Periprothetische Frakturen bei Hüfttotalendoprothese

Different operative techniques of stem revision for the treatment of periprosthetic fractures type Vancouver B2 and B3 are described. Our prospective study of 32 periprosthetic fractures (22?Vancouver type B2, 10?Vancouver type B3) with a follow-up period of at least 24?months showed that stem revision employing a transfemoral surgical approach and a modular, cementless, tapered and fluted revision stem led to reproducibly good results with respect to fracture healing, stability of the prosthesis stem, dislocation, intraoperative fracture, and clinical outcome. All fractures healed with a mean time of 14.5?±?5.2?weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al. concerning the biological fixation of the stem, bony ingrowth fixation was observed in 28?cases and stable fibrous fixation was observed in 4?cases. One dislocation and one case of deep vein thrombosis occurred, and there were no cases of intraoperative fracture. The Harris Hip Score rose continually (3?months postoperation: 59.2?±?14.6 points; 24?months postoperation: 81.6?±?16.5?points). According to the classification of Beals and Tower, all results were rated as excellent.     

Periprothetische Frakturen nach Hüft- und Knietotalendoprothesenimplantation

Periprosthetic fractures following hip and knee arthroplasty are potentially severe complications. As a fundament in diagnostic and therapeutic procedures, specific classification systems are necessary to ensure an optimal individualized treatment of these sometimes complicated fractures. This review article summarizes the epidemiological aspects, risk factors and diagnostics of periprosthetic hip and knee fractures. The most frequently used location related fracture classifications systems are explained. In addition, the recently introduced unified classification system (UCS), which is applicable to any location of periprosthetic fractures, is described in detail. Initial studies have shown a reliable applicability of the UCS to periprosthetic hip and knee fractures.     

Hüftendoprothese bei Koxarthrose nach Azetabulumfrakturen

Aim

This study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component.

Material and method

A total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component.

Results

Of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53–55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment.

Conclusion

Patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.     

Traumatische periprothetische Frakturen bei einliegender Hüftprothese

Die Unfallchirurgie - Aufgrund der Zunahme der endoprothetischen Versorgungen wächst auch die Zahl der periprothetischen Hüftfrakturen. Diese Frakturen benötigen ein abgestuftes und...     

Periprothetische Infektion nach Hüftendoprothetik

Background

Periprosthetic infections (PPI) represent one of the most complex complications in arthroplasty concerning both, diagnosis and therapy. The incidence of PPI of the hip is approximately 1?% after primary procedures and 4?% after revision surgery. About two thirds of PPIs occur via intraoperative contamination and the remaining PPIs are acquired by hematogenous seeding.

Aim

This article presents an overview of up to date evidence-based diagnostics and therapy of PPI of the hip with the establishment of a clear algorithm.

Methods

A selective literature search was carried out with the inclusion of own work.

Results

A PPI must be actively excluded in cases of a painful prosthesis or signs of loosening within the first years after implantation. Measurement of C-reactive protein (CRP) can be normal especially in cases of chronic (low grade) PPI and cannot be used as an exclusion criterion. The standard diagnostic procedure includes preoperative joint aspiration with culture and leukocyte counts as well as culture and histology of periprosthetic tissue. Imaging techniques, such as magnetic resonance imaging (MRI) and scintigraphy are of inferior significance. Newer methods, such as sonication of removed implants have revolutionized the diagnostics and several cases which had previously been considered aseptic loosening failures have now been reclassified as PPI. Essential parameters for the treatment algorithm are maturity of the biofilm, stability of the prosthesis, the causative organism and the state of the soft tissue. Retention of the prosthesis can only be considered when the biofilm is still immature (acute PPI). In chronic (low grade) PPI eradication of the infection can only be achieved by exchanging the prosthesis. This has to be performed either as a one-stage procedure or as a two-stage exchange with a short (2–4 weeks) or a long (>?6 weeks) interval. Biofilm active antibiotics play an essential role in the treatment of PPI and have to be used as targeted therapy.

Discussion

Successful therapy and diagnostics of PPI require following an exact algorithm. The interdisciplinary cooperation between specialists for infectious diseases and microbiologists represents a decisive factor.     

Frühkomplikationsrate bei hüftgelenknahen Frakturen

Die Unfallchirurgie - Leitlinien fordern die frühe Operation hüftgelenknaher Frakturen, weshalb diese häufig in der Bereitschaftsdienstzeit erfolgt. Multimorbide Patienten erleiden...     

