Unfallchirurgie (Heidelberg, Germany)最新文献

Due to the increasing numbers of implantations by total hip arthroplasty and the simultaneous aging of the population, in many countries the prevalence of periprosthetic fractures (PPF) is increasing. Older people with corresponding comorbidities are particularly affected. The frequent cause is low-energy trauma in the sense of a stumbling fall. The surgical treatment in orthopedics and trauma surgery is challenging. It cannot be compared with an elective shaft exchange or a solitary osteosynthesis. The combination of a vulnerable patient group and complex surgical procedures results in operations that are associated with high complication and mortality rates. Therefore, patients must be preoperatively prepared in the best possible way and these must also be performed with the least possible stress for the patient. The aim of this review article is to describe the risk factors of these injuries based on the current literature. The aspects of preoperative preparation, the classification of the fractures and the options for surgical treatment of Vancouver B2 and Vancouver B3 fractures are presented. The selection of implants and the form of fixation of the revision prostheses are also included. It is decisive that the approach is protective with respect to muscle tissue and results in a stable postoperative implant as patients are often cognitively not in a position to carry out partial weight bearing. Furthermore, aspects of postoperative aftercare, possible complications and prevention are described.

Peri-implant fractures of the femur and tibia shaft represent an increasing challenge in the clinical routine due to rising incidence, an aging and multimorbid patient population and often unfavorable postoperative outcomes. This article provides an overview of classification systems, diagnostic approaches and therapeutic strategies, with particular emphasis on aspects relevant to geriatric trauma care. The Vancouver, Lewis-Rorabeck, and Felix classifications form the basis for making treatment decisions in periprosthetic fractures of the femur and tibia. The management is primarily guided by the fracture location, implant stability, and bone quality. In cases of stable implants, locking plate osteosynthesis or intramedullary nailing is commonly used. When prosthetic loosening is present (e.g., Vancouver B2/B3 or Lewis-Rorabeck type III classification), revision arthroplasty is generally required. Interprosthetic fractures represent a distinct biomechanical challenge due to the presence of the implant and necessitate lengthy, locking bridging constructs or, in selected cases, the use of a megaprosthesis. In the context of geriatric trauma care, early mobilization that enables immediate full weight-bearing and interdisciplinary treatment within a certified geriatric trauma center are essential to reduce morbidity, mortality and the level of long-term care needed. Furthermore, the use of cemented stems can reduce the risk of periprosthetic proximal femoral fractures. These aspects should be incorporated into the management of geriatric trauma patients to contribute to an improvement in long-term outcomes.

Background: Tibial plateau fractures (TPF) have significantly increased over the last decade, with a notable proportion being bicondylar fractures. The necessity of a temporary external fixator (tEF) as an initial treatment for bicondylar TPF remains controversial, with limited data available regarding associated complications.

Aim of the study: The aim of this study is to investigate the complication rates between patients with and without initial treatment using tEF in patients with bicondylar TPF.

Material and methods: This monocentric retrospective study analyzed the complication rates of bicondylar TPF from January 2011 to December 2020 at a university national trauma center. The bicondylar TPFs were divided into two groups based on the respective initial treatment: temporary external fixator (tEF, n = 67) and primary immobilization in brace/cast (iBC, n = 82). The complication rate was determined using univariate regression analysis.

Results: Overall, there was no significantly increased relative risk of complications between tEF and iBC (odds ratio, OR 1.97, 95% confidence interval, CI 0.90-4.37, p = 0.069). The specific complication of a postinterventional infection, however, was significantly more frequent with the use of tEF (OR 5.11, 95% CI 1.27-29.88, p = 0.01) but the use of tEF was not associated with an impaired range of motion (ROM).

Discussion: The overall postoperative complication rate for tibial plateau fractures is not influenced by the initial treatment with a temporary external fixator or a brace/cast. The decision for a tEF should be made individually and based on clear indications. The higher infection rate in patients with tEF represents a risk that must be considered in the context of potential bias related to more complex soft tissue and bone injuries as well as multiple injuries. Further studies are needed to validate these findings and provide further analysis to improve clinical decision making.

