Wachstumsprothesen zur Rekonstruktion von Defekten der unteren Extremit?ten beim Kind

Objective

Bone defect reconstruction with growing prostheses after resection of malignant bone tumors using the technique of extendable prostheses.

Indications

Limb salvage surgery after resection of primary malignant bone tumors in the growing skeleton for expected leg length deficiencies >?4?cm.

Contraindications

Palliative tumor resection, infection, systemic metastases at the time of diagnosis, social contraindications, lack of compliance of the patient and/or family.

Surgical technique

Wide resection of the tumor with resection of the biopsy location. Reconstruction with the growing prosthesis. Planned lengthening operations.

Postoperative management

Mobilization with crutches, weight bearing or partial weight bearing according the prosthesis?? fixation. Chemotherapy as defined in the chemotherapy protocol. Planned minimally invasive lengthening or noninvasive lengthening according to the type of growing module.

Results

Since 1969, more than 8,632?patients have been registered in the Vienna Bone and Soft Tissue Tumor Registry. Of these, 691?patients suffered from osteosarcoma and 243 from Ewing??s sarcoma. A total of 513?patients were <?18?years of age (54.4%). Since 1987, 71?patients have been treated with growing prostheses: 13?patients died of disease, and 44?patients reached maturity. The overall 5- and 10-year survival were 84% and 77%, respectively. The patient group consisted of 26?girls and 18?boys, mean age at surgery 10?±?3?years. The diagnosis was 34?osteosarcoma and 10?Ewing??s tumors. The patients had a mean of 4?±?3 elongation procedures to reach an elongation of 72.5?±?53.45?mm. The average elongation per procedure was 14.83?±?4.6?mm.     

Amputation oder Rekonstruktion der unteren Extremität

Reconstructive surgical techniques have advanced immensely in recent decades to the extent that secondary amputations following traumatic injuries have been reduced. Nevertheless, amputation of lower limbs is still necessary 20 times more frequently than amputation of upper extremities. The state-of-the-art treatment considered necessary to preserve lower extremities is presented. The functional and cosmetic components necessary to obtain a stump capable of supporting prosthesis in the case of extremity loss are discussed.     

Planung von Korrekturosteotomien der unteren Extremität

Deformities of the lower extremities can result in local complications, chronic pain and early arthritis. To correct these deformities, several techniques of osteotomies are available. In general continuous deformity correction and acute, one step procedures are available. The exact diagnostics and precise planning of the operative correction is crucial to avoid iatrogenic complications. This summary describes basic principles and indications for different types of osteotomies.     

Chronische Osteitis der unteren Extremität

Introduction

The purpose of this investigation was the retrospective analysis of patients with delayed infections, chronic posttraumatic osteitis of the lower extremities and free-flap coverage after radical debridement of bone and soft tissue.

Methods

From the time period 1994–2003 a total of 22 patients including 4 females and 18 males were investigated. In 16 patients treatment was carried out on the lower leg and in 6 patients the foot was treated with subsequent free-flap coverage. In 14 cases the latissimus dorsi muscle was used, in 5 cases the gracilis muscle, in 2 cases parascapula flaps were used and in 1 case the serratus anterior muscle. The average age of the patients was 43 years (range 17–63 years) and grouping was according to the HOST classification. Functional outcome was evaluated by a standardized questionnaire (Funktionsfragebogen Hannover FFbH-OA 2,0), quality of life and social reintegration by non-standardized questionnaires.

Results

In the cases investigated the following results could be achieved: full leg activity 55%, leg pain while walking 73%, special footwear 68%, normal gait 55%, positive quality of life and social reintegration 55%, port activities 36% and reemployment 45%.

Conclusion

According to the results of this study the quality of life of patients with chronic osteitis of the lower leg is in general satisfying. In order to improve quality management and cost reduction in public health an interdisciplinary treatment concept of plastic and orthopedic surgeons should be established for complex fracture management as this is the most effective tool in treating chronic osteitis.     

Die Circulation der unteren Extremität

Ohne Zusammenfassung Theilweise vorgetragen auf dem X. Congress der Deutschen Gesellschaft für Chirurgie zu Berlin 1881.     

Die Leitungsanästhesie der unteren Extremität

Ohne Zusammenfassung (Mit 4 Abbildungen.)     