Die Zuggurtungs-Hüftendoprothese

Zusammenfassung Unter Zugrundelegung theoretischer und experimenteller Untersuchungsergebnisse zum Problem des endoprothetischen Hüftgelenkersatzes und der an der Prothesenverankerung angreifenden Kräfte wurde ein neues Prothesenmodell für den praktischen Einsatz entwickelt und hergestellt. Diese Zuggurtungsprothese wird in ihren biomechanischen Grundlagen und der praktischen Ausführung in der vorgelegten Arbeit beschrieben.Die an der neuen Prothese verwirklichten biomechanischen Voraussetzungen, welche von uns zum Ausschluß der mechanischen Komplikationen von Prothesenlockerung und Prothesenschaftbruch als vorrangig angesehen werden, sind auch beim Einsatz optimierter Werkstoffe ausschlaggebend und ermöglichen darüber hinaus eine primär stabile Prothesenverankerung auch ohne Knochenzement.

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Zuggurtungs-hip joint endoprosthesis

Summary On the basis of theoretical and experimental investigations to the problem of endoprosthetic replacement of the hip joint and the forces concerning the anchorage of the prosthesis a new model of prosthesis was developed and realized for practical use. In this paper this new Zuggurtungs-Hüftendoprothese and the biomechanical principles are described in detail.The biomechanically derived postulations realized in the new prosthesis which are of primary importance to avoid the mechanical complications of loosening and breaking of the prosthesis are also decisive when optimal materials are used. They allow the implantation without bone cement by the primary acievable stable anchorage.

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Herrn Prof. Dr. F. Kümmerle zum 60. Geburtstag gewidmet.     

Akutschmerztherapie bei Patienten mit hüftgelenknahen Frakturen

BACKGROUND: The aim of this study was to compare safety and efficacy of catheter-mediated femoral nerve block analgesia with systemic pain therapy in patients with proximal femoral fractures in the pre-operative and post-operative setting using a protocol for coordinating pain management.METHODS: In a prospective randomised trial of patients attending the emergency department, 100 individuals were selected with a clinically diagnosed proximal femoral fracture. Patients were divided into two equal groups A and B. Group A (n=50) received a catheter-mediated femoral nerve block with 1% prilocaine (40 ml) and post-operatively 0.2% ropivacaine (30 ml) 6 hourly. Group B (n=50) initially received intravenous metamizol (1 g) and a fixed combination of oral tilidine (100 mg) + naloxone (8 mg). Patients aged 90 years or more received a reduced dose (tilidine 75 mg + naloxone 6 mg). In the post-operative period regular oral ibuprofen (400 mg, 8 hourly) in addition to oral tilidine (50 mg) + naloxone (4 mg) was given as required for break through pain. Pain intensity was measured using a verbal rating scale (VRS) from 1 to 5: pain free (=1), mild pain (=2), moderate pain (=3), severe pain (=4), excruciating pain (=5). Pain scores were recorded at rest (R), during passive anteflection (30 degrees ) of the hip (PA) on arrival and at 15 and 30 min after initial administration of analgesia. Thereafter, recordings were made 4 times a day up to the third post-operative day.RESULTS: Pain scores were comparable for both groups on admission (VRS in R 2.50 vs. 2.46; VRS during PA 4.30 vs. 4.34). Significant pain relief was achieved in both groups following initial administration of analgesia, but the total pain scores in group A were significantly lower than in group B (VRS in R 1.22 vs. 1.58, p<0.01 and VRS during PA 2.66 vs. 3.26; p<0.001). No difference was noted between the two groups during the first 3 post-operative days. No severe complications occurred as a result of analgesia, however, the catheter was dislodged in 20% of patients in group A resulting in the need for systemically administered analgesia.CONCLUSION: All patients presenting with proximal femoral fractures should receive adequate analgesia within the emergency department even prior to radiographic imaging. Femoral nerve block should be considered as the method of choice. The insertion of a femoral nerve block catheter has the dual advantage of early analgesia permitting repeated clinical examination in addition to continued post-operative pain management. The cumbersome logistics inherent in this technique within the clinical setting limits its practical application. An initial single-shot regional nerve block followed by a systemic post-operative analgesia protocol was considered an appropriate alternative. The execution of safe, consistent and appropiate regional nerve block anaesthesia is reliant on formal guidelines and protocols as agreed by the multidisciplinary teams involved with patient-directed pain management and good clinical practice.     

Hüftgelenknahe Frakturen im hohen Lebensalter

Background

Osteoporotic fractures of the femoral neck and trochanteric region pose an ever-expanding existential problem both for the individual and for society. Despite numerous innovations and advances regarding implant design, mortality and the systemic and mechanical complication rates remain high.

Objectives

Depiction of treatment options for femoral neck fractures and trochanteric femur fractures in the elderly comparing joint replacement and osteosynthesis.

Methods

A search of the Medline, Embase and Cochrane databases was carried out focusing on hip fracture treatment. Randomized or quasi-randomized controlled trials, meta-analyses and reviews comparing joint replacement or fixation implants in the elderly were included.

