Achs- und rotationsgerechte Positionierung des bikondylären Femurschlittens

Background

Clinical outcome and durability of a bicondylar knee endoprosthesis depend on a correct positioning of the femoral prosthesis which should be implanted perpendicularly to the mechanical femoral axis and parallel to the transepicondylar axis to guarantee a harmonic balance of ligaments..

Method

Neither the mechanical axis nor the transepicondylar axis can be correctly defined intraoperatively without an instrumental device. Using the method presented here these axes can be determined indirectly using distal and dorsal femoral condyle tangents. Both tangents can be properly defined preoperatively as well as operatively. An x-ray of the whole femur is necessary for the mechanical femoral axis and a thin-layer computed tomography (CT) scan is necessary for the transepicondylar axis. Plug-in sleeves for the 4-in-1 block from 0–13° and a special angle measurement device are required for the operative transfer.

Results

This method has been used on 783 patients of whom 38 have been examined in a follow-up study. The deviation of the perpendicular to mechanical axis was on average 0.32° and the average deviation from the parallel to transepicondylar axis was 1.04°.

Conclusion

The presented procedure is safe and economical and saves operating time.     

Kniegelenkendoprothese zur primären Therapie der intraartikulären Tibiakopffraktur im höheren Alter

Zusammenfassung Intraartikuläre Tibiakopffrakturen bedeuten eine große Herausforderung an den Operateur. In den letzten Jahrzehnten wurde ein Anstieg dieser Verletzung beim älteren Patienten festgestellt. Im Gegensatz zum jüngeren Patienten spielt der Luxationsmechanismus eine untergeordnete Rolle. Neben der schwerwiegenden knöchernen Verletzung und dem Weichteilbegleitschaden findet sich beim älteren Patienten eine Reihe weiterer, sich negativ auf den Behandlungsverlauf auswirkender Faktoren. Hierzu zählen u. a. die Osteoporose, arterielle und venöse Gefäßerkrankungen, primäre Arthrosen, eingeschränktes Koordinationsvermögen des Patienten, begrenzte Verfügbarkeit autologer Spongiosa und Neuropathien. Klinisch relevante sekundäre Korrekturverluste (Achsenfehlstellung, Sinterung des Gelenkplateaus mit Stufenbildung) nach osteosynthetisch versorgten Tibiakopffrakturen bis hin zum Versagen der Osteosynthese sind jedem unfallchirurgisch-orthopädischen Operateur bekannt. Wir versorgten zwei ältere Patienten mit unterschiedlichen Zusatzbefunden primär mit Hilfe der Implantation einer Knie-TEP, z. T. kombiniert mit osteosynthetischen Maßnahmen, und konnten eine sofortige belastungsstabile Situation sowie ein gutes funktionelles Frühergebnis erreichen. Die sicherlich seltene Indikation der primären Endoprothesenimplantation bei intraartikulären Tibiafrakturen sollte bei der Wahl des Versorgungsverfahrens mit einbezogen werden—gerade bei Vorliegen von B3- und C2–C3-Frakturen und problembehafteten Zusatzbefunden. Studien mit entsprechenden Langzeitergebnissen fehlen bisher.     

Ulnarisläsion nach Osteosynthese der suprakondylären Humerusfraktur im Kindesalter

Zusammenfassung Bereits 1948 wurde die geschlossene Reposition und Osteosynthese mit 2 gekreuzten Kirschner-Drähten bei der suprakondylären Humerusfraktur etabliert. Trotz der langen Entwicklungs- und Erfahrungsphase machen bis zum heutigen Tag immer wieder Autoren auf die Problematik der Ulnarisläsion aufgrund des blind eingebrachten medialen Kirschner-Drahtes aufmerksam. Nur wenige Publikationen beschäftigen sich allerdings mit der progredienten Ulnarisparese und Empfehlungen zum Zeitpunkt einer operativen Revision.Es werden 4 Fälle mit einer progredienten motorischen und sensiblen Ulnarisparese beschrieben. Intraoperativ zeigte sich in allen Fällen eine Vernarbung bei erhaltener Kontinuität. Nach Revision und mikrochirugischer Neurolyse fand sich bei allen 4 Patienten zum Untersuchungszeitpunkt nach 1 Jahr eine vollständige Wiederherstellung. Bei progredienter Ulnarisparese ist daher eine frühzeitige operative Revision nach 3 Monaten zu empfehlen.     

