Sekundäre posttraumatische Schulterendoprothetik

Trauma und Berufskrankheit - Skapulafrakturen sind seltene Bruchverletzungen, welche sich prinzipiell in extra- und intraartikuläre Formen unterteilen lassen. Sie können selbst bei...     

Primäre posttraumatische Radiuskopfprothetik

Radial head fractures are common injuries in elbow trauma. Non-displaced fractures are best treated conservatively. Simple but displaced fractures require anatomic reduction and fixation, typically using screws. The treatment course for complex fractures with multiple fragments is still being debated, as results are less predictable. Radial head resection is not advised if concomitant injuries of the coronoid process or the collateral ligaments with instability are present. Favorable outcomes following open reduction and fixation using plates were reported recently. However, complication rates are very high. Radial head replacement is a valuable tool in treating complex fractures of the radial head with predominantly good and excellent results. Patients who suffer radial head fractures are typically of a younger age, resulting in high functional demands. Certainly, unspecific and specific complications related to radial head arthroplasty were reported in up to 40?% of cases in an acute fracture setting. This article highlights common complications in radial head arthroplasty and aims to present strategies to avoid them.     

Sekundäre Kieferspaltosteoplastik

Secondary cleft osteoplasty as part of the treatment of patients with cleft lip, jaw and palate is performed between the ages of 6 and 12 years to reconstruct the bony defect in the alveolar ridge area. Graft material is usually obtained from the iliac crest, followed by reconstruction of the nasal floor, osseous augmentation, and wound closure. This procedure serves physiological eruption of cleft-adjacent teeth during orthodontic treatment and, amongst numerous others benefits stabilizes the upper jaw segments.     

Primäre Schulterendoprothetik nach Trauma

Indications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.     

Sekundäre Bandrekonstruktion am Ellenbogen

Chronic ligamentous elbow instabilities are posttraumatic in most cases, can lead to severe functional limitations, and are a risk factor for the development of an elbow joint arthrosis. Successful treatment requires an accurate knowledge of the pathogenesis, the necessary diagnostic options and the different reconstruction procedures. According to the direction of instability, chronic posterolateral rotatory instability, lateral, medial and combined multidirectional instabilities can be distinguished. Lateral and medial collateral ligament reconstruction using autologous or allogenic tendon grafts result mainly in good clinical outcomes. However, specific complications such as recurrent instability or ulnar neuropathy are not uncommon. In cases of bilateral ligamentous instability the box-loop technique allows to reconstruct both the lateral and medial collateral ligaments using a single tendon graft circumferentially looped through the humerus and ulna. If sufficient residual ligamentous tissue is still present, a direct augmented repair of the collateral ligaments may be performed even in chronic cases. Elbow joint arthrosis is the main limiting factor for good clinical results and therefore a relative contraindication for collateral ligament reconstruction in chronic cases.     

Sekundäre Hormonablation beim hormonunabhängigen Prostatakarzinom

After an average of 18–24 months under androgen suppression therapy, almost all patients with prostate cancer show a PSA progress. At this hormone-independent stage, a PSA regress can be achieved by secondary hormonal manipulation in approximately 50% of patients for 6–12 months before they become hormone-refractory. After progress under complete androgen ablation, in 40% of cases a temporary regress can be achieved by discontinuing of the anti-androgen. The administration of an alternative anti-androgen results in a PSA decrease in 80% of the patients responding to anti-androgen deprivation. Inhibition of the adrenal testosterone synthesis by oral administration of ketoconazol can further delay disease progression. Transdermal application of estrogens also allows temporary control of tumor activity by modulating the LHRH and testosterone release as well as directly effecting tumor cell apoptosis. Recent therapeutic modalities as for example somatostatin analogues influence the microenvironment of tumor cells and thereby intensify the effect of anti-tumor therapy.     

Sekundäre anatomische Rekonstruktion fehlverheilter zentraler Talusfrakturen

Background

Malunion or nonunion of central talar fractures lead to significant impairment, pain and decreased motion of the foot and ankle. In a 20-year period from 1994 to 2013 at the Trauma Department of the University Hospital“Carl Gustav Carus” of the Technical University of Dresden we treated a total of 25 patients with secondary anatomical reconstruction of the talus.

Method

The mean age of the patients was 39.9 years (range 15-71 years) and only 4 out of the 25 patients were female. Of these patients 11 patients were treated conservatively, 3 minimally invasive with external fixation and were admitted on average 7.6 months (range 1.5-42 months) after the initial fracture. Of the patients 11 had previously been treated in another hospital by open surgery on average 8.4 months (range1–24 months) months before. There were 9 malunions or nonunions of talar fractures of the shaft, 14 of the neck and 2 of the head. Only 3 cases were old fractures ≥ 6 weeks and 22 were malunions or nonunions ≥ 3 months. According to an in-house classification 12 malunions (type I), 5 nonunions (type II), and 8 malunions/nonunions with partial necrosis (type III) were treated.