Results

Displaced fractures of the femoral neck often require total joint arthroplasty whereas trochanteric fractures are amenable to internal fixation. Cemented total hip replacement as opposed to cementless techniques is recommended in the elderly and yields good functional results in active patients. Hemiarthroplasty is the treatment of choice in infirm patients with multiple comorbidities and cognitive impairment. Trochanteric fractures (AO/OTA types A1 and A2) can be successfully treated with intramedullary or extramedullary fixation. Adequate reduction and stable fixation are prerequisites for uneventful healing. A meticulous operative technique can prevent iatrogenic complications.

Conclusion

In summary, there are many parameters affecting the outcome in the treatment of fragility and hip fractures. Technical features as well as surgeon characteristics play an important role and the ultimate solution has yet to be developed. Even though fracture morphology may indicate a specific treatment option, patient characteristics play an important role in decision-making. The development of centers of fragility fracture care in Germany could help to lower the complication rate and increase quality of life in hip fracture patients in the future.     

Der minimal-invasive Zugang zur Implantation der Hüftendoprothese

Early experiences with the two-incision approach at the hip joint are reported. We started in July 2002 and until now 272 procedures have been performed. Blood loss (292 ml) and the need for rehabilitation are reduced, the patients will achieve a Harris Hip Score of more than 90 points within 6 or 8 weeks. Complications related to the approach primarily include irritation of the lateral femoral cutaneous nerve. During the learning curve when the initial shaft model was used, shaft fractures or fissures occurred in 4% of the cases. This complication was no longer observed with the ML Taper shaft model now employed (n=102). The development and establishment of minimally invasive approaches constitute a valuable and seminal option for implantation of hip endoprostheses. In the medium term, the time spent in rehabilitation could conceivably be reduced. Conventional approaches still represent the gold standard.     

Hüftarthroskopische Therapie bei veralteten extrakapsul?ren traumatischen Hüftluxationen bei Kindern

We report about the first hip arthroscopies of extracapsular neglected hip dislocations with concomitant injuries in two children (2 and 4 years old). The major problem of traumatic hip dislocation is avascular necrosis. Further problems are possible concomitant injuries. It is important not to cause further damage by therapeutic procedures. In a 4-year-old child the hip could be reduced under visualization and in a 2-year-old child with epiphyseal fracture the extent of the operation could be reduced. In both children large avulsion injuries of the ligamentum capitis femoris could be resected via hip arthroscopy. Hip arthroscopy can reduce surgical morbidity considerably and can possibly contribute to prevention of the feared avascular necrosis of the femoral head.     

Kongenitale Hüftluxation bei Neugeborenen

Objective

Early diagnosis and rapid closed reduction under arthrographic control to initiate retention in a new position during the interval of maximum subsequent maturation power. This allows a (nearly) physiological ripening of the femoral head and acetabulum (AC) with restoration of the congruence of the joint partners (containment) and joint stability.

Indications

Clinically- and ultrasound-proven dislocation of the hip in the newborn.

Contraindications

Increased bleeding, increased risk of anesthesia due to immaturity/prematurity, inability to use a retention cast due to malformations of the urogenital system, spinal deformities, or hernias requiring treatment or supervision.

Surgical technique

Palpation of the tuberosity of the ischium in 110° flexion and 40–50° abduction of the leg and then puncture lateral to this point. Advance the needle parallel to the plane of the table in the direction of the empty acetabulum and x-ray control. Control of intra-articular needle position by injection of isotonic saline solution. Test reflux by disconnection. Cautious instillation of 0.2–0.4 ml of contrast medium under X-ray control. Closed reduction under X-ray control by pulling slightly, flexion and abduction of the hip joint. Cast applied in approximately 110° hip flexion and 40° abduction.

Postoperative management

MRI control on postoperative day 1. Spica cast for 4 weeks. Then cast removal, clinical and ultrasound examination and immediate start of further treatment with a hip splint in 110° hip flexion and 30–40° abduction. Ultrasound follow-up every 3–4 weeks.

Results

A total of 40 patients (female:male =?33:7) with 49 hip dislocations were analyzed. The mean age at reduction was 73 days (range 1–334 days). In 21 cases, treatment was started at another hospital. Intra- or immediate postoperative complications were not detectable. According to the control MRI on the first postoperative day, the cast had to be removed in 7 cases (17.7?%) due to insufficient reduction, although no classical need for repositioning could be identified in the MRI analysis. Instead, compared to cases with sufficient hip reduction, significantly reduced acetabular articular surfaces were found, so that in these cases, a lack of stability due to the lack of congruency between the femoral head and the AC must be considered. Signs of a fulminant avascular necrosis (AVN, grade 3 and 4 according to Kalamchi) and a pathological acetabular angle (grade 3 and 4 according to Tönnis) were observed during follow-up in 17.3 and 40.7?% of cases, respectively.     

