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Following a period of conservative treatment of acetabular fractures in the past, the use of classifications and defined acetabular surgery indications was introduced because of an increasing number of extended surgical approaches for operative stabilization of acetabular fractures. This development has enabled minimally invasive procedures using three-dimensional (3D) visualization and navigation techniques in the operating room (OR), with the expectation of reduced intraoperative morbidity and optimized surgical precision. Most common in acetabular navigation is 3D C-arm-based navigation, which has enabled new techniques in combination with other modern OR systems. In special cases, techniques based on computed tomography and 2D C-arms are still used.     

Ligamentäre Ausheilungsergebnisse nach Beckenringfrakturen Typ C

Background

Posterior pelvic ring fractures are often associated with injuries of lumbopelvic soft tissue structures. The aim of this prospective MR study was to examine whether ruptured iliolumbal ligaments could be diagnosed in types B and C pelvic ring fractures. The influence of triangular lumbopelvic stabilization (TLPS) was also investigated with respect to stiffening of the lumbopelvic region.

Material and methods

Using a 1.5 Tesla MRI, 20 patients with types B and C fractures were examined to identify ruptured iliolumbal ligaments. In a retrospective study of 30 patients previously stabilized with a TLPS, pain scores, clinical instability testing and measuring of the segmental dislocation in extension, flexion and lateral flexion based on x-rays were also investigated.

Results

Of the patients 3 (1 type B, 2 type C fractures) had incompletely ruptured iliolumbal ligaments. In five patients pain intensity and localization could be significantly correlated with clinical instability of the lumbopelvic region, segmental hypermobility and instability.

Conclusion

Pelvic ring fractures types B and C can be associated with ruptured iliolumbal ligaments. Lumbopelvic instability can be correlated with early implant loosening of TLPS.     

Primäre Kniegelenkendoprothese nach Trauma

Intraarticular knee fractures and, in particular, complex fractures of the tibial head remain challenging for orthopaedic surgeons. Surgical reconstruction in elderly patients is limited due to several factors: osteoporosis, osteoarthritis, bone defects and limited coordination. Posttraumatic or secondary osteoarthritis with compromised soft tissue are predisposing factors for bad functional outcome. In such cases, primary total knee arthroplasty is a realistic treatment option. The few existing studies on this surgical approach reported on a reliable and safe procedure with moderate complication rates. Primary knee arthroplasty enables elderly patients to be mobilized while full weight bearing postoperatively and precludes complex revision arthroplasty. Although currently not an established procedure, primary arthroplasty could represent a viable option for the treatment of complex fractures. Further long-term studies are warranted to support these results.     

Linksventrikuläre Projektilmigration nach akzidentiellem Schrotschuss aus nächster Nähe

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.     

Stationäre Rehabilitation nach sprunggelenknahen Frakturen

Fractures close to the ankle joint are the most frequent occupational injuries at the workplace and often lead to high medical costs and long-lasting inability to work. The present prospective study evaluated the effects of in-patient rehabilitation treatment over a period of 3–4 weeks on 76 patients with fractures close to ankle joint and a delayed healing process. Functional parameters were measured at the beginning and at the end of the in-patient rehabilitation treatment. In addition, patients were questioned about pain intensity and health-related quality of life. From the measured deficits it can be concluded that the examined patient groups have a great need for rehabilitation. For the period of in-hospital treatment the deconditioning cycle caused by patients attempting to protect the injured limb could be interrupted and the functional restrictions were significantly improved by a predominantly activating therapy, although they could not be completely removed. The main goal of the medical treatment of these patients should be the avoidance of chronic pain. At the first signs of a delayed healing process, high consequential costs due to long periods of work disability can be avoided by beginning in-patient treatment (BGSW - Professional trade association) in a timely manner.     

Extraartikuläre subtalare Arthrodese nach Grice

Zusammenfassung Es wurden 23 Fälle von extraartikulären Arthrodesen nach Grice (von Herbst 1958 bis 1960) in der Klinik Balgrist nachkontrolliert. Es handelte sich 19mal um hochgradige paralytische, 4mal um kongenitale Knicksenkfüße. Häufig bestand eine Spitzfußkomponente (8mal). Bei 15 Füßen konnte die Stellung gebessert werden. Von Kindern und Eltern wurde in diesen Fällen das Resultat auch positiv gewertet. Acht Fälle zeigten unbefriedigende Ergebnisse. Zweimal war das schlechte Resultat auf Spanresorption, einmal auf verzögerte Konsolidation zurückzuführen, und bei fünf Füßen kann die Ursache nicht mit Sicherheit gefunden werden.Möglichst sorgfältige Herstellung des Muskelgleichgewichts scheint uns zur Erreichung optimaler Resultate von größter Bedeutung zu sein.Mit 3 Textabbildungen (17 Einzelbilder)     

Ulzeroglanduläre Tularämie nach Kontakt mit Wildschwein

Die Unfallchirurgie - Vorgestellt wird ein Fall von ulzeroglandulärer Tularämie mit lokaler Lymphknotenmanifestation bei einem Hobbyjäger. Eine adäquate Diagnosestellung und...     

