Gelenkflächenersatz des lateralen Tibiakopfplateaus mittels Patellatransplantation

A case of surgical reconstruction of the lateral tibial plateau after impression fracture (Type 41-B3.1) of an 47-year-old female is presented. Joint reconstruction was performed by using a free patellar graft. The 16-year follow-up shows a very good functional outcome without subjective complaints. This case underlines that performing patellar autografting for surgical reconstruction of severe injury of the tibial plateau seems to be a promising alternative especially considerating young patients in spite of avoiding total knee replacement.     

Aufklappende Osteotomie des Tibiakopfes

Background

Lesions of the popliteal artery during high tibial osteotomy are rare complications, consequently the majority of publications are case related. The interval between surgery and diagnosis is reported to be as long 3 years; therefore, the current literature probably does not reflect the true incidence of vascular injuries.

Objective

The case reports published in the literature were further evaluated. The focus was on the normal vascular anatomy of the popliteal region and anatomical deviations that predispose to vascular injury. As the flexion angle of the knee joint is considered to be decisive for vascular injury, this aspect was also an additional focus. For the unlikely event of a vascular injury, recommendations are presented which indicate diagnostic and therapeutic decisions.

Methods

We analyzed the available literature and present own magnetic resonance imaging (MRI) investigations of the popliteal artery with different angles of flexion in six healthy volunteers.

Results and discussion

A variation of the origin of the anterior tibial artery with a course between the posterior tibial cortex and the popliteal muscle was found in 6?% of all patients and predisposes to an accidental injury during osteotomy. The results in the literature and our own MRI findings suggest that a flexion angle of 90° facilitates anatomical dissection and osteotomy but cannot be regarded as a reliable protection against vascular injury.     

Organerhaltung durch Rekonstruktion des Ductus Wirsungianus bei kompletter Pankreasruptur

Zusammenfassung Traumatische Pankreasläsionen beim stumpfen Bauchtrauma stellen hdufig eine Indikation zur partiellen bis subtotalen Organresektion dar, insbesondere bei Verletzungen des Ductus pancreaticus. Anhand einer Kasuistik eines 9jährigen Jungen mit totaler Pankreasruptur wird ein Verfahren zur Gangrekonstruktion dargestellt, durch das eine vollständige Organerhaltung möglich war.

---

Organ preservation by reconstruction of Wirsung's duct after complete pancreatic rupture

Summary Blunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.

     

Rekonstruktion eines offenen Quadrizepssehnendefekts mit dem erweiterten lateralen Gastrocnemiussehnenlappen

We describe a modified technique to reconstruct a damaged knee extensor mechanism after infected patellar fracture. After resection of infected soft tissue and quadriceps tendon a compound suprapatellar defect existed. Due to compromised tissue on the medial aspect of the calf, we used this flap, which consists of the lateral gastrocnemius muscle with parts of the adjacent Achilles tendon. After a follow-up period of several months the range of movement is 0-0-120°.     

18. Die Rekonstruktion des Oesophagus und Hypopharynx durch das freie Jejunum-Interponat

Zusammenfassung Die primäre Rekonstruktion des Hypopharynx und Oesophagus durch das freie Jejunum-Interponat stellt neben konventionellen Methoden eine zusätzliche Moglichkeit der Passagerekonstruktion dar. Von 48 freien Jejunum-Transfers wurden 32 als Patch zu Mundboden- und 16 Interponate zur Passagerekonstruktion verwendet. In 7 Fällen lag ein Hypopharynx- in 6 Fällen ein Oesophagus-Carcinom vor. 3 Patienten litten unter einer Korrosionsstenose des Oesophagus. 11 Interponate heilten komplikationslos ein. In 2 Fallen kam es zu einer Nekrose des Interponats, bei 3 Patienten wurde eine Fistel im distalen Anastomosenbereich gesehen. Der Vorteil des freien, mikrochirurgisch vascularisierten Jejunum-Interponats liegt in der Bestrahlungstoleranz sowie in der Einseitigkeit des operativen Eingriffs, durch welche eine physiologische Passagerekonstruktion ermöglicht wird.     