Geschichte der Exoprothetik an der unteren Extremität

Following the development of prosthetics for the lower limb since the middle of the 18th century one will find very interesting similarities to modern prostheses. This becomes evident when looking at former knee and ankle joint mechanisms or socket designs. Also, the materials used for the prostheses underwent very interesting variations. In our paper we will describe the development of socket designs and several materials from the beginning of the 19th century. Several still obtainable books dealing with 200 years of prosthetics development, were reviewed. Charles White describes in the year 1761 a supramalleolar amputation using the flap technique and the specially built BK prostheses the socket. V. Brünninghausen describes in 1809 a socket made of tin sheet. It was built oval, as the normal transverse section of the thigh is. Stump adhesion was obtained when a shortly trimmed dog fur--panelling the socket and covering the stump--was attached like brushes end on end. A similar fitting was described by Heine in 1811, v. Dornblüth in 1831, and Mrs. Eichler in 1836. Hermann first mentioned the need of a perpendicular construction of prostheses. Parmelee developed in 1868 the first suction socket. The first tuber-enclosing socketdesign was made by Riedel in 1911. We will show documents from this time and will also show, that muscle-physiological aspects had a very important influence on socket designs.     

Amputationen und Prothesenversorgung der unteren Extremität

Gerade an der unteren Extremit?t konnte die Zahl der Amputationen in den letzten Jahren durch erhebliche Fortschritte und Verbesserungen in der Behandlung der h?ufigsten zugrundeliegenden Erkrankungen deutlich vermindert werden. Bei den vaskul?ren Erkrankungen basieren die verbesserten therapeutischen M?glichkeiten auf den Fortschritten der Bypasschirugie, der interventionellen perkutanen Angioplastie und der rekonstruktiven Operationen beim diabetischen Fu?. Bei Traumapatienten ist die Notwendigkeit zur Amputation durch die Erfolge und M?glichkeiten der wiederherstellenden Chirurgie mit Replantationen und Lappenplastiken reduziert worden. Letztere machen auch bei der Behandlung schwerer Infektionen den Extremit?tenerhalt m?glich. Bei Tumorerkrankungen, insbesondere bei den Sarkomen jugendlicher Patienten, sind die Erfolge der multimodalen Therapiestrategien und der rekonstruktiven Eingriffe nach Tumorresektion Grundlage für den immer h?ufiger m?glichen Extremit?tenerhalt ohne dabei aber die onkologisch erforderliche Radikalit?t einzubü?en. All diese Fortschritte sind erst durch die Optimierung der interdisziplin?ren Zusammenarbeit geschaffen worden und k?nnen nur bei Aussch?pfung dieser infrastrukturellen M?glichkeiten genutzt werden. Trotz all dieser, hier nur ansatzweise genannten therapeutischen Fortschritte sind Amputationen der unteren Extremit?t in etwa um das 20-fache h?ufiger durchzuführen als Amputationen an der oberen Extremit?t. Dabei gelten in den Situationen, die eine Amputation der unteren Gliedma?e unausweichlich werden lassen grunds?tzlich die gleichen, bereits im ersten Teil “obere Extremit?t” [11] ausführlich dargelegten besonderen Anforderungen an das Management von Amputationen. Das Behandlungsziel beinhaltet hierbei den m?glichst weitgehenden Erhalt der betroffenen Gliedma?e, das Erreichen eines belastungsf?higen Stumpfes und die Wiedererlangung der Mobilit?t der betroffenen Patienten.     

Entfernung von Verriegelungsnägeln an der oberen und unteren Extremität

BACKGROUND: Absolute indications for removing intramedullary locking nails (ILN) are undisputed, but there are also relative indications when implant removal might be discussed. The aim of our study was to evaluate complications of ILN removal in the upper and lower extremities. METHODS: Four hundred sixty (460) patients who underwent interlocking nail removal were reviewed regarding complications after removal of implants in the humerus, femur, or tibia. RESULTS: The most common complications were delayed wound healing and wound infections. For the humerus, the complication rate of implant removals due to absolute indication was 29%, and the rate for removals due to relative indication was 12%. In the forearm, no complications were seen. Patients who underwent ILN removal in the femur or tibia for absolute indication had a 21% complication rate; the complication rate in patients with relative indication was 10%. CONCLUSION: The complication rate of interlocking nail removal is too high to justify such a procedure without clear indication.     

