Die früh infizierte Duokopfprothese

Background

In a retrospective study, we compared the results of different surgical therapies in 30 patients who had an early-onset infection after implantation of a hip hemiarthroplasty.

Material and methods

Patients were divided into two groups: In group 1 (n=16, deep infection), we changed the polyethylene inlay as well as the femoral head. In group 2 (n=14, deep infection), an acetabular component was also implanted.

Results

In group 1, successful treatment was achieved in 37.5% of patients 6 months after the last operation, compared with 71.4% in group 2 (p=0.019). All patients were supported with antibiotics. In group 1, three patients died from septic multiorgan failure. Two patients in group 1 and one patient in group 2 received a Girdlestone operation.

Conclusions

These results suggest that aggressive surgical treatment with soft tissue revision, lavage, and implantation of an acetabular component in combination with antibiotics is a useful technique for treating early-onset infection.     

Die infizierte Osteosynthese am oberen Sprunggelenk

Background

Should osteosynthesis infection occur after ankle fractures in patients with microangiopathy, the infection needs to be cured quickly and safely to protect implants, bone, and tendons. Vacuum therapy (TNP) provides a perfect treatment plan that keeps the inpatient time low whilst ensuring high patient comfort.

Methods and patients

Four angiopathic patients with deep wound infection after ankle osteosynthesis were treated. At admission, loss of stability and spread of the infection were the immeadiate risks. To prevent this, we treated the patients with vacuum therapy after initial debridement until skin cover was achieved.

Results

In all cases stability was secured and after 2 dressing changes, the swabs were sterile. The inpatient time was 13 days; overall vacuum therapy time was 59 days. Patient satisfaction was high.

Discussion

Vacuum therapy is a perfect strategy after surgical debridement and before secondary mesh grafting. It protects the stability of the bone and open-lying delicate structures in patients with infected osteosynthesis of the ankle and angiopathy and offers an easy, safe, and successful treatment path with a short inpatient time.     

Targon® Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

Purpose

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon® FN fixation concept is innovative; two small case series are promising. We present the first larger series.

Methods

We conducted prospective documentation of all Targon® FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

Results

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4 %. Conversion to joint replacement was necessary in 9.6 %. Complication rate was significantly higher in displaced fractures.

Conclusions

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.     

Duodenum-Preserving Total Pancreatic Head Resection for Benign Cystic Neoplastic Lesions

Background

Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment.

Objectives

The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment.

Patients

Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed.

Results

Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ.

Conclusion

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.     

Tibial tubercle osteotomy in septic revision total knee arthroplasty

Purpose

The incidence of revision knee arthroplasty for infection is increasing and the required surgical approach for the revision is a challenge for surgeons. Extensile approaches are frequently used when it is impossible to evert the extensor mechanism. The aim of this paper is to report our experience with tibial tubercle osteotomy (TTO) and the functional results in patients who underwent a two-stage revision due to prosthesis infection.

Methods

Twenty-six patients underwent a TTO as a surgical approach in the second stage of revision for infection. The patients were clinically assessed by means of functional scales (the Knee Society Score and WOMAC) and X-rays.

Results

The TTO healed without complications in 22 patients (84.6 %) and the average length of follow-up was 3.4 years. Non-union was observed in two patients. One patient presented an extension lag of 5°. A total of 23 patients (88.4 %) were free from infection. Twenty-five patients (96.1 %) had better scores on the Knee Society Score and WOMAC after the procedure.

Conclusions

In patients undergoing the second stage of revision total knee arthroplasty for infection, the TTO approach provides a large operating field. This enables surgeons to withdraw spacers and position new implants without damaging the extensor mechanism of the knee or altering the postoperative rehabilitation process. The complications that have been reported as a result of this procedure could be reduced by performing a meticulous surgical technique.

Level of evidence

Retrospective case series, Level IV.     

Ossäre Tuberkulose als seltene Differenzialdiagnose der Femurkopfnekrose

Background

We report on a 60-year-old immunocompetent German male patient without risk factors, who had been suffering from pain in the right hip for 8 months.

Diagnostics

Radiographs showed destruction of the femoral head with a collapse of the main weight-bearing area, which was interpreted as femoral head necrosis.

Therapy

A cement-free total hip prosthesis was then implanted. The femoral head was sent for routine histological analysis and PCR amplification yielded a positive result for Mycobacterium tuberculosis complex DNA, leading to immediate guideline-based tuberculostatic treatment.

Conclusion

Tuberculosis should be considered as a differential diagnosis in the case of destruction of the femoral head, especially in immunocompromised patients, patients with a foreign background or destructive osteoarthritis of the hip with an atypical course. Antibiotic treatment is necessary postoperatively. Under this therapy, a good clinical outcome can be expected comparable to that achieved in patients with primary osteoarthritis without infection.     

Transaxilläre oder supraklavikuläre Dekompression bei Kompressionssyndromen der oberen Thoraxapertur?