Die elastisch stabile intramedulläre Osteosynthese der diaphysären Klavikulafraktur

Background

The aim of this study was to compare the outcome of open reduction versus closed reduction of midclavicular fractures using elastic stable intramedullary nailing (ESIN) in both groups.

Methods

Titanium elastic nails were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction.

Results

The Constant Score revealed no significant differences between the two groups (closed 87.4±9.0; open 85.3±7.1) nor did the DASH Score (closed: 5.0±6.5; open 5.8±7.3). The strength measurement of shoulder abduction was consistent in each group: 75.7±22.0 N in the closed reduction group and 74.2±26.0 N in the group with open treatment.

Conclusion

There was no difference comparing right- and left-sided injuries and the outcomes were consistent irrespective of the treatment method. When appropriately indicated open and closed intramedullary nailing are very successful modalities of treatment. There were no significant differences in shoulder function after either procedure.     

Arthroskopisch gesteuerte Osteosynthese der dislozierten intraartikulären distalen Radiusfraktur

Objective

Anatomical reconstruction of the distal radius after intra-articular fractures with special consideration of the articular surface and treatment of concomitant ligament injuries.

Indications

Intra-articular distal radius fractures in adults under 65 years of age.

Contraindications

Osteoporotic deterioration of metaphyseal bone, radiocarpal fracture dislocation and open fractures.

Surgical technique

Conventional palmar approach for plate fixation of the fracture with a fixed angle locking plate. Arthroscopy of the wrist is performed for reduction of the articular fracture component using the standard 3?4 and 6R portals. Following temporary Kirschner (K) wire fixation of the fracture, angle stable locking screws are inserted into the most distal portion of the plate. Finally, the intercarpal ligaments and the triangular fibrocartilage complex (TFCC) are checked for concomitant lesions and if necessary subsequent treatment within the same operation.

Postoperative management

Plaster cast fixation for 4 weeks followed by a physiotherapy program.

Results

After arthroscopically assisted reduction of an intra-articular distal radius fracture, 17 out of the 23 patients were available for follow-up examination an average of 31 months after the procedure. The mean disabilities of the arm, shoulder and hand (DASH) score was 4.9 and the mean patient-rated wrist evaluation (PRWE) score was 6.0 at final follow-up. Except for wrist flexion, an active range of motion at the wrist as well as forearm rotation of more than 90?% was achieved compared with the uninjured contralateral side. Grip strength averaged 96?% compared with the contralateral side and pain levels under stress varied between 1 and 3 on a visual analog scale (range 0–10).

     

Akute intestinale Kolonpseudoobstruktion 2 Tage nach Versorgung einer pertrochantären Femurfraktur

Acute colonic pseudoobstruction, following traumatic injuries, is a rare diagnosis. Nevertheless it is life threatening, if it is not recognized and treated promptly. We report one case of this so-called Ogilvie's syndrome, which followed fixation of a trochanteric fracture by intramedullary nailing within 2 days. Due to massive acute colonic distension, the patient suffered from respiratory failure. We excluded other intestinal diseases by CT scanning. After conservative colonic decompression, he recovered after 2 days in the intensive care unit. We describe a variable treatment depending on the severity of the colonic atony. Knowledge of Ogilvie's syndrome, or acute colonic pseudoobstruction, is a must for trauma surgeons, since it can occur within a few hours and can lead to dramatic situations.     