Symptomatische Verkalkung des lateralen Kniegelenkkollateralligaments

We describe a case of symptomatic calcification of the lateral collateral knee ligament in a 53-year-old female patient. The calcification became extremely painful and increased in size and it was decided to resect the calcification operatively because of pain progression. After operative resection of the deposits the patient is currently free of complaints and relapse-free after 4.5 years. In the literature four cases of calcification of the medial collateral ligament are described which were also successfully treated by operative resection.     

Die Verletzung des lateralen Kapsel-Band-Apparats des Sprunggelenks

Lateral ligament injuries are the most common sports injury and have a high incidence even in non-sportive activities. Although lateral ligament injuries are very common there is still a controversial debate on the best management. The diagnosis is based on clinical examination and X-ray images help to rule out fractures. Further imaging, especially magnetic resonance imaging (MRI) is used to diagnose associated injuries. According to the recommendations of the various scientific societies the primary therapy of lateral ligament injuries is conservative. Chronic ankle instability develops in 10-20 % of patients and the instability can be a result of sensomotoric deficits or insufficient healing of the lateral ligament complex. If the patient does not respond to an intensive rehabilitation program an operative reconstruction of the lateral ligaments has to be considered. Most of the procedures currently performed are anatomical reconstructions due to better long-term results compared to tenodesis procedures.     

Rekonstruktion des vorderen Kreuzbandes

The treatment of ruptures of the anterior cruciate ligament (ACL) plays an essential role for both clinicians and resident physicians. To date many questions regarding the outcome as well as ACL reconstruction techniques have not yet been conclusively clarified. Whether reconstruction of the ACL protects the knee from osteoarthritis is still unproven; however, it is well known that an unstable knee joint is more vulnerable to secondary injuries, such as meniscal tears. Thus, early ACL reconstruction is recommended to minimize the risk of these secondary injuries. Three alternative sources of material for autologous ACL reconstruction are commonly utilized. An accessory hamstring (i.e. semitendinosus tendon with or without the gracilis tendon), a central strip of the patellar tendon with bone blocks and a central strip of the quadriceps tendon with or without bone block are the most common donor tissues used in autografts. Besides selection of the type of graft, the tendon diameter also plays a crucial role. Some progress has recently been made with respect to tunnel placement. The aim is to find an anatomical tunnel position. Reconstruction of both the anteromedial and the posterolateral ACL bundles helps to rebuild the anatomy of the original ACL; however, scientifically this approach did not lead to any improvement in the results. For fixation techniques a differentiation is made between aperture, extracortical and implant-free fixation. Generally, re-ruptures are less common than revisions as a result of graft ruptures due to technical mistakes during surgery. The most common mistakes concern tunnel placement and graft fixation. Also overlooked instability can have a negative influence on the outcome of ACL reconstruction.     

Rekonstruktion des vorderen Kreuzbandes

Rupture of the anterior cruciate ligament (ACL) is a common acute injury representing a pre-arthrotic deformity whether treated surgically or not. Surgical treatment in actively sportive patients with instability should be prompt. The most frequently used transplantations include hamstring tendons and the middle third patellar tendon. Both transplantats achieve good results, although the hamstring tendons produce less donor site morbidity. The standard surgical technique is the 1-bundle reconstruction with anatomic positioning of the bone tunnel. The femoral tunnel should be placed over the anteromedial portal, to enable a lateral position. Fixation should be close to the joint without damaging the transplant. Hybrid fixation with the hamstring transplant seems to achieve the best primary stability.     

Die Rekonstruktion von langstreckigen Achillessehnendefekten durch einen Transfer des Musculus flexor hallucis longus

Objective

The aim of flexor hallucis longus (FHL) transfer is to bridge long defects of the Achilles tendon. In addition to the substitution of the Achilles tendon by the tendon graft, the flexor hallucis longus muscle changes its function to plantar flexion of the ankle. A part of the muscle belly is placed into the paratendon sheath which supports healing even in patients with critical soft tissue injuries.

Indications

Extended Achilles tendon defects, extended degenerative disease of the Achilles tendon, and reruptures, especially in patients with significant soft tissue injuries.