Aktuelle Therapieoptionen bei Hüftkopfluxationsfrakturen

Fractures of the femoral head (Pipkin fractures) are relatively uncommon. In cases of immediate, gentle reposition and considerate soft tissue treatment during operative treatment, Pipkin 1 and 2fractures can heal with good long-term results. However, some long-term problems regularly occur. Conservative therapy is possible in cases of anatomic articulation or the presence of only very small fragments that do not compromise articulation after closed reduction. Differentiated indications for conservative treatment in Pipkin 1 and Pipkin 2 fractures can result in a better outcome than operative treatment. All other fractures should be treated operatively. The approach has to be adapted to fragment size and location. Small fragments in Pipkin 1 fractures can simply be removed, but larger fragments in Pipkin 1 and Pipkin 2 fractures should be fixed, preferably via an anterior approach. Pipkin 3 fractures generally require total hip arthroplasty. Pipkin 4 fractures have a relatively poor outcome. The strategy of treatment depends on the necessity of operative fixation of the acetabular fracture and the size of the femoral fragment. The anterior approach is preferred in cases of stable joint situations with only a small acetabular rim fragment, and in cases of instability the dorsal approach is preferred. Surgical luxation can be advantageous for the treatment of Pipkin 4 fractures.     

Hüftendoprothetik bei posttraumatischer Koxarthrose

Trauma und Berufskrankheit - Frakturen im Bereich des Hüftgelenks stellen schwerwiegende Verletzungen dar. Sie prädisponieren und beschleunigen degenerative Veränderungen am Gelenk....     

Fusionskriterien für Cages als Wirbelkörperersatz bei thorakolumbalen Frakturen

Background

No commonly accepted criteria to evaluate bony incorporation of cages as vertebral body replacement in thoracolumbar fractures exist. The goal of this study was a thorough radiological evaluation of the fusion process in posterior-anterior stabilized fractures.

Patients and methods

In this study 35 patients were evaluated radiologically including computed tomography (CT) scanning and bone mineral density measurement inside the cages. Correction loss, cage subsidence and tilting, bone growth in and around the cages as well as bone mineral density were assessed. Fusion grading was assessed with defined criteria (i.e. bridging bone, bone growth through the cage, stability in functional X-rays and no radiolucent lines).

Results

After 12 months minor subsidence and tilting of the cages had caused significant correction loss of the basal plate angle of 2.4° on average. Of the patients 20 (57?%) fulfilled the criteria for complete or incomplete fusion and 5 (14?%) showed no signs of bony fusion. Bone mineral density measurements were unreliable due to metallic artefacts.

Conclusions

The advocated criteria allow accurate assessment of bony incorporation of cages. Bony incorporation can be detected in and around the cages over time; however, only 57 % of patients showed signs of bony fusion after 1 year.     

Über pathologische Frakturen bei Mammacarcinom

Zusammenfassung Von den in den Jahren 1943–1959 in der Heidelberger Chirurgischen Klinik beobachteten 93 pathologischen Frakturen waren 31 oder genau ein Drittel der Fälle durch Mammacarcinommetastasen bedingt. Von 19 Patientinnen, deren pathologische Schenkelhals- und Oberschenkelschaftfrakturen durch Marknagelung bzw. Schenkelhalsbolzung versorgt wurden, konnte bei neun Kranken wieder Gehfähigkeit erreicht werden. Bei einigen weiteren Fällen kamen die Frakturen nach Ausschaltung der Hypophyse durch Implantation von radioaktivem Gold zur knöchernen Konsolidierung. Wenn auch im allgemeinen das Fortschreiten der Krankheit selbst dadurch nicht beeinflußt wird, ist der Gewinn für die Kranken doch so groß, daß auf diese Behandlungsmöglichkeiten nicht verzichtet werden sollte, solange der Allgemeinzustand der Patienten sie noch zuläßt.Mit 3 Textabbildungen     

Komplikationen bei pertrochant?ren Frakturen

Fractures at the coxal end of the femur have an incidence of almost 100.000 p.a. in Germany. Pertrochanteric femur fractures make up almost half of this collective. The highest incidence of 1.32% is seen in patients over the age of 85. Osteosynthesis is the treatment of choice. The options include extramedullary nail/screw systems or intramedullary nail systems. Study findings to date do not show a clear advantage of one procedure over another. The published complication rates remain high. The main complication is secondary reduction loss with cutout of the hip screw. Other complications include femoral neck shortening and lateralization of the hip screw with local irritation at the iliotibial tract. Functional outcomes after osteosynthesis are still less than satisfactory. Surgery only frees one third of patients from pain. In addition, a majority of patients also suffer loss of independence and social contacts. An alternative approach to treatment is total joint replacement. This is indicated in extreme cases of osteoporosis in combination with osteoarthritis. However, initial high stability must be weighed against an increased risk of dislocation and a higher rate of 1-year mortality.