Zentralneurologische Komplikation einer interskalenären Plexuskatheteranlage

Die Anaesthesiologie - Eine 78-jährige Patientin erhält zur perioperativen Schmerztherapie bei Implantation einer inversen Schulterprothese einen interskalenären Plexuskatheter...     

Die Implantation einer unikondylären Schlittenprothese

Objectives Correction of axial malalignment and restoration of a normal pain-free joint function through insertion of a unicompartmental runner. Indications Medial or lateral unicompartmental osteoarthritis. Osteonecrosis of the medial femoral condyle. Age over 60 years. Contraindications Osteoarthritis of more than one compartment. Ligamentous instability (instability due to cartilage loss is not a contraindication). Rheumatoid arthritis. Chronic synovitis. Systemic affections of joints (i. e., hemophilia). Neuropathic joint diseases. Obesity. Axial malalignment exceeding 20°. Flexion contracture exceeding 20°. Sugical Technique Medial approach. After visual confirmation that only one compartment is affected, resection of the tibial plateau while preserving cruciate and collateral ligaments. Preparation of the femoral condyle and restoration of axial alignment through insertion of the unicompartmental components. Avoid overcorrection. Results Between 1986 and 1990 a unicompartmental arthroplasty was done in 34 men and 115 women (62–86 years). 44 had died for unrelated reasons. 35 answered a questionnaire by phone, 45 could be examined clinically and radiologically. 23 patients had undergone a revision surgery for various reasons. The duration of follow-up varied between 8 and 12 years. The clinical assessment was based on the HSS score. Results were good to excellent in 80%, moderate in 7.5%, and poor in 12.5%. Patients with a poor result were scrutinized paying special attention to the surgical indication. Main reasons for poor results were rheumatoid arthritis, advanced osteoarthritis, loosening and subsidence of the tibial component. The survival rate after more than 10 years of 84 patients at risk, with the need of revision as endpoint, was 83.7%.     

Versorgung von bikondylären Tibiakopf-Frakturen mit einem unilateral platzierten winkelstabilen Plattensystem

Background

This study was initiated to evaluate early results of a locked screw plate for unilateral fixation of bicondylar fractures of the tibial plateau. Emphasis was laid on malreduction, secondary loss of reduction, union rate, and infection.

Material and methods

A case series of patients with AO/ASIF 41-C type fractures treated with the less invasive stabilization system for the proximal lateral tibia (LISS PLT) were prospectively followed up until 11–13 months after surgery. Malreduction and malalignment were defined as an intra-articular step-off of 2 mm or more or as a malalignment in the frontal or sagittal plane of more than 5°.

Results

Sixty-eight patients with 69 fractures were involved. Fourteen fractures were open. Primary bone grafting was performed in 13 patients. Significant malreduction was seen in 16 patients. Sixty-two (91%) patients returned for follow-up. All but one fracture healed eventually. The number of infections was low (4 superficial, 1 deep). Nine patients had a significant loss of reduction. Of 54 patients outcome scores were good to excellent in 47 patients on the Lysholm score (average 87.2) and in 44 patients on the Rasmussen score (average 26.7).

Conclusion

We concluded that unilateral locked screw plating is a good alternative in the treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.     

Osteosynthese von per- und subtrochantären Femurfrakturen mit dem proximalen Femurnagel

Objective

Restoration of function and anatomy of the proximal femur. Possibility of full weightbearing after surgery. Less invasive intramedullary osteosynthesis.

Indications

Unstable trochanteric fracture (AO classification 31-A2, 31-A3), subtrochanteric fracture (AO classification 32-A1), fracture of the femoral shaft in the proximal region.

Contraindications

Ipsilateral coxarthrosis, open growth plate, hip fracture.

Surgical technique

Closed or open reduction on the extension table. Intramedullary reaming of the proximal femur, insertion of PFNA and blade as proximal locking screw, static or dynamic distal locking screw. Implantion of bone cement via blade, if necessary.

Postoperative management

Weightbearing as limited by pain. Osteoporosis diagnostics and initiation of treatment, if necessary.

