Implantation einer Sprunggelenktotalendoprothese vom Typ Salto 2

Aim of surgery

Operative treatment of advanced primary and secondary arthritis of the ankle was carried out with the aim of achieving pain-free movement and retention of mobility.

Indications

Surgery is indicated when conservative therapy is no longer sufficient for treatment of arthritis of the ankle with painful limited movement, sufficient bony joint conditions and correctable instability or axis malpositioning.

Contraindications

Surgery is not recommended with general surgical or anesthesiological contraindications, rampant infections, severe disturbances of peripheral perfusion, bony defects in areas relevant for anchoring, unstable soft tissue conditions, talus necrosis >30?%, manifest osteoporosis and severe non-correctable instability or malpositioning.

Operation technique

Tibial and talar bone resection was carried out via ventral access to the ankle through an incision and if present, soft tissue correction of instability after insertion of test components. Cement-free implantation of the original implants followed by subtle reconstruction of the extensor retinaculum and layer for layer closure of the wound.

Additional interventions

Additional measures were necessary on the periarticular soft tissues, the hindfoot and lower leg due to movement restrictions, instability and axis malpositioning which could be carried out in a one or two stage procedure depending on the extent and morphology.

Results

Between February 2009 and February 2010 a total of 115 patients (52?% with posttraumatic arthritis) received a cement-free implantation with a Salto 2 prosthesis. Additional corrective interventions were carried out in the presence of varus and valgus deformities. The degree of movement for dorsal extension and plantar flexion could be increased by an average of 8.3°. The interventions resulted in a significant reduction in pain from an average preoperative visual analogue pain scale (VAS) score of 7.8 (range 5–10) to an average postoperative score of 1.9 (range 0–6.1).     

Botulinumneurotoxin Typ A bei neurogener Detrusorüberaktivität

The use of botulinum neurotoxin (BoNT-A) for suppression of neurogenic detrusor overactivity was first reported in 2000. Since that time, this method has gained widespread use. A number of recommendations and consensus statements have already been published. The current practice-oriented consensus paper takes into account recent developments and the over 10-year experience of most members of the Working Group Neuro-Urology of the German-speaking Medical Society for Paraplegia (DMGP) with a focus on the use of BoNT-A in paraplegic patients and in patients with multiple sclerosis.     

Beckenstabilisierung bei septischer Instabilität

The combination of transiliac screws and lumbopelvic distraction osteosynthesis is usually an appropriate procedure to treat vertical pelvic ring instabilities under the condition of full weight bearing. In this case, due to the extent of septic destruction of the dorsal portion of the iliac bone, the common triangular fixation method using conventional pedicle screws was not possible. Using the transiliac dorsoventral screw position with special long screws, we achieved high mechanical triangular stability sufficient for pelvic ring fusion despite the large bony defect.     

Patellafraktur nach MPFL-Rekonstruktion bei femoropatellarer Instabilität

We report on a 20-year-old female patient with a fracture of the patella after she fell on“black ice” 2 months after medial patellofemoral ligament (MPFL) reconstruction for patellar instability. For reconstruction of the MPFL, a single hamstring tendon graft was passed through the medial intermuscular septum and was fixed to the superomedial pole of the patella. The fracture was reduced by wire cerclage. Intraoperatively it was shown that the fracture line went through the patellar drill hole. No complications occurred during the further postoperative period. The literature contains only a few case reports describing fractures of the patella after MPFL reconstruction without any specific trauma. In this case, an interruption in blood supply with resulting avascular necrosis was suspected as a causal factor.     

Radialer externer Fixateur zur geschlossenen Behandlung problematischer suprakondylärer Humerusfrakturen Typ III und IV bei Kindern und Jugendlichen

Objective

Closed, anatomical reduction and reliable fixation of type III and IV supracondylar fractures that are either difficult or impossible to treat with conventional methods.

Indications

According the Pediatric Comprehensive AO Classification for long bones this technique is preferred for type III and IV supracondylar fractures that cannot be reduced using closed standard manipulative techniques, where stable fixation using standard percutaneous wire configurations cannot be achieved, when severe swelling, open fracture, primary neurological or vascular problems (“pulseless pink hand”) or multiple injuries indicate that optimal management of the injured limb should be free from cast. In patients with comorbidities (e.g., seizures or spasticity) requiring more stable fixation.

