Unfallchirurgie (Heidelberg, Germany)最新文献

Background: Periprosthetic fractures of the knee joint are among the major complications following joint replacement surgery. The surgical treatment is challenging and therefore requires careful preoperative planning in order to select the best possible treatment strategy.

Material and methods: This review article was compiled based on a selective literature search of the PubMed database. Evidence-based treatment recommendations are provided using common classification systems and current research results.

Results: Regardless of the location of a periprosthetic fracture in the knee, at first it has to be determined whether the knee joint endoprosthesis is stable or loose. If the implant is stable, the prosthesis can be retained with osteosynthetic treatment. In the case of a loose implant, prosthesis malfunctioning, malalignment or malpositioning, ligament instability, infection or deficient bone substance, the prosthesis has to be replaced. Knowledge of the exact classification of the fracture and the implant in place is therefore essential for determining the surgical strategy. This article focuses primarily on the different strategies for prosthesis replacement.

Conclusion: Periprosthetic fractures of the knee are complex injuries that require extensive expertise in trauma and arthroplasty in order to provide the best possible surgical treatment.

Background and question: The challenge in the rehabilitation of polytraumatized people is the lengthy path to the best possible recovery, which requires patience on the part of the person undergoing rehabilitation as well as continuous support. The aim of this analysis is to identify specific factors and times that are important in the rehabilitation process.

Study design and investigation methods: A total of 50 documented courses of rehabilitation management with 214 course documentations were evaluated. Problems in the course and measures taken were clustered for statistical evaluation.

Results: The patient population was similar to that of the Trauma Register of the German Society of Trauma Surgery (TR-DGU). The start of care was on average 200 days after the accident. In the initial period 4-5 months after the accident, medical and technical measures, especially obtaining second opinions, predominated in 78% of cases, further hospitalizations in 42% and further medical rehabilitation measures in 54%. Problems of occupational participation became relevant 11-12 months after the accident. Social rehabilitation management came to the fore after 15-16 months.

Conclusion: In summary, rehabilitation after polytrauma requires a comprehensive, individually adapted concept that takes the physical, psychological and social aspects of recovery into account.

Periprosthetic acetabular fractures (PPAF) are a rare but increasingly relevant complication following total hip arthroplasty. The management is complex and requires expertise in fracture treatment and revision arthroplasty. The treatment planning is based on the morphological fracture characteristics according to the column concept (Letournel), the extent of bone defects (fracture-related or pre-existing), the stability of the acetabular component and patient-related factors. This review article presents a practice-related algorithm on how to approach PPAFs. In addition to the preoperative diagnostics, established classification systems, surgical approaches and treatment strategies for various fracture scenarios are also presented.

Shaft fractures of the upper extremities represent a significant challenge in trauma surgery due to their functional importance. The epidemiological analysis reveals characteristic distribution patterns: humeral shaft fractures (1.2-5% of all fractures) show a bimodal age distribution, with peaks at 20-30 years and above 60 years. Forearm shaft fractures (13.8/100,000 inhabitants [1]) occur particularly frequently in children and decrease with advancing age. The classification primarily follows the AO/OTA system, which was comprehensively revised in 2018, supplemented by specific classifications for special types, such as Monteggia and Galeazzi fractures. In the diagnostics, conventional radiography remains the initial standard, while computed tomography (CT), magnetic resonance imaging (MRI) and increasingly high-resolution sonography serve as complementary methods for assessing complex fracture morphologies and associated soft tissue injuries. Concomitant neurological injuries, especially radial nerve palsy in humeral shaft fractures (2-17%), which otherwise occur less frequently in routine trauma surgery, require differential diagnostics and individualized treatment concepts. While the majority of nerve lesions show spontaneous remission, microsurgical reconstruction techniques exist for persistent cases. Innovative approaches such as biological augmentation, virtual reality (VR)-based neurorehabilitation or functional electrical nerve stimulation could improve outcomes in the future. Interdisciplinary collaboration between orthopedic surgery, neurology and rehabilitation medicine is essential for optimal treatment results.

The tertiary survey serves to identify injuries and their consequences in the hours and days following polytrauma. A structured process has been proven to result in a high rate of previously missed additional diagnoses, leading to subsequent changes in patient management; however, to date there are no concrete practical recommendations or widespread implementation of the tertiary survey in German trauma centers. We recommend performing the tertiary survey for the first time as early as possible in the intensive care unit, followed by repeated assessments as needed when the patient´s clinical condition changes. Furthermore, we recommend utilizing the tertiary survey as a structured re-evaluation of the patient beyond physical examination. This should include the assessment of psychological stress, a thorough review of imaging and consultative findings and the collection of additional information regarding the accident and the patient´s medical history. After compiling all information further treatment plans should be evaluated and defined. The Trauma Section of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) is developing a freely available tertiary survey form, which will undergo continuous optimization supported by scientific evaluation. In the long term, the goal is to provide a standardized tool for integration into local standard operating procedures of trauma centers, quality management systems and digital emergency care pathways.