Ökonomische Auswirkungen einer erfolgreichen sekundären Rekonstruktion im Bereich der unteren Extremität

The courses of 25 patients insured with the German employers’ compensation insurance who were treated at the Berufsgenossenschaftliches Unfallkrankenhaus Hamburg (BUKH) for nonunions of the femur (n = 15) or the tibia (n = 10) by implantation of plates with angular stability and spongiosa grafts were evaluated. In 80% of the patients with femoral and 40% of the patients with tibial nonunion multiple injuries had initially been present. The mean duration from the accident to the operation was 18 months for the femoral and 15 months for the tibial nonunions. The mean number of local previous operations was 2.5 (1–6) for the patients with femoral and 1.9 (1–4) for those with tibial nonunions. In all cases bony union was achieved. The savings realized through the difference between the imaginary partial disability (MdE) without successful treatment of the nonunion and the real MdE minus the total inpatient and outpatient treatment costs averaged 93,630 EUR (183,125 DM) per case for the femoral and 41,872 EUR (81,895 DM) per case for the tibial nonunions. Due to the successful vocational rehabilitation and lack of increased need for treatment the total savings for the insurance and the national economy are markedly higher.     

Periphere Nervenblockaden an der unteren Extremität

Peripheral nerve blocks (PNBs) of the lower extremities are effective techniques for anesthesia and postoperative pain control. So far, these techniques have been used less frequently than PNBs of the upper limb. Nevertheless, growing awareness of complications of neuroaxial techniques, improved equipment and modern techniques for nerve localization have led to an increased use of PNBs of the lower limb. Anesthesiologists should be familiar with the anatomical basics and procedural details of these PNBs. They should also know the typical complications and side-effects and thoroughly inform patients about such potential problems. Continuous PNBs (perineural catheters) allow the benefits of PNBs to be prolonged into the postoperative period. Compared to continuous neuroaxial techniques continuous PNBs are equally effective for pain control but seem to be associated with fewer complications and side-effects.     

Die Verkürzungen der unteren Extremität

Ohne Zusammenfassung Mit 11 Abbildungen im Text.     

Stumpferhalt und Stumpfverlängerung an der unteren Extremität

Despite new techniques and better health programs in western industrialized nations, the numbers of amputations on the lower extremity remain constant. Approximately 100,000 amputations are performed annually in the U.S. and about 10,000 in Germany, more than 90% for gangrene resulting from ischemia and/or infection. Micro- and macroangiopathic changes in diabetes are the major cause of ischemia in the leg. The preservation of limb length and construction of an end bearing stump are important criteria for the functional outcome after amputation. Especially in trauma and tumor patients with "planned" amputations, all effort should be made to achieve an end bearing stump with sufficient length respectively an amputation level that is suitable for orthosis instead of prosthetic supplementation. After amputation, an interdisciplinary approach is mandatory to achieve sufficient soft tissue coverage or stump distalization. In case of insufficient bearing ability of the stump, various reconstructive possibilities must be considered to assure optimal outcome.     

Das Manteltransplantat zur Defektrekonstruktion nach Resektion maligner Knochentumoren an der unteren Extremität

We treated 11 patients with primary sarcoma and 1 patient with enchondroma of the femur or tibia. Bridging the osseus defect we used an intercalary allograft shell and contralateral fibula as described by Capanna et al. [7]. The median bone defect after resection of the tumor was 15.7 (9.0-28.5) cm, average follow up was 29.2 (13-56) month. Anastomosis of the autologous fibula was successful in 8 cases. There were 3 cases necessitating later amputation. The other cases showed good clinical (Enneking-score) and radiological (ISOLS-score) results. These results indicate the described technique as a suitable method for defect reconstruction with good functional outcome.     

Orthopädisch-technische Hilfsmittel zur Behandlung von Kontrakturen der oberen Extremität

Zusammenfassung Es wird über Indikation und Anwendung einiger orthopädisch-technischer Hilfsmittel sowie deren geschichtliche Entwicklung berichtet.Mit 9 Textabbildungen (15 Einzelbilder)Meinem verehrten Lehrer, Herrn Professor Dr. L. Kreuz, zum 75. Geburtstag gewidmet.