Operative Orthopadie Und Traumatologie最新文献

Objective: To describe the indications, operative technique, and long-term outcomes of patients treated with the Scheker (Aptis) distal radio-ulnar joint (DRUJ) prosthesis.

Indications: The Scheker prosthesis is intended to replace the DRUJ in patients with rheumatoid, degenerative, or posttraumatic arthritis of the sigmoid notch and/or ulnar head, or in cases of gross instability of the DRUJ. Moreover, a Scheker prosthesis can be used to treat failed salvage procedures, such as the Sauvé-Kapandji procedure, ulnar head resection, and ulnar head arthroplasty.

Contraindications: Severe osteoporosis, active infection, immature skeleton, less than 14 cm of the proximal ulna remaining.

Surgical technique: In supine position with the forearm in full pronation, an ulnar S‑shaped incision is made. The ulnar head is resected and the proximal part is brought to the palmar side to enable visualization of the sigmoid notch. Following preparation of the sigmoid notch and the proximal ulnar part of the radius, a radial plate is attached. When the position is verified with fluoroscopy, screw holes are drilled together with a separate hole for the radial peg. A metal stem is inserted in the ulnar shaft. A polymer ball is then slid on to a polished peg on top of the ulnar stem. This polymer ball is seated in the socket of the radial plate and fixed with a small metal cap. Radiographic images are made for confirmation of correct positioning and full pro- and supination is tested, after which the wound is closed.

Postoperative management: After 48 h of pressure bandages, patients are instructed to start with full range of motion and weight-bearing exercises under the guidance of a hand therapist. Weight-bearing is constrained to 10 kg.

Results: We retrospectively assessed 50 Scheker prostheses in 48 patients treated between 2016 and 2021. The median age was 56 years (IQR: 50-65) and 30 (60%) were female. Median follow-up was 29 months (IQR: 12-48). The primary outcome was the PRWE score. The median PRWE score at the final follow-up was 23 (IQR: 4-52) for the operated side versus a median PRWE score of 5 (IQR: 0-25) for the non-operated side (p < 0.005). Six patients had a complication. Three patients developed extensor carpi ulnaris tendinitis with one patient requiring additional surgery. One patient developed a neuroma of the distal branch of the ulnar nerve that was surgically removed. One synovectomy was performed because of synovitis and one endoscopic ulnar release was performed because of hyperesthesia of the ulnar area. None of the prostheses had to be removed.

Objective: For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function.

Indications: Soft tissue sarcoma, metastases.

Contraindications: Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care.

Surgical technique: Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus.

Postoperative management: Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up.

Results: Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.

The planning and implantation of a customized partial pelvis replacement places high demands on both the surgeon and the entire team (engineer, assistants, surgical team). Thanks to careful preoperative planning and meticulous perioperative execution, customized partial pelvic replacement represents a complex but reliable procedure for defect reconstruction even with highly complex acetabular bone defects or after multiple previous surgeries.

Objective: Three-dimensional (3D) analysis and implementation with patient-specific cutting and repositioning blocks enables correction of complex tibial malunions. Correction can be planned using the contralateral side or a statistical model. Patient-specific 3D-printed cutting guide blocks enable a precise osteotomy and reduction guide blocks help to achieve anatomical reduction. Depending on the type and extent of correction, fibula osteotomy may need to be considered to achieve the desired reduction.

Contraindications: a) Poor soft tissue (flap surgery, adherent skin in field of operation); b) infection; c) peripheral artery disease (stage III and IV classified according to Fontaine, critical transcutaneous oxygen partial pressure, TcPO₂); d) general contraindication to surgery.

Surgical technique: Before surgery, a 3D model of both lower legs is created based on computed tomography (CT) scans. Analysis of the deformity based on the contralateral side in a 3D computer model (CASPA) and planning of the osteotomy. If the contralateral side also has a deformity, a statistical model can be used. Printing of patient-specific guides made of nylon (PA2200) for the osteotomy and reduction. Surgery is performed in supine position, antibiotic prophylaxis, thigh tourniquet, which is used as needed. Ventrolateral approach to the tibia. Attachment of the patient-specific osteotomy guide, performance of the osteotomy. Reduction using the guide. Fibula osteotomy through a lateral approach is performed if the reduction of the tibia is hindered by the fibula. This can be performed freehand or with patient-specific guides. Wound closure.

Postoperative management: Compartment monitoring. Passive mobilization of the ankle in the cast as soon as the wound healing has progressed. Partial weightbearing in a lower leg cast for at least 6-12 weeks, depending on the routinely performed radiographic assessment 6 weeks postoperatively. Thromboprophylaxis with low molecular weight heparin until cast removal.

Results: Patient-specific correction of malunions are generally good. This could be confirmed for distal tibial corrections. For tibial shaft deformities, the final results are still pending. Preliminary results, however, show good feasibility with a pseudarthrosis rate of 10% without postoperative infection.

Objective: Three-dimensional correction of the bony alignment in the frontal and sagittal plane of the proximal tibia; surgery is performed via an open- or closing-wedge osteotomy to improve ligament stability and reduce joint degeneration.

Indications: Chronic anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) instability and ligament revision surgeries; subjective knee instability in patients who are ambitious athletes and people who do physical labor; moderate joint degeneration with meniscus and cartilage damage, post-traumatic deformities.