Background: As part of the evaluation of a virtual multidisciplinary expert board to improve the treatment of trauma to the lower extremities (project EXPERT), work-related aspects are examined in addition to medical and economic outcomes. Initial results of a survey of employees involved in EXPERT are presented here.

Material and methods: Clinical staff worked on an online questionnaire on the topics of workload, work commitment, work-related resources and technical readiness. Work-related resources are physical, social and organizational aspects for overcoming work demands, such as peer support, feedback, opportunities to learn and meaningfulness of work. Factors that have a significant effect on work commitment and willingness to work were recorded.

Results: At the beginning of the project, the work commitment was very high, although the individual workload was also high. When individual stress was high, the willingness to use technology increased if sufficient work-related resources were available. Nonmedical staff showed a high willingness to use technology, especially with limited resources. With high team-related stress, e.g. due to conflicts and only a few resources, the willingness to use technology was particularly low.

Discussion: Diverse work-related resources not only strengthen work commitment but also the acceptance of digital innovations. In the case of high individual stress, employees, especially members of the nonmedical professions, perceived the use of technology as helpful. The prerequisite for this is that the cooperation in the team works.

The management of shaft fractures of the upper extremities is an integral part of trauma surgery in the clinical routine. While sport-associated injuries predominate in young adults, the incidence of osteoporotic fractures greatly increases in older patients. Despite established treatment strategies, complications such as wound healing disorders, infections, neurovascular injuries, malalignment, pseudarthrosis and implant failure are frequent. An effective complication management requires detailed knowledge of the morphological features of fractures, individual risk factors and differentiated revision strategies. With the presentation of two clinical cases, we aim to highlight the necessity of individualized treatment concepts. Due to the increasing number of war casualties transferred for secondary treatment to Central Europe, the likelihood of encountering unfamiliar injury patterns, such as blast or gunshot wounds, is rising. This development presents new challenges in daily clinical practice. Physiotherapeutic and occupational therapy support play a central role in achieving favorable functional outcomes following revision surgery for diaphyseal fractures of the upper extremities. In geriatric care, orthogeriatric concepts have significantly decreased mortality and improved mobilization as well as self-sufficiency among older patients. Managing patient expectations and providing close supervision throughout the rehabilitation process are decisive factors for successful recovery.

Forearm shaft fractures are the most common fractures of the upper extremity in young adults. By definition, these fractures are diaphyseal fractures; however, due to the complex functional unity formed by the forearm shaft during motion both bone forearm fractures are treated as intra-articular fractures [1, 3]. This is why the gold standard of treatment in adults is osteosynthesis. The aim of the surgical intervention is the anatomical reduction with exact reconstruction of length, shaft axis and rotation. This particularly concerns Monteggia and Galeazzi fractures where the adjacent joint needs to be addressed and/or the joint must be fixated to gain a precise joint position [2, 9]. Instability of the interosseous membrane must also be kept in mind, which is classically accompanied by comminuted radial head fractures (Essex-Lopresti injury) but can also occur with shaft fractures after complex and massive trauma [9, 10]. Complications with these three types of injury occur when the joint involvement is overlooked and hence must be specifically searched for [9]. A typical complication after forearm fractures is the formation of pseudarthrosis [4, 5, 11, 12]. For prevention, a procedure must be selected that preserves the soft tissue and periosteum as much as possible; locking plates enable a stable fixation without compression of the periosteum [1, 4]. Nerve damage can occur either posttraumatically or after surgical intervention and is frequently seen with very proximal forearm fractures [3, 5, 12]. Refractures are rarely seen with inlaying implants but commonly occur after implant removal, which is why it should be done 24 months postoperatively at the earliest [2, 5, 13]. With concomitant fractures of the radius and ulna there is a high risk of synostosis which often leads to considerable impairment of movement [5, 11, 12]. In some cases, especially with traumatic brain injury, a synostosis cannot be avoided even with preventative measures and subsequently must be resected [5]. Furthermore, insufficient osteosynthesis or implant failure can lead to axial malalignment and subsequently to limited rotational mobility [5]. The renewed open anatomical reduction with compression osteosynthesis and secure plate fixation, fixated with three screws proximal and distal to the fracture, enables an exact reconstruction of the bone shape as well as the avoidance of secondary malalignment through implant loosening [1, 5].

Shaft fractures in children and adolescents differ from those of adulthood in terms of the fracture pattern and treatment. With respect to the procedure, humeral shaft fractures must be differentiated from forearm shaft fractures. Almost no axial deviation can be tolerated on the forearm shaft, even at a young age as this could lead to functional restrictions in the rotation of the forearm. For these reasons, closed reduction and elastic stable intramedullary nailing (ESIN) nowadays represents the gold standard for dislocated or unstable fractures. A special type is the greenstick fracture of the forearm shaft where there is also a risk of refracture due to the partial healing disorder. In the region of the humeral shaft, residual axial deviations play a role mainly with respect to the cosmetic results. Substantial functional limitations are not to be expected. Many of these fractures can be treated conservatively. In cases of instability or unacceptable dislocation, ESIN osteosynthesis is the first choice as a minimally invasive procedure for surgical treatment.