Results

The stabilization of trochanteric fractures is usually done with PFNA. Compared to other methods, e.g., DHS, fewer complications were observed with the PFNA. Subtrochanteric fractures were associated with higher complication rates compared to intertrochanteric fractures.     

Ausgeprägtes Emphysem nach Marknagelung einer pertrochantären Fraktur

Die Unfallchirurgie - Die Ausbildung eines Emphysems nach Marknagelung kann eine gut beherrschbare Komplikation darstellen, differenzialdiagnostisch kann es sich jedoch um eine lebensbedrohliche...     

Mediale Schenkelhalsschraubendislokation nach Gammanagelosteosynthese einer pertrochantären Femurmetastase

If the standard technical guidelines are ignored so that the antirotation screw is not correctly placed during gamma nail osteosynthesis, dislocation of the hip screw is possible. In the rare cases of migration into the pelvis, the consequences may be lethal.     

Qualitätsmanagement einer pflegebasierten Ersteinschätzung im Interdisziplinären Notfallzentrum

Background

At the Interdisciplinary Emergency Center (“Interdisziplinären Notfallzentrum”, INZ) of the University Hospital of Bonn (Germany) a structured, computer-based triage protocol is performed by triage nursing staff for approximately 25,000 emergency patients each year. The aim of the analysis presented here was to monitor and improve the quality of nursing staff-based triage through the development of an advanced, formal audit procedure.

Material and methods

A two-step quality audit process was developed and examined the achievement of specific targets prescribed in the protocol.

Results

In the first audit the targets set in the Manchester Triage System (MTS) were not achieved. Based on INZ-specified targets, adequate collection of vital signs was carried out in only 33?% of cases (n?=?110), an initial neurological assessment was performed in only 62?% of cases (n?=?34), and an initial trauma assessment was performed in only 34?% (n?=?17) of cases. A mandatory second opinion was given in only 53?%of cases (n?=?40) in which the prescribed physician contact time had been exceeded. In the second audit, the goal of the MTS Group was achieved with 95.4?% accuracy. Vital signs were fully measured in 97?% (n?=?169; p?<?0.05). A neurological initial assessment was performed in 86?% of cases for which this was required (n?=?19; p?<?0.05). An initial trauma assessment was made in 80?% (n?=?12; p?<?0.05). Lastly, the mandatory second opinion was obtained in 97?% (n?=?33; p?<?0.05).

Conclusion

Advanced formal audit procedures can improve the quality of nursing staff-based triage.     

Verbesserung einer höchstgradig eingeschränkten linksventrikulären Pumpfunktion

With the introduction of transcatheter aortic valve implantation (TAVI), an alternative therapy to surgical aortic valve replacement exists. General guidelines for indications for TAVI procedures are still lacking. Herein, we report a 57-year-old patient with aortic valve stenosis and severely impaired left ventricular function. Twelve months after transfemoral implantation of a 29 mm Medtronic CoreValve prosthesis, left ventricular function and clinical symptoms have significantly improved. As long as no general guidelines on the indications for TAVI procedures exist, patients with aortic valve stenosis and severe comorbidities must undergo careful risk assessment and evaluation in order to offer the individual patients the therapy with the lowest risk.     

Generalisierter Krampfanfall während der Anlage einer axillären Plexusblockade

Die Anaesthesiologie - Eine junge Patientin erleidet während der Anlage einer axillären Plexusblockade einen generalisierten Krampfanfall. Die Mechanismen, im Wesentlichen die vermutlich...     

Verletzung der A. profunda femoris mit transfusionspflichtiger Blutung durch sekundäre Dislokation des Trochanter minor nach Osteosynthese einer pertrochantären Femurfraktur

Die Unfallchirurgie - Ein 95-jähriger Patient erlitt eine transfusionspflichtige Blutung nach Osteosynthese einer pertrochantären Femurfraktur mittels proximalem Femurnagel. Das bei der...