Extraartikuläre Arthrorise nach Grice/Green vs. Kalkaneusverlängerungsosteotomie nach Evans

Background

Common reasons for juvenile neurogenic pes planovalgus are hypoxic brain damage, birth defects of the spinal canal, trauma and cerebral cancer. When symptoms persist despite conservative treatment of symptomatic pes planovalgus, surgery is indicated. Objectives of the operation are improved gait and mobilization as well as an improved basis for wearing shoes. Joint preserving and ankylosing procedures as well as combinations of both are available. The aim of this study was a retrospective comparison of the Grice/Green extra-articular arthroreisis versus the Evans calcaneal lengthening operation.

Material and methods

Between October 2001 and October 2009 a total of 75 arthroereisis operations were performed according to Grice/Green and in the period from April 2006 to February 2010 a total of 83 calcaneal lengthening operations according to Evans. The focus of the study was on patients with an underlying neurogenic disease which resulted in 72 cases in the Grice/Green group and 70 cases in the Evans group. The average age was 14.6?±?5.0 years in the Evans group and 10.1?±?3.4 years in the Grice/Green group. Of the patients in the Grice/Green group 17 had infantile cerebral palsy (ICP) and 25 had other neuromuscular diseases and in the Evans group 14 patients had ICP and 28 patients had other neuromuscular diseases. The medical records, preoperative and postoperative radiographs were analyzed. In addition information was obtained on the quality of life (EQ-5D), mobility and the supply of mobility aids using a specially designed questionnaire. The radiological evaluation was based on preoperative and postoperative lateral and dorso-plantar radiographs. The follow-up time for the questionnaire was on average 54 months (range 12–109 months) for the Grice/Green group and 22 months (range 9–53 months) for the Evans group. The postoperative treatment was similar in both groups.

Results

The talometatarsal (TMT) index could be improved by surgery according to Grice/Green from ??50.2° to ??28.1° and in the Evans group a correction from ??49.6° to ??31.8° was possible. Considering the cases with severe preoperative deformities (TMT index <??50°) there was a significantly greater correction of the lateral talocalcaneal (TC) angle by the method of Grice/Green. In 67?% of patients in the Grice/Green group and 57?% in the Evans group a significant improvement in terms of pain was possible. A significant improvement in gait and possible walking distance was found in 33?% of the Grice/Green group and 43?% of the Evans group and an average improvement was possible in 40 % and 43?%, respectively. The operation was considered to be very successful by 67?% of patients in the Grice/Green group and in 57?% of patients in the Evans group but the difference was not significant. In the Grice/Green group no revisions were necessary and revision was performed in two cases after surgery in the Evans group due to wound infections.

Conclusions

Both of the processes investigated in this study are suitable for treatment of pes planovalgus. In cases of neurogenic pes planovalgus and also in extreme cases (TMT index <?-50°) the procedure according to Grice/Green has radiological advantages for reconstruction of the lateral TC angle.     

Die sekundäre Gelenksteife als Hauptkomplikation nach Monteggia-Verletzungen

Introduction

Monteggia fractures represent a rare and often underestimated injury (2–5% of proximal forearm fractures). Even though there is good understanding of the biomechanics of the fracture and the advantage of the operative treatment, the rates of complications, revisions, and disappointing functional outcome results are high. The purpose of the study was to evaluate the complications after operative treatment of Monteggia injuries due to the fracture type, additional injuries, and initial operative treatment.

Patients and methods

During the period from January 2003 to December 2007, we treated 21 patients with a Monteggia fracture at our institution. There were 12 females and 9 males. The mean age was 51 years (range 23–77 years). The patients were followed up clinically and radiologically for a mean of 24 months (range 3–40 months).Clinical assessment was performed using the Morrey and the Leipziger Elbow Scores. Postoperative complications were evaluated and the patients were reevaluated clinically and radiologically after operative treatment of the complications.

Results

Complications were found in 6 of 21 patients. Four patients developed secondary stiffness (19%) and 2 patients developed a non-union of the proximal ulna (10%). The overall Morrey Score was 96.6 points in 17 patients (excluding the 4 patients with secondary stiffness) and the overall Leipziger Elbow Score was 85.2 points. After 6 months, the 4 patients after revision surgery due to secondary stiffness achieved slightly inferior results according to the Morrey and Leipziger Elbow Scores (Morrey Score: 89 points, Leipziger Elbow Score: 71 points).