Bone defects in the limbs may result from trauma, debridement during osteitis or pseudarthrosis resection or tumors [1]. Treating bone defects of the femur and tibia poses a substantial challenge in trauma surgery and orthopedics. Interdisciplinary orthoplastic treatment combined with soft tissue reconstruction is often necessary to preserve the extremity and its function. In addition to shortening surgery, various procedures are available for biological reconstruction, including autogenous and allogeneic bone transplantation, the use of osteoconductive bone substitutes, the induced membrane technique also known as the Masquelet technique, distraction osteogenesis and vascularized fibula transfer. Alternatively, megaprostheses can be used as metallic bone substitutes, especially for metaphyseal bone defects of the femur or proximal tibia [1].Bone defects up to 3 cm in size can usually be successfully treated with shortening or primary cancellous bone grafting; however, leg length difference is known to result in functional limitations [2]. The two-stage Masquelet technique can successfully be used to treat not only small and medium-sized defects but also larger defects through modification [2, 3]. Although the Masquelet technique can be used for larger defects, more complex surgical procedures are often employed in such cases. Callus distraction with segment transport is the most common procedure. In addition to external procedures with monorail or ring fixators, internal lengthening procedures with a transporting nail or plate-assisted bone segment transport (PABST) are now available as well [2].

Background: Multilevel fractures are breaks of a single bone at multiple levels, often as a combination of diaphyseal and metaphyseal sections. They are usually caused by the effect of strong direct force. Combined injuries of a bone are fractures accompanied by joint distortion. This results in ligament ruptures or avulsions together with a shaft fracture. Surgical treatment is always challenging and requires a differentiated approach.

Objective: The aim of this review article is to highlight the diagnostic and surgical procedures for multilevel fractures. Particular attention is paid to the importance of the fracture location and joint involvement in order to ensure targeted treatment for functional restoration.

Material and methods: A literature search was conducted to identify possible treatment strategies. In addition, clinical case studies from our own patient population were reviewed and discussed.

Results and conclusion: Multilevel injuries rarely occur in both the femur and tibia. In cases of compromised soft tissue or unstable cardiac circulation, external fixation is the primary treatment. For femoral fractures all-in-one, miss-a-nail or rendezvous techniques are common options for definitive treatment. In multilevel fractures of the tibia, the strategy depends on the involvement of the joint. Anatomical joint reconstruction is the top priority. The goal in shaft fractures is always to restore the axis, length and rotation. An accompanying fibular shaft fracture can be indicative of a fracture of the upper ankle joint. Restoration of ankle joint congruency is then essential.

Retrograde intramedullary nailing of the tibia is not a routine clinical procedure but is a valuable treatment option in special cases, such as pseudarthrosis in the presence of a knee endoprosthesis. This article reports on a 61-year-old female patient with a grade III open fracture of the lower leg with complex vascular and soft tissue injuries and failure of the docking site to heal after repeated callus distractions and plate osteosynthesis. Successful surgical treatment included retrograde tibial nailing with cancellous bone grafting for complete bony consolidation and good functional recovery.

Background: Femoral intramedullary nailing is the gold standard in the surgical treatment of femoral shaft fractures and can generally be performed using an antegrade or retrograde technique. As an intramedullary load-sharing device this type of osteosynthesis has biomechanical advantages. Retrograde intramedullary nailing is becoming increasingly more important in the treatment of periprosthetic, metaphyseal and intra-articular distal femoral fractures.

Objective: This article aims to demonstrate the value of retrograde femoral nailing and to discuss the clinically relevant advantages and disadvantages that need to be considered.

Material and methods: Systematic literature search using PubMed, Google Scholar and Cochrane Library using the keywords "femoral fracture, retrograde nailing, periprosthetic fracture, intramedullary nailing and locking plate osteosynthesis".

Results: In distal femur fractures retrograde nailing shows significantly less nonunions and infections than lateral locking plate osteosynthesis. In the treatment of intra-articular comminuted distal femur fractures, the rates of complications and revisions were lower with retrograde nailing than with plate osteosynthesis. Counterintuitively, there was no increased risk of septic arthritis of the knee joint after primary treatment of open fractures with a retrograde femoral nail. There is an increased risk of postoperative knee complaints.

Discussion/conclusion: Retrograde intramedullary femoral nailing provides many advantages with a comparatively low risk profile and can be used in a variety of forms for femoral fractures. The risk of postoperative knee complaints should be considered when determining the indications.

The wrist extends anatomically and functionally from the distal forearm to the metacarpal bones and encompasses the entire carpal region. The large number of bones and joints involved are stabilized in a highly complex system of extrinsic and intrinsic ligaments, which enables a variety of different movements and stability in all positions for the best possible use of the hands. While injuries to individual ligaments or joints, most commonly the scapholunate (SL) ligament, can cause major problems the injuries associated with perilunate dislocations and dislocated fractures represent one of the greatest challenges in hand surgery.