Objective

Thoracic outlet syndrome (TOS) is caused by an inherent constriction of the upper thoracic outlet and can be classified into several forms based on the compressed structures. The diagnosis is difficult; there are several possible approaches for surgical therapy.

Materials and methods

Technique, risks and results of the transaxillary and the supraclavicular approaches are presented according to the current literature. MEDLINE (1966–2012) was searched using the key words TOS, supraclavcular and transaxillary incision.

Conclusion

Both procedures are suitable for the surgical treatment of TOS; however, based on existing studies no procedure can be preferred. In addition to absolute success rates, local surgical expertise seems to be of great significance in the treatment of this complex clinical picture.     

Digastric trochanteric flip osteotomy and surgical dislocation of hip in the management of acetabular fractures

Objectives

To assess the efficacy and safety of digastric trochanteric flip osteotomy technique in the management of acetabular fractures and to evaluate surgical outcome in terms of fracture reduction, femoral head viability of selected acetabular fractures treated operatively using a digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with surgical dislocation of the femoral head.

Design

Prospective.

Patients

Eighteen patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures.

Outcome evaluation

Clinical and radiographic analysis after a minimum 18 months follow-up.

Methods

A single modified approach involving digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with anterior (n = 14) or posterior (n = 4) surgical dislocation of the femoral head, was done for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement.

Results

At a mean follow-up of 26 months (18–40 months), the 17 patients presented with a good to excellent clinical result according to the d’Aubigné score. In all subjects, anatomical reduction was achieved during surgery. The osteotomy site healed at an average of 7 weeks and all the patients recovered abductor strength at 12 weeks. One avascular necrosis occurred in a case of posterior column plus wall fracture (who presented to us after 3 weeks). No heterotopic ossification interfering with hip function was found.

Conclusion

This technique gives good exposure (especially in posterior wall, dome area, posterior fracture-dislocation with intra-articular fragments/femoral head fractures and T-fractures), preservation of abductor strength (which may be lost with excessive retraction of abductors to see dome area in classical posterior approach), reliable healing of osteotomy (in contrast to conventional trochanteric osteotomy) without risking the vascularity of femoral head.     

Open reduction and internal-fixation versus radial head replacement in treatment of Mason type III radial head fractures

Purpose

The purpose of this study was to demonstrate whether open reduction and internal-fixation (ORIF) was superior to radial head replacement in treatment of Mason type III radial head fractures by comparing postoperative complication rate and satisfactory rate.

Methods

Clinical trials comparing ORIF with radial head replacement for Mason type III radial head fractures were reviewed published up to September 1, 2012. Methodological quality of each included trials was assessed using the Jadad scale. The analyses were performed with Cochrane RevMan software version 5.1.

Results

One prospective randomized controlled trial and one comparative study involving 67 patients with 67 cases were included in this systematic review and meta-analysis. Both the forest plots of complication rate and satisfactory rate indicated statistical differences between the two surgical techniques in treatment of Mason type III radial head fractures. The complication rate was 13.9 % in patients treated with radial head replacement and 58.1 % in patients treated with ORIF. The satisfactory rate was 91.7 % in patients treated with radial head replacement and 51.6 % in patients treated with ORIF.

Conclusions

Given the available evidence, radial head replacement appeared to reach better outcomes in patients with Mason type III radial head fractures followed 5 years or less.

Level of evidence

Therapeutic II.     

Die Klavikulaosteitis

Aim

Osteitis of the clavicle is a rare but challenging disease. In this prospective study, the results of surgically treated patients (evidence level IV) are reported.

Method

From 1995?C2010, 34 patients [15 women, 19 men; average body mass index 25.5 kg/m², average age 46 years, average follow-up 16.1 (range 3?C53) months] with osteitis of the clavicle were enrolled in this case series. In addition to an aggressive surgical approach, local and systemic antibiotics were important parts of the treatment regime. Data collection included clinical examination including the Constant Murley score (CMS), laboratory findings, and radiographs for every patient pre- and postoperatively.

Results

At the time of follow-up, all patients were free of infection. In 8 patients, surgical revision was required. In 22 patients, surrounding joints were involved in the infection. The average CMS showed a significant increase from 60 to 84 points at follow-up.

Conclusion

The presented follow-up study shows encouraging results with high infection elimination rates and good functional outcomes with an aggressive surgical approach. It is mandatory to address surrounding joints since they are often involved in the infection.     

Chirurgisches Management von infizierten Prothesen der aortoiliakalen Strombahn

Background

Aortic graft infections are associated with mortality rates of up to 30?% and amputation rates of up to 25?%. There is no gold standard in terms of surgical management.

Patients and methods

This study involved a retrospective analysis of patients treated between 1994 and 2013.

Reuslts

This study analyzed the cases of 28 men and 3 women with a median age of 64 years. In 51.6?% of patients an infection of an aortobifemoral graft occurred and in 12.9?% each of aorto-biiliacal and aortofemoral grafts. The diagnosis was confirmed clinically and by laboratory tests and in 38.7?% a computed tomography (CT) scan revealed typical findings, such as an abscess. Bacteria could be identified in all early infections and in 63.6?% of late infections. The surgical management was graft removal and extra-anatomical reconstruction in 70.9?% of patients which resulted in a mortality rate of 18.1?% and an amputation rate of 12.9?%. The 5-year survival rate was 47?% in this patient series.