Contraindications

Ruptures of the Achilles tendon which can be treated by direct reconstruction.

Surgical technique

The patient is placed in a prone position. After a central longitudinal approach to the Achilles tendon and debridement of the diseased tendon material, the deep fascia is split. After identification of the flexor hallucis longus tendon, the tendon is retracted with a plantiflexed hallux and dissected at the entrance point to the tarsal tunnel. The tendon is fixed to the calcaneus via a 6?mm drill hole using an interference screw in the press-fit technique.

Postoperative management

A lower limb orthosis is used for the first 8?weeks: the first 4?weeks plantar flexion of 30° with partial weight bearing of 20?kg, then full weight bearing for 2?weeks with 15° plantar flexion, and another 2?weeks with neutral position of the ankle. After removal of the orthosis, a heel lift of 1.5?cm (e.g., silicon heel cushion) is recommended for 3?months. Running activities are restricted for 6?months.

Results

In a series of 25 consecutive patients (15?men, 10?women) with an average age of 61?years (range 37?C79?years), it was possible in all cases to reconstruct the Achilles tendon function. The AOFAS Hindfoot Score improved from 62 to 89 points. Especially in the category pain, the patients reached 38?of a maximum of 40?points. Compared to the healthy leg, a limitation in maximum strength in plantar flexion was found (42?of a maximum of 50?points).     

Rekonstruktion des hinteren Kreuzbands

The main function of the posterior cruciate ligament (PCL) is stabilization of the tibia against posterior subluxation in flexion of the knee. Isolated PCL deficiency causes increased subluxation of the knee joint in flexion, which can be compensated by the quadriceps muscle. Therefore, patients do not initially suffer from instability. Nevertheless, there is a high incidence of osteoarthritis after 10–20 years due to higher stress in the medial and retropatellar compartments. Osseous avulsion of the PCL from the tibia has a good prognosis when treated by bony fixation. Ruptures of the ligament should not be treated by suture repair. Long-term results do not show a better prognosis after surgery in isolated PCL tears. The authors have developed a special arthroscopic technique for PCL replacement featuring femoral and tibial fixation of the grafts with resorbable cross pins. Osseous abnormalities and posterolateral rotary instability must be addressed in complex chronic instabilities of the knee. Osteotomy is indicated in the presence of a varus morphotype. Reconstruction of the posterolateral capsular ligament complex is recommended if posterolateral instability exists.     

Rekonstruktion des Gesichts bei Verbrennungen

Reconstruction of the face in patients who have suffered major burns is a complex undertaking, both the primary treatment and the transplantation technique being of considerable importance for the final result. As well as the functional reconstruction of scar contracture, ectropion and incomplete lid closure, cicatricial stenostomia and cicatricial obstruction of the nostrils, techniques that are mainly known from aesthetic surgery are now used: hair transplantation, laser resurfacing of scarred skin, and epilation are some examples of such techniques. These additional surgical treatments, which are often used in a late phase after burn injury, can improve the way the patients are accepted and their quality of life. In the setting of our increasingly cost-oriented health system it is important not to lose touch with these aims. These measures, which may in themselves seem to be trivial and therefore unnecessary and to offer potential savings if they are discontinued, should not be withheld from burn patients.     

Langzeitverlauf nach Gallengangverletzung durch laparoskopische Cholecystektomie und Rekonstruktion durch ein Jejunuminterponat

Im Krankheitsverlauf von Patienten mit schweren Gallengangverletzungen im Rahmen einer laparoskopischen Cholecystektomie werden oft sekund?re Komplikationen beobachtet. Berichtet wird über eine Patientin mit langem Krankheitsverlauf nach intraoperativer Gallengangverletzung und anschlie?ender Rekonstruktion durch End-zu-End-Anastomose über einer T-Drainage. Mehr als 5 Jahre nach wiederholten endoskopischen Gallenwegdilatationen und mehrfachen Einlagen von Stents wurde zuletzt ein selbstexpandierender Metallgitterstent eingesetzt. Die Symptomatik mit rezidivierenden Cholestasen und Cholangitiden wurde nicht beherrscht. Bei der erneuten Operation wurde jetzt der stenttragende D. choledochus reseziert, die Gallenwegrekonstruktion erfolgte durch ein isoperistaltisches Jejunuminterponat. Mehr als 24 Monate sp?ter ist die Patientin beschwerdefrei und arbeitet wieder.     