Conclusion

Patients with secondary stiffness due to operative treatment of a Monteggia fracture benefit from open arthrolysis, despite the Morrey and Leipziger Elbow Scores showing slightly inferior results. Secondary stiffness is often associated with additional fractures of the radial head, intraarticular fractures, and soft tissue injuries. The patient must be informed about the severity of this type of fracture and its complications, including possible reoperation.     

Vaskuläre Komplikationen nach endovaskulärer Therapie bei traumatischer thorakaler Aortenruptur

Zusammenfassung Die endovaskuläre Stentgraftimplantation bei einer traumatisch bedingten thorakalen Aortenruptur Loco typico stellt ein faszinierendes Therapiekonzept dar, weil die Hauptkomplikationen der offenen chirurgischen Rekonstruktion—die perioperative Letalität und die Paraplegierate—deutlich und überzeugend reduziert werden konnten. Die für dieses endovaskuläre Therapieverfahren spezifischen anatomisch und technisch möglichen Komplikationen (Dissektion der A. iliaca externa, Subclavian-steal-Syndrom) werden am Fallbeispiel einer 35-jährigen Patientin erläutert und diskutiert.Die endovaskuläre Stentgraftbehandlung der traumatischen Aortenruptur stellt aus technischer Sicht kein Problem mehr dar. Die durch die Methode implizierten Komplikationen müssen jedoch bekannt sein, damit sie bei entsprechender Klinik primär oder sekundär behandelt werden können. Im vorliegenden Fall wurde bei der 35-jährigen Patientin sekundär die Dissektion der Beckenarterie durch eine retrograde Becken-TEA und ein Subclavian-steal-Syndrom nach Überstenten der linken A. subclavia durch eine Karotis-Subklavia-Transposition therapiert.     

Periprothetische intertrochantäre Femurfraktur nach Oberflächenersatz des Hüftgelenks

Improvements in implant design, material combination and operating instruments have led to an increased number of resurfacing arthroplasties of the hip joint especially in younger patients. Therefore, there is generally a higher risk of periprosthetic fractures even with this type of prosthesis. These fractures are divided into mainly iatrogenic fractures of the head/neck part of the femur and trochanteric fractures of the femur caused by trauma. Especially in the second group preservation of the prosthesis is much desired since the patient cohort is often very young and active. We report on a 31-year-old male patient who suffered an intertrochanteric fracture (classification AO 31 A2.1) after resurfacing arthroplasty of the hip joint (McMinn BHR prosthesis). The patient was treated with 3 AO lag screws by the percutaneous technique following closed reduction. During follow-up 22 months after the operation the reduction was preserved and the fracture fully consolidated with a good range of motion of the hip joint. The Harris hip score gave a result of 97 points.     

Osteotomie bei Zugängen zum Kniegelenk

The present article summarizes the different osteotomy techniques for an extension of standard surgical approaches to the knee joint in selected patients. The aim is to achieve satisfactory exposure and reduce potential postoperative complications compared to alternative techniques, such as the V-Y plasty or the quadriceps snip procedures. Osteotomy of the tibial tubercle is a reasonable extension of the anteromedial or the anterolateral surgical approach in selected patients undergoing revision total knee replacement. This osteotomy will provide excellent surgical exposure of the knee without the risk of avulsion of the patellar tendon and will preserve the blood supply of the patella and the surrounding soft tissue. Moreover, functional clinical outcome will be improved by minimizing damage to the extensor mechanism. Osteotomy of the lateral femoral condyle gives excellent exposure of the posterolateral aspect of the knee joint which might be necessary in some patients with fractures of the posterolateral tibial plateau as well as patients undergoing open allograft transplantation of the lateral meniscus. An alternative option for an extended exposure to the posterolateral knee joint is accomplished by osteotomy or partial resection of the fibular head which is also described as having good clinical results and a low complication rate.     

Primäre und früh-sekundäre Endoprothetik nach Brüchen des Hüftgelenks

Trauma und Berufskrankheit - Die Endoprothetik nach Acetabulumfrakturen stellt eine alternative Therapieoption zur Osteosynthese dar. Sowohl beim älteren als auch beim jungen Menschen ist es...     

Primäre und früh-sekundäre Endoprothetik nach Brüchen des Hüftgelenks

Endoprosthesis after acetabular fractures represents an alternative therapy option to osteosynthesis. In both elderly and young people it is essential to exactly define the indications for both procedures and to demarcate them from each other.