.

Contraindications: Inadequate blood flow to the lower extremity, soft tissue issues, obesity, osteoporosis.

Surgical technique: Through a primary medial approach to the distal femur, a ventral open wedge osteotomy is performed using chisel bunch formation and arthrodesis spreader. For symmetrical expansion, another lateral approach at the distal femur and insertion of another arthrodesis spreader is performed. Osteosynthesis was performed with an angle stable plate from the medial side and with additional stabilization using a 4-hole angle stable plate from the lateral side. The osteotomy gap was filled with a bone graft wedge.

Postoperative management: Partial weight-bearing of 20 kg was allowed for 6 weeks with passive exercise and lymphatic drainage. A hard frame orthosis for immobilization at 0-10-90° was fitted for 6 weeks. Radiographic controls were performed at 6 weeks, 3 months, and 1 year. After the last radiographic control, hardware was removed.

Results: There are no reports in the current literature regarding the effect of a change in the sagittal plane at the distal femur on alignment, stability, and biomechanics of the knee. This case report shows that genu recurvatum with physiological posterior tibial slope can be successfully treated with anterior femoral flexion osteotomy. Hyperextension was completely eliminated at the follow-up examination after hardware removal after 12 months.

Objective: Defect reconstruction of the hand by means of the free medial sural artery perforator (MSAP) flap.

Indications: Reconstruction of full-thickness defects on the hand with a thin non-bulky flap in cases of exposure of functional structures or in combination with simultaneous osteosynthetic procedures.

Contraindications: Prior surgery at the donor site or progressive peripheral artery occlusive disease. Defect size that exceeds the maximum width of the free MSAP flap for primary closure of the donor site. Lack of patient consent or compliance.

Surgical technique: Suitable perforators are identified through a medial incision on the calf. The vascular pedicle is then completely followed subfascially along the gastrocnemius muscle until its source vessel the medial sural artery is reached. Subsequently, the flap design is adapted to the perforator anatomy and the flap is completely elevated. Indocyanine green fluorescence angiography can be used to identify the size of the reliable angiosome.

Postoperative management: Close monitoring of the flap is required for the first 48 hours after surgery. Anticoagulation with low-molecular weight heparin should be administered for thrombosis prophylaxis. The hand can be mobilized on the first day after surgery.

Results: Between May 2017 and March 2022 a total of 16 free MSAP flaps were carried out for hand defect reconstruction. All donor sites were primarily closed. The reconstruction was successful in all cases. In one patient venous thrombosis occurred postoperatively, which was successfully revised. In two flaps, surgical hematoma evacuation was necessary within 24 hours after surgery. Complications or wound healing disorders at the donor site were not observed.

Objective: Transfer of the gluteus maximus with refixation at the greater trochanter for treatment of abductor deficiency.

Indications: Symptomatic abductor deficiency with atrophy and fatty degeneration of the gluteal muscles > 50% (grade 3 by quartile) with good strength of the gluteus maximus.

Contraindications: Low atrophy or fatty degeneration of less than 50% of the gluteal muscles, limited strength of the gluteus maximus, infection.

Surgical technique: First, the fascia lata is incised dorsally to the tensor fascia latae muscle, with the incision extending approximately 1.5 cm proximal to the iliac crest. A second incision divides the gluteus maximus muscle longitudinally along the muscle fibers and continues towards the fascia lata distal to the greater trochanter. These incisions result in a triangular muscle flap, which is elevated and divided into anterior and posterior portions. The posterior flap is positioned ventrally over the femoral neck and fixed to the anterior capsule and the anterior edge of the greater trochanter. The anterior flap is placed directly on the proximal femur. For this purpose, a groove is prepared in the area of the proximal femur using a spherical burr to freshen up the future footprint. The anterior flap is positioned from the tip of the greater trochanter towards the insertion of the vastus lateralis muscle. Subsequently, the anterior flap is fixed to the created groove with transosseous sutures and positioned under the elevated vastus lateralis muscle in 15° abduction of the leg. To provide additional stabilization to the tendinous part of the anterior flap, a screw is inserted distally to the greater trochanter. The vastus lateralis muscle is attached to the distal tip of the anterior flap, and the remaining gluteus maximus muscle is sutured to the fascia lata to cover the anterior flap. Additionally, a flap of the tensor fascia latae muscle can be mobilized and adapted to the reconstruction. Layered wound closure is performed.

Results: The technique of a gluteus maximus transfer represents a method for the treatment of chronic abductor deficiencies and improves abduction function as well as the gait pattern in short-term follow-ups. Fifteen patients (mean age at time of surgery 62 years) had after a mean follow-up of 2.5 years. The modified Harris Hip Score (mHHS) improved from 48 points preoperatively to 60 points at follow-up. Preoperatively, 100% had a positive Trendelenburg sign; at follow-up, this was about 50%.

Objective: Correction of pseudoinstability and tibial malalignment by re-establishment of the pretraumatic tibial axis.

Indications: Posttraumatic valgus malalignment accompanied by pseudoinstability.

Contraindications: Infections, significant inhibition of movement and multidirectional ligament instability.

Surgical technique: Standard anterolateral approach to the proximal tibial head. Lateral open wedge high tibial osteotomy above (supra) the tibiofibular joint and opening until the pseudoinstability of the lateral collateral ligament is levelled.

Postoperative management: Partial weight bearing for 4 weeks, after radiological control full body weight loading is allowed. Implant removal after full bony consolidation.

Results: There is limited evidence in the current literature but the available results show good results in 70% of the cases in long-term follow-up.

Objective: Correction of a proximal tibial valgus deformity.

Indications: Lateral osteoarthritis of the knee or cartilage damage in a valgus deformity > 5° with a medial proximal tibial angle (MPTA) > 90°.

Contraindications: Medial proximal tibial angle < 90°, medial cartilage damage, medial meniscus loss.

Surgical technique: Skin incision medial of the tibial tuberosity approximately 8-10 cm. Insertion of two converging guidewires directly above the pes anserinus, ascending obliquely, and ending at the tip of the fibula. Control of the wire position with the image intensifier. Osteotomy with an oscillating saw. Removal of the wedge and closure of the osteotomy. Osteosynthesis with a medial angle-stable plate.

Postoperative management: Partial load bearing with 10-20 kg for 2 weeks, then step-wise increase in load. Mobility: free.

Results: We performed this surgery in the manner described in 21 patients with lateral osteoarthritis or cartilage damage (17 men, 4 women, average age: 51 years). The valgus deformity was reduced from an average of 5.6 to -0.5°. The KOOS-PS (Knee Injury and Osteoarthritis Outcome Score-Physical Function Short-form) score decreased significantly from 39.1 ± 14 to 25.8 ± 20 points.