Operative Orthopadie Und Traumatologie最新文献

Objective: The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus.

Indications: Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided.

Contraindications: Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis.

Surgical technique: Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through a paratricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired.

Postoperative management: Early functional rehabilitation in a hinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed.

Results: Between 2018 and 2022, 18 patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after a mean follow-up of 12 months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination.

Objective: Treatment of focal cartilage defects of the humeral capitellum with autologous bone-cartilage cylinders to prevent development of arthritis of the elbow joint.

Indications: High-grade, unstable lesions (> 50% of the capitellum, grade III-IV according to Dipaola), including those involving the lateral edge of the capitellum and with a depth of up to 15 mm.

Contraindications: Stable lesions and generalized osteochondritis of the capitellum (including Panner's disease), as well as a relative contraindication for lesions > 10 mm, as the largest punch has a maximum diameter of 10 mm.

Surgical technique: Arthroscopy of the elbow joint, transition to open surgery. First, the size of the cartilage defect in the capitellum is determined. Then, one (or several) osteochondral cylinders (OATS Arthex) are removed, which as far as possible completely encompass the defect zone. Corresponding intact bone-cartilage cylinders are obtained from the ipsilateral proximal lateral femoral condyle, each with a 0.3 mm larger diameter via an additive miniarthrotomy. The "healthy" cylinders are then inserted into the defect zone in a "press fit" technique.

Postoperative management: An upper arm cast in neutral position of the hand for 10-14 days, simultaneously beginning physiotherapy (active-assisted movements) and lymphatic drainage. As soon as painless range of motion (ROM) is restored (goal: by week 6), isometric training can be started. Resistance training starts from week 12. Competitive sports are only recommended after 6(-8) months.

Results: The current state of research on the surgical treatment of OCD of the humeral capitellum using autologous osteochondral grafts shows mostly promising results. A recent meta-analysis of 24 studies reports a significantly higher (p < 0.01) rate of return to sports (94%) compared to fragment fixation (64%) or microfracture and debridement (71%) [41]. However, the increased donor-site morbidity must be taken into account (ca. 7.8%).

Objective: Minimally invasive stabilization of metatarsal fractures to enable adequate fracture healing in a correct position to restore anatomy and biomechanics of the foot.

Indications: A. Dislocated diaphyseal and subcapital fractures of the second to fifth metatarsal (> 3 mm, > 10° dislocation). B. Fifth metatarsal fracture at the metadiaphyseal junction (Lawrence and Botte type III).

Contraindications: High grade soft tissue damage or infection at the implant insertion site.

Surgical technique: A. Fluoroscopically assisted closed reduction and antegrade intramedullary fixation of diaphyseal and subcapital fractures of the second to fifth metatarsal. B. Fluoroscopically assisted wire-guided intramedullary screw fixation of fifth metatarsal fractures at the metadiaphyseal junction.

Postoperative management: A. Mobilization with partial weight bearing (20 kg) for 6 weeks wearing a stiff sole; implant removal under local anesthesia after 6-8 weeks, followed by a free range of movement and weight-bearing as tolerated (WBAT). B. Early mobilization with weight-bearing as tolerated (WBAT); removal of the orthosis after 6 weeks, implant removal optional.

Results: A. Antegrade nailing of subcapital and shaft fractures of metatarsals II-V achieves good clinical results with low complication rates both when using prepared Kirschner wires or elastically stable intramedullary nails (ESIN). B. According to current literature, intramedullary screw osteosynthesis of proximal metatarsal V fractures of zone II and III according to Lawrence and Botte leads to faster bony healing with a lower nonunion rate compared with conservative treatment. It is recommended especially, but not only, for active athletes.

Objective: A rotational osteotomy requires a complete cut of the bone in order to correct maltorsion. An additional correction of the frontal axis can be achieved via an oblique cut of the bone. The osteotomy with bone to bone contact is fixed with an angle stable plate.

Indications: Symptoms such as anterior knee pain, inwardly pointing knee syndrome, lateral patellar subluxation or dislocation, lateral patellar hypercompression syndrome are a common indication for derivational osteotomy if clinically increased femoral internal rotation and radiologically increased femoral antetorsion is detected.