Langzeitverlauf nach Gallengangverletzung durch laparoskopische Cholecystektomie und Rekonstruktion durch ein Jejunuminterponat

Zusammenfassung. Im Krankheitsverlauf von Patienten mit schweren Gallengangverletzungen im Rahmen einer laparoskopischen Cholecystektomie werden oft sekund?re Komplikationen beobachtet. Berichtet wird über eine Patientin mit langem Krankheitsverlauf nach intraoperativer Gallengangverletzung und anschlie?ender Rekonstruktion durch End-zu-End-Anastomose über einer T-Drainage. Mehr als 5 Jahre nach wiederholten endoskopischen Gallenwegdilatationen und mehrfachen Einlagen von Stents wurde zuletzt ein selbstexpandierender Metallgitterstent eingesetzt. Die Symptomatik mit rezidivierenden Cholestasen und Cholangitiden wurde nicht beherrscht. Bei der erneuten Operation wurde jetzt der stenttragende D. choledochus reseziert, die Gallenwegrekonstruktion erfolgte durch ein isoperistaltisches Jejunuminterponat. Mehr als 24 Monate sp?ter ist die Patientin beschwerdefrei und arbeitet wieder.      

Frakturen der lateralen Klavikula und des Akromions

Fractures of the lateral clavicle and the acromion are uncommon and represent a separate entity. Fractures of the lateral clavicle demonstrate a high rate of problems, such as non-union, malunion and functional impairment when treated nonoperatively. The aim of any treatment option is full restoration of shoulder function by achieving fracture healing without significant malpositioning. Unstable fracture patterns have to be identified and should be fixed using an appropriate technique, which include plating, K-wire fixation and arthroscopic techniques which bring the dislocated fragments into contact. Dislocated fractures of the acromion can usually be treated by plating.     

Die Fraktur der Gegenkortikalis bei der aufklappenden Osteotomie des Tibiakopfes

Background

Open wedge high tibial osteotomy (HTO) is an increasingly more common surgical method. A typical problem of this procedure is fracture of the lateral hinge.

Objectives

The aims of this article are to present the special issue of fractures of the lateral hinge after HTO and to discuss surgical hints on how to prevent and treat this problem.

Methods

The results of recently published clinical studies are summarized and tips from own clinical experiences are given.

Results

Type II fractures of the lateral hinge are unstable and can create a major problem. Using short spacer plates results in a problem of stability for all types of fractures.

Conclusion

The classification into Takeuchi grades I-III has been proven to be suitable for fractures of the lateral hinge. The TomoFix? plate is a safe implant to stabilize the osteotomy in type I and III fractures with which healing can be achieved with no problems. Type II fractures can be stabilized with the TomoFix? plate; however, an autologous bone graft has to be taken into consideration. For fractures of the lateral hinge short spacer plates are not recommended due to stability issues.     

Die Rekonstruktion des Oesophagus mit Kunststoffen

Zusammenfassung Das Einheilen von alloplastischen Prothesen in Oesophagusdefekte ist nicht möglich. Um die Prothese herum kommt es innerhalb weniger Tage zur Ausbildung eines Prothesenbettes aus Granulationsgewebe. Eine Passage durch die Prothese hindurch ist aber nur für einen limitierten Zeitraum möglich.Hauptursache für das Nichteinheilen der Kunststoffe ist die unvermeidbare Infektion. Dadurch bedingt ist eine Unterbrechung der natürlichen Heilvorgänge. Es erfolgt keine Epithelisierung trotz guter Regenerationstendenz des Oesophagusepithels. Stattdessen verursachen die Kunststoffprothesen selbst Spätkomplikationen (Perforationen und Stenosen), die immer fatal enden.In weiteren Versuchen wurden deshalb Kunststoffe nurmehr eingefügt, um für die natürlich ablaufenden Heilvorgänge temporär eine Leitschiene zu bilden.