Unfallchirurgie (Heidelberg, Germany)最新文献

Trauma surgery and emergency medical care are facing growing challenges: rising patient numbers, a shortage of specialists and a high diagnostic workload are leading to diagnostic errors, up to 80% of which relate to overlooked fractures. Systems based on artificial intelligence (AI) for fracture diagnostics offer promising support in this context. Modern deep learning algorithms, in particular convolutional neural networks, achieve high sensitivities and specificities in the detection of frequent fractures in large validation studies. As a "second reader", they increase diagnostic accuracy, reduce diagnostic time and improve patient safety, especially in the case of subtle fractures or limited practitioner experience. Additional applications include automated triage, angle measurements, bone age determination and the detection of other pathologies. Limitations include heterogeneous training data, limited performance in complex fractures and regulatory requirements. The continuous technological development promises increasing performance and broader fields of application for AI in fracture diagnostics. Future systems will also increasingly enable multimodal and 3D analyses as well as deeper integration into the clinical workflow. The use of AI does not replace physicians but acts as an assistive tool to increase quality and efficiency; however, further independent, prospective and patient-orientated studies and integration into clinical guidelines are required for a broad implementation.

The bony consolidation of fractures depends on various factors. Under optimal conditions fracture healing takes place within a few weeks. An essential requirement for fracture healing is the restoration of adequate biomechanical stability with an interfragmentary movement which is as ideal as possible. Distal femoral fractures can be particularly challenging especially in the presence of extensive soft tissue damage, multiple fragmented fractures and involvement of the joint. The currently applied surgical techniques of single lateral plate, double plate and intramedullary nail osteosynthesis as well as combination procedures have a relatively high complication rate. The principle of the biphasic plate is based on the transverse and longitudinal slots placed in the plate, which enables a "controlled instability". This results in a relatively high interfragmentary movement even at low loads (flexible phase) and a low movement at high loads (stiff phase). Therefore, the implant becomes more rigid at higher mechanical demands. In biomechanical tests the stress distribution of the implant, the number of cycles up to failure and the maximum load are superior compared to the locking compression plate distal femur (LCP-DF). Future studies will need to compare and evaluate the potential clinical and economic benefits in direct comparison to the currently established surgical techniques. Preclinical studies have so far demonstrated the safety and applicability of the biphasic plate and the innovative principle of controlled instability in fracture healing.

The postoperative assessment of fracture healing remains a clinical challenge despite established treatment standards. The lack of reliable information on the mechanical stability of the fracture complicates individualized follow-up care. This increases the risk of delayed mobilization, implant overload or late detection of healing complications.Sensor-based implants, such as the AO Fracture Monitor enable objective, continuous measurement of implant load, offering a novel approach to evaluating the healing process. Preclinical studies demonstrate a significant correlation between mechanical load and radiological healing parameters, confirming the potential of instrumented implants for diagnostic and preventive applications. Initial clinical data are currently being collected as part of a multicenter study. Additional application areas, such as spinal fusion and hip fracture treatment are the focus of ongoing research and commercial development efforts.Continuous data acquisition enables uninterrupted remote monitoring, independent of scheduled follow-up examinations. This opens new possibilities for dynamic adjustment of treatment protocols, early detection of complications and targeted rehabilitation management; however, integrating such systems into routine clinical practice poses substantial regulatory and procedural challenges. Current studies therefore provide an essential foundation for the gradual establishment of personalized follow-up strategies in routine clinical care.

Reduction of acetabular fractures places high demands on the treating surgeon due to the complex three-dimensional anatomy of the hemipelvis. Knowledge of various reduction instruments, step by step reduction techniques and approach-related intraoperative visualization are the basis for the as optimal as possible anatomical reduction. Marginal impactions are particularly challenging for the treating surgeon as often only an indirect approach to address these concomitant injuries is possible as these fragments are difficult to visualize intraoperatively.

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.