Conclusion

The favored surgical approach for aortoiliac graft infections is graft removal and extra-anatomical reconstruction which showed acceptable mortality and amputation rates in this case series.     

The use of vancomycin powder reduces surgical reoperation in posterior instrumented and noninstrumented spinal surgery

Background

Surgical site infections can complicate posterior spine surgery. Multiple hospital admissions may be required to adequately treat a surgical site infection, which is associated with increased costs and lower patient satisfaction. The objective of this study was to evaluate the efficacy of prophylactic intra-wound vancomycin powder in reducing the incidence of repeat surgery for infections after posterior instrumented and noninstrumented spine surgery.

Methods

A series of consecutive patients who underwent instrumented or noninstrumented posterior spine surgery for any indication by two surgeons from July 2010 to July 2012 were reviewed. The preoperative antibiotic regimens of both surgeons were identical, except that one surgeon applied 1 g vancomycin powder directly to the surgical bed before wound closure, while the other did not. Patient demographics, operative details, and rates of reoperation for wound infection in the control and the treatment groups were compared.

Results

Both the control group and treatment group consisted of 150 patients; mean ages were 58.33 and 54.14 years, respectively. Both groups had low rates of deep infection requiring surgical intervention. The treatment group had a significantly lower rate of infection requiring reoperation or surgical debridement (0 %; 95 % CI: 0 %–2.4 %) compared with the control group (4 %; 95 % CI: 1.5 %–8.5 %) (P?=?0.0297). The six infections identified in the control group resulted in 12 repeat operative debridement procedures. Gram-positive organisms were identified in 66.7 % of infections. No complications were related to the application of vancomycin powder.

Conclusions

The results of this study demonstrate that adjunctive vancomycin powder applied directly to the surgical bed before closure seems effective in preventing deep infections that require operative debridement following posterior spine surgery.     

Civilian injuries due to unexploded ordnance in military training areas in southern Israel

Background

The problem of unexploded ordnance (UXO) is global and is usually associated with active or former war zones. Civilian injuries due to UXO in military training areas are not common.

Methods

This is a retrospective case series study based on prospectively collected data on patients who sustained injuries from UXO explosions and were admitted to the Soroka University Trauma Center during a five-year period.

Results

Twelve patients were included in this series. All patients were Bedouin and the distribution of injuries was concentrated around the head and upper and lower extremities, with sparing of the torso.

Conclusion

Awareness and implementation of preventive measures are expected to reduce the incidence of this type of injury.     

Surgical approach for treatment of pedunculated ulnar polydactyly: our experience

Background

Pedunculated ulnar polydactyly type II(A) variety has been treated with ligature of pedicle, but surgical excision of the accessory digit with high transection and retraction of the accompanying accessory digital nerve may prevent the complications associated with suture ligation. In order to assess the efficacy of surgical excision of pedunculated ulnar type II(A) polydactyly, the current study was undertaken.

Methods

From June 2007 to May 2008, all patients with bilateral pedunculated type II(A) ulnar polydactyly attending the surgery department were treated with excision of the accessory digit and high transection and retraction of supernumerary digital nerve. Patients were regularly followed up postoperatively up to 2?years to assess any complication.

Results

Ten patients were included in the study. The age ranged from 6?months to 3?years. There was one case of wound infection successfully managed with antibiotics. No other complications like painful neuroma and postoperative bumps or nubbins were detected during the follow-up.

Conclusion

The surgical approach seems to be the treatment of choice for pedunculated ulnar polydactyly and can be performed effectively and safely with negligible rate of complications.     

What Is the Effect of Stoma Construction on Surgical Site Infection After Colorectal Surgery?

Introduction

The aim of our study was to evaluate the effect of stoma creation on deep and superficial surgical site infections after an index colorectal surgical procedure.

Methods

We designed a retrospective cohort study from the National Surgical Quality Improvement Program. We evaluated all patients who underwent colorectal surgery procedures from January 2005 to December 2009 with or without creation of a stoma and sought to identify the effect of stoma creation on deep and superficial surgical site infections.

Results

A total of 79,775 patients underwent colorectal procedures (laparoscopic 30.7 %, open 69.3 %), while 8,113 patients developed a surgical site infection (10.2 %). The univariate analysis revealed that surgical site infections were much more common in patients with a stoma compared to those with no stoma (11.8 % vs. 9.5 %, p?<?0.0001). On multivariate analysis, stoma construction during the index colorectal procedure (OR 1.3, CI 1.2 to 1.4), ASA class ≥2, smoking, and abnormal body mass index were associated with surgical site infection.

Conclusions

The construction of a stoma with colorectal procedures is associated with a higher risk of surgical site infection. Although the stoma effect on surgical site infection is attenuated with laparoscopic techniques, the association remained statistically significant.