Contraindications

In principle there are no contraindications.

Surgical technique

Prior to reduction of the fracture, fluoroscopically controlled insertion of a single Schanz screw into the lateral (radial) aspect of the distal fragment, which is defined by bulls eyeing the capitellum in the perfect lateral radiographic projection of the epiphysis, parallel to the physis. For very distal fractures this screw may be intra-epiphyseal, although usual placement is in the metaphysis just distal to the fracture line. After obtaining perfect lateral radiographic projection of the distal humeral metaphyseal–diaphyseal junction, a second Schanz screw is inserted independently into the proximal fracture fragment at the proximal end of the lateral supracondylar ridge in the sagittal plane perpendicular to the long axis of the humeral diaphysis. By bringing the screws parallel to each other in the coronal and transverse planes direct manipulations of the fragments and anatomical reduction using the so-called joystick technique is achieved. Fracture reduction can then be adjusted anatomically under fluoroscopic control and through clinical assessment. Once reduction is achieved the fragments have to be secured with a so-called “anti-rotation” K-wire. This wire significantly enhances stability and prevents pivoting of the fracture fragments around the Schanz screws in the sagittal plane and assists in prevention of medial collapse of the reduced fracture.

Postoperative management

No additional plaster cast fixation required; mobilization of the upper limb as comfort allows.

Results

The majority of children have a normal range of motion at the time of external fixator removal. At follow-up (40 months), 30 of 31 children had normal function and a normal, anatomical axis as judged against the contralateral upper limb.     

Lumbopelvine Stabilisierung bei bilateraler lumbosakraler Instabilität

Background

Bilateral lumbopelvic instabilities are rare; for the affected patients, however, they mean a severe reduction in quality of life. Optimal results can only be achieved with a well-adapted therapy algorithm that balances surgery and non-surgical procedures.

Objectives

The present article addresses the indications, strategy, and techniques of bilateral lumbopelvic fixation in the operative treatment of bilateral lumbopelvic injuries and review of the literature and personal experience.

Results

The overall incidence of lumbosacral instabilities is low and mainly caused by high energy trauma, osteoporotic insuffiencies (e.g., primarily or secondary after long segment lumbar instrumentation), and tumors. Dramatic soft tissue injuries can occur in addition to hidden neurological impairments, and therefore it is important to diagnose and evaluate all concomitant comorbidities. The keys to success are gaining stability in the lumbosacral junction possibly combined with neuronal decompression and meaningful coordination of all disciplines, certainly challenged by finding the correct moment for surgery which is between 2 days and 2 weeks. Based on the superficial anatomy of the bony structures in the lumbosacral junction, the surgical approach has to match the pathology and should be tissue saving.

Conclusions

Treatment of bilateral lumbopelvic instabilities requires an accurate examination, sophisticated therapy protocol, and a multidisciplinary approach. Surgery with a bilateral lumbopelvic fixation combined with neuronal decompression is an adequate treatment that creates early bony stability, thus, promising functional weight-bearing mobilization.     

Patellofemorale Instabilität bei Kindern und Jugendlichen

Die Unfallchirurgie - Die Luxation der Kniescheibe stellt im Kindes- und Jugendalter eine der häufigsten Kniegelenkverletzungen dar. Nach eingehender klinischer und radiologischer...     

Die direkte Osteosynthese instabiler Atlasfrakturen Gehweiler Typ III

This retrospective study evaluates eight patients with unstable fractures of the atlas vertebra, treated operatively in the Central Clinic Bad Berka between January 1995 and December 2001. In all cases, we were confronted with unstable and dislocated type III fractures according to Gehweiler, caused by an injured transverse ligament. Mean age was 34 years (range 20-49) in two women and six men. We introduce a new technique of direct reconstruction of the atlas vertebra. This technique leads to a stable ring construct that allows compression osteosynthesis of the fracture. Spinal fusion can be avoided, as can postoperative immobilization, since sufficient stability for functional postoperative treatment is achievable. The follow-up control 38 months (range 6-75) after surgery showed solid bony fusion in all cases, in one case after revision surgery. All patients showed good functional results, there was no need for analgesics and all patients could be reintegrated into their former occupation.     