Contraindications: Time pressure (immediate meniscus surgery, since planning and production of patient-specific tools is time-consuming), lack of compliance (need for partial weight bearing, crutches), excessive smoking, vascular pathologies.

Surgical technique: Planning based on computed tomography (CT) data, determination of the axis of rotation with open or closing wedge, or dome osteotomy; production of corresponding patient-specific cutting blocks. Surgery is performed using the known standard approaches for a high tibial osteotomy (HTO). Exact positioning of cutting guides on the exposed bone. Sawing and adjusting the correction using an osteotomy chisel so that the reduction guide can be attached. Fixation of the achieved correction with angle-stable plate fixator.

Postoperative management: Partial weight bearing based on the extent of the correction for 6 weeks, free range of motion if no additional ligamentous reconstruction was performed. Subsequent full weight bearing after X‑ray and, if necessary, CT control.

Results: No general results can be presented, since the surgical procedure, the indication, and the patient group are extremely heterogeneous. Accuracy of the cutting blocks used has been presented in other studies and is given as 0.8° ± 1.5° in relation to the frontal axis. However, the intraoperative change in the correction and adaptation to the surgical site that is presented depends on the surgeon and can greatly influence the extent of correction in terms of accuracy in complex corrections.

Objective: Patient-specific osteosynthesis for pseudarthrosis of the acromion.

Indications: Symptomatic pseudarthrosis of the acromion at the level of a meta/mesacromion.

Contraindications: Infection; patient noncompliance regarding postoperative treatment protocol.

Surgical technique: Preoperatively, a patient-specific three-dimensional model of the scapula is printed. A locking compression plate (LCP) is individually adapted to this model. Via a dorsal surgical approach over the scapular spine, the pseudarthrosis is refreshed and autologous cancellous bone from the iliac crest is embedded in the fracture zone. This is followed by fixed-angle osteosynthesis with the individualized plate. In addition, tension banding with tapes is performed to reduce the tensile and shear forces on the fracture caused by the muscle.

Postoperative management: Consistent wearing of a shoulder-arm brace for 6 weeks postoperatively, active-assisted increase in range of motion for an additional 3 weeks, then gradual increase in weight-bearing and initiation of daily activities without additional weights until 12 weeks postoperatively.

Results: Treatment with the presented technique resulted in radiographic consolidation of the fracture and significant improvement in range of motion and pain at the 1‑year follow-up.

Objective: Restoration of the original anatomy with reduction of both current symptoms and risk of posttraumatic osteoarthritis.

Indications: Symptomatic intra- or extra-articular malunion due to limitation of movement and/or painful function, intra-articular step of > 1 mm, instability of the distal radioulnar joint.

Contraindications: Minimal deformity. Pre-existing osteoarthritis Knirk and Jupiter II or higher. Simpler surgical alternative, e.g., ulna shortening osteotomy. Smoking or advanced age are not contraindications.

Surgical technique: Preoperative assessment and performance of a bilateral computed tomography (CT). Three-dimensional (3D) malposition analysis and calculation of the correction. Planning of the corrective osteotomy on the 3D model and creation of patient-specific drilling and sawing guides. Performing the 3D-guided osteotomy.

Postoperative management: Early functional unloaded mobilization with the splint for 8 weeks until consolidation control with CT.

Results: Significant reduction of the step to < 1 mm (p ≤ 0.05) can be achieved with intra-articular corrections. In extra-articular corrective osteotomies, a mean residual rotational malalignment error of 2.0° (± 2.2°) and a translational malalignment error of 0.6 mm (± 0.2 mm) is achieved. Single-cut osteotomies in the shaft region can be performed to within a few degrees for rotation (e.g., pronation/supination 4.9°) and for translation (e.g., proximal/distal, 0.8 mm). After surgery, a mean residual 3D angle of 5.8° (SD 3.6°) was measured. Furthermore, surgical time for 3D-assisted surgery is significantly reduced compared to the conventional technique (140 ± 37 vs 108 ± 26 min; p < 0.05). Thus, the progression of osteoarthritis can be reduced in the medium term and improved mobility and grip strength are achieved. The clinical outcome parameters based on patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) scores are roughly comparable.

Objective: The goal of osteotomy is either to restore pretraumatic anatomic conditions or to shift the load to less affected compartments.

Indications: Indications for computer-assisted 3D analysis and the use of patient-specific osteotomy and reduction guides include "simple" deformities and, in particular, multidimensional complex (especially posttraumatic) deformities.

Contraindications: General contraindications for performing a computed tomography (CT) scan or for an open approach for performing the surgery.

Surgical technique: Based on CT examinations of the affected and, if necessary, the contralateral healthy extremity as a healthy template (including hip, knee, and ankle joints), 3D computer models are generated, which are used for 3D analysis of the deformity as well as for calculation of the correction parameters. For the exact and simplified intraoperative implementation of the preoperative plan, individualized guides for the osteotomy and the reduction are produced by 3D printing.

Postoperative management: Partial weight-bearing from the first postoperative day. Increasing load after the first x‑ray control 6 weeks postoperatively. No limitation of the range of motion.

Results: There are several studies that have analyzed the accuracy of the implementation of the planned correction for corrective osteotomies around the knee joint with the use of patient-specific instruments with promising results.