Contraindications: Increased hip external rotation versus internal rotation, increased femoral torsion but no increased internal hip rotation, malcompliance, inability for partial weight bearing, risk of delayed union (nicotine abuse and obesity) as well as patellofemoral arthritis and systematic glucocorticoids, immunosuppressants are (relative) contra-indications.

Surgical technique: A lateral or optionally medial approach to the distal femur and exposure of the bone with Eva hooks for the osteotomy is done. The use of patient-specific cutting blocks accurately specify the planned extent of derotation and level of incision. A defined oblique cutting plane of the single-cut osteotomy and derotation will additionally correct/change frontal axis. An additional biplanar osteotomy with an anterior wedge increases intraoperative stability and generates a larger bone contact area for consolidation.

Postoperative management: With the use of an extra medullary fixation device partial weight bearing with 15-20 kg with crutches up to 6 weeks is required, but no restriction on knee movement is given.

Results: The literature shows significantly improved patient satisfaction regarding patellofemoral stability and knee function. With the use of patient-specific cutting guides, high accuracy of the osteotomy and 3‑dimensional correction can be achieved, while delayed union rate is up to 10%.

Objective: Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy.

Indications: Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment.

Contraindications: Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered.

Surgical technique: The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws.

Postoperative management: Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment a

Objective: Stabilization of metastatic acetabular defects with a bone cement-augmented revision support cup for remobilization of oncological patients in advanced cancer stages.

Indications: Metastatic acetabular defects (Metastatic Acetabular Classification, MAC 2-4) in patients with a prognostic medium or long-term survival.

Contraindications: Highly limited survival due to metastatic disease (< 6 weeks). Local bone or soft tissue infection. Primary bone tumor with curative treatment option. Advanced pelvic discontinuity. Recent wound compromising systemic therapy.

Surgical technique: Standard hip approach. Curettage of the metastatic defect and careful reaming of the acetabulum before insertion of the cup. Predrilling of the dome und flange screws before application of the bone cement through the center hole of the implant and filling of the acetabular defect. Complete insertion of the screws for compound osteosynthesis. Implant of a modular inlay or dual mobility system.

Postoperative management: Full weight bearing or mobilization with two crutches according to the level of pain. Adjuvant local radiation therapy after wound consolidation. Continuation of systemic therapy according to tumor board decision.

Results: Between 2012 and 2019, we treated 14 patients with metastatic acetabular defects using the modular revision support cup "MRS-TITAN® Comfort", MRS-C, Peter Brehm GmbH, Weisendorf, Germany) at our institution. Mean Harris Hip Score improvement was 23.2 with a mean patient's survival of 9.7 months due to the reduced cancer-related prognosis; 13 of the 14 implants endured the patient's prognosis. One implant had to be removed due soft tissue defect-related periprosthetic joint infection.

Objective: The aim of this paper is to describe the anterolateral approach using an anatomical plate for ankle arthrodesis and to present the first mid-term results with this technique in a high-risk population.

Indications: The indication for arthrodesis of the ankle joint with this described technique is moderate to severe osteoarthritis of the ankle.

Contraindications: In addition to the general contraindications typical of any operation, there is a specific contraindication in cases of active infection of the soft tissues and accompanying osteomyelitis at the ankle.

Surgical technique: The incision is made along the course of the peroneus tertius muscle. After that, the mobilization of the peroneus superficialis nerve is carried out, followed by the mobilization of the long extensor tendons, especially the extensor digitorum muscle in a medial direction opening the capsule and removal of the residual cartilage on the distal tibia and talus. Subsequently, the subchondral sclerosis is opened, and the implantation of a suitable osteosynthesis material, e.g., an anatomical angle-stable plate, is carried out. Finally, wound closure is performed involving the muscle belly of the extensor digitorum muscle covering the plate.

Postoperative management: Immobilization of the ankle for 5-7 days in a dorsal knee-high splint. Retention in a walker after decongestion for another 5 weeks. Increased loading can be done after X‑ray/computed tomography (CT) control from the 6th week.

Results: In all, 11 patients were observed retrospectively for an average of 14 months. There were no complications. The European Foot and Ankle Society (EFAS) score improved significantly from 3.3 to 17.8 points. All patients were subjectively satisfied with the result and would have the operation again.