Sakrumfrakturen und lumbopelvine Instabilitäten bei Beckenringverletzungen

Multiplanar posterior pelvic ring instabilities are severe injuries and typically occur in the os ilium, the sacroiliac joint, the sacrum and/or in a combination of these sites. They pose challenges to the orthopedic trauma surgeon during reconstruction, particularly when these injuries are associated with multiplanar sacral fractures and involvement of the lumbosacral junction. Due to the multidirectional forces affecting the pelvic ring, one has to have basic knowledge about the mechanism of injury, its biomechanics, and the various treatment options. In the following we give an overview on injury classifications, biomechanical aspects of the injuries and various types of operative treatments and osteosynthesis techniques.     

Multidirektionale atlantoaxiale Instabilität bei adultem Os odontoideum

Increasing neck pain in a 29 year old woman after a frontal car collision gave reason for a conventional x-ray that presented a traumatically displaced os odontoideum positioned at the top of the dens axis. No neurological defect was seen. Dynamic flexion/extension film showed a movement to an atlantoaxial dislocation with a shift of the os odontoideum. The sclerotic structure of the corresponding bony surfaces was confirmed by computed tomography, whereas magnetic resonance imaging demonstrated a posttraumatic signal change in front of the base of dens axis and os odontoideum.Fusion was achieved by computed navigation with C1/C2 transfacetal screws as described by Magerl and interspinal fusion with a bicortical autologous iliac crest graft and a posterior tension band as described by Brooks. An exact positioning of screws past the asymmetric course of both arteria vertebrales was possible by navigation. The patient was free of pain 5 months after the fusion.     

Instabilitätsarthropathie

Glenohumeral arthritis may develop after primary or recurrent shoulder dislocation or after surgery for stabilization. Postoperatively, the incidence is reported to be from 12% to 62%, depending on different risk factors. There is no certain correlation between the surgical technique and the rate of arthrosis. Capsulorraphy arthropathy is biomechanically and clinically a well defined entity. The risk of developing severe arthrosis of the shoulder following dislocation of the shoulder is between 10 and 20 times greater in comparison to the normal population. Risk factors are the age during the first episode of instability, the age at instability surgery, bony lesions on the humeral head or the glenoid and rotator cuff tears. For mild stages of glenohumeral arthritis, arthroscopic revision with removal of intraarticular metallic parts, arthroscopic debridement or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For more severe stages mobilization of the internal rotation contracture and glenohumeral arthroplasty are indicated. With sufficient integrity of the head and glenoid, a surface replacement is adequate. With intact rotator cuff and without bone graft the results for shoulder arthroplasty are comparable to those following primary omarthrosis. With a bone graft at the glenoidal side the risk for implant loosening is 10 times greater. For the functional outcome the quality of the rotator cuff, i.e. the fatty degeneration, is more predictive than the type of previous surgery or the preoperative external rotation contracture.     

Heparininduzierte Thrombozytopenie Typ II mit Thrombosen bei einem Intensivpatienten

Heparin-induced thrombocytopenia (HIT) type II is a life-threatening complication of heparin therapy. The present case report describes the therapeutic management of HIT type II with thrombosis using the direct thrombin inhibitor argatroban in an intensive care patient after successful surgery of a ruptured infrarenal abdominal aortic aneurysm. Despite high dosing and long-term application of argatroban, anticoagulation remained uncritical and was well controllable by monitoring the activated partial thromboplastin time. In consideration of the pharmacological characteristics, therapy suspension due to invasive interventions and switching to an oral vitamin K antagonist by defined algorithm resulted in an effective management.     

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.     

Bandnaht und/oder Kapsulodese bei skapholunärer Instabilität

We have reviewed 37 patients with scapholunate instability, operated in Paris between 1979 and 1995 7 months after the injury. There were 12 partial and 18 complete ligament ruptures, but also 4 distensions. The repair was a secondary suture in 16 cases (7 direct, 1 transosseous, 1 combined, 5 anchor, 2 transosseous with anchor). A capsulodesis was performed 7 times as an isolated and 8 times as a combined procedure. 6 previous cases have been treated by ligamentoplasty. We present the results after a mean postoperative follow-up of 27 months, with good results on pain and grip, maintaining a satisfactory range of motion.