Results

Of the patients 21 out of 25 needed a bilateral approach and 6 additionally an osteotomy of the medial malleolus.The mean follow-up of 22 out of 25 patients was 5.4 years (range1.0-21.5 years). The preoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score increased on average from 36.6 to 86.7 points (p<0.001) at the time of follow-up.     

Sekundäre Rhinoplastik bei Patienten mit Lippen-Kiefer-Gaumen-Spalte

The secondary correction of cleft lip nose deformity as an ongoing stigma is an important part of surgical rehabilitation for affected patients. It also includes functional improvements. Numerous reports on surgical techniques can be found in the literature. However, the results published worldwide often show that optimal results have not been achieved in all cases. Rhinoplasty on cleft lip and palate (CLP) patients requires extensive rhinosurgical knowledge. There is no universal, generally accepted method that would be applicable to all cleft-related nasal anomalies. Each patient has individual nasal features, and there is remarkable variability of the expression of cleft nose deformity. It is therefore necessary to plan each patient’s treatment separately and to select and apply the available range of rhinosurgical techniques concretely for the individual case. By means of the surgical methods available today, esthetically pleasing results can be achieved. Nevertheless, complete elimination of all cleft-related malformations of the nose is not always possible. Pre-existing scars and skeletal anomalies of the facial skull sometimes require compromises. However, this must not be a reason to be satisfied with moderate results. The best possible functional and esthetic result enables patients with a CLP good quality of life and should be the goal of any surgical rehabilitation.     

Sekundäre Endoprothetik des Ellenbogengelenks nach distaler Humerusfraktur

Good short-term results have been reported for primary total elbow arthroplasty (TEA) but implant longevity is limited. Therefore, primary TEA should be reserved in particular for older patients with severe comminuted distal humeral fractures in whom successful osteosynthesis is often impossible. Angular locking compression plates afford stable fracture fixation even for a severe intra-articular fracture pattern. To date primary TEA for treatment of severe distal humeral fractures is rarely used. Secondary TEA is used in failed osteosynthesis of distal humeral fractures and in unstable post-traumatic elbow joints with osteoarthrosis. Additionally, secondary TEA has become more popular in younger patients for immediate pain reduction and functional improvement. However, weight bearing is limited to 5 kg, racket sports are prohibited and good patient compliance is mandatory. Long-term results of TEA are poorer for trauma patients than those with rheumatoid arthritis.     

Sekundäre Rekonstruktion des digitalen A2-Ringbands

Objective

Secondary reconstruction of A2 flexor pulley for after closed rupture.

Indications

Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints.

Contraindications

Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints.

Surgical technique

A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost.

Postoperative management

Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months.

Results

Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97?%, the average power grip strength 96?%, the finger pinch strength 100?%, and the average circumference 95?% of the uninjured contralateral side. The Buck–Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.     

Sekundäre Individualprävention von Rückenschmerzen bei Pflegepersonal

Background

To prevent occupational disability due to low back pain, nursing staff is offered a secondary prevention activity by the statutory accident insurance.

Objectives

The efficacy regarding the development of back pain was examined and risk factors for the development of adverse back pain were identified.

Materials and methods

In this retrospective cohort study, persons who participated in secondary prevention activities from 2009–2011 were interviewed in 2012.

Results

Of the 1282 participants (response rate: 80?%), pain scores were statistically reduced for both the overall group and for subgroups. For employees of nursing homes and persons who did not participate in the refresher course, increased odds ratios for adverse pain development were observed (OR?=?1.9, 1.4, respectively).

Conclusion

In the framework of the study design, the multimodal concept of the back school shows significant efficacy in the context of back pain reduction. For nursing home employees, the training seems to be less effective than for hospital nurses.     

Inverse Schulterendoprothetik bei Frakturfolgezuständen

Posttraumatic fracture sequelae of the proximal humerus represent an extremely heterogeneous pathology. In severe cases they are often associated with marked soft tissue scarring, osseous defects and insufficiency of the rotator cuff, resulting in a static instability of the humeral head. The aim of this article is to demonstrate the possibilities and early results of reverse shoulder arthroplasty for the operative management of this complex injury pattern.     

Sekundäre Wiederherstellung von Nervenverletzungen und motorischer Ersatz an der oberen Extremität

Trauma und Berufskrankheit - Verletzungen von großen Nerven an der oberen Extremität können langfristige Einschränkungen für den Patienten bis hin zum Wechsel des Berufs...     

Schulterendoprothetik bei posttraumatischen Deformitäten durch Frakturfolgen

The sequelae of fractures of the proximal humerus can be of considerable clinical significance. Careful classification of the sequelae allows precise determination of whether correction osteotomy, reconstruction, or implantation of one of the various prostheses available is indicated. The integrity of the greater tuberosity, its position and continuous osseous integration to the metaphysis of the proximal humerus is the most important predictive factor for a good outcome following implantation of an anatomical shoulder prosthesis. When there is some incongruence of the glenohumeral joint while the greater tuberosity remains intact, shoulder arthroplasty can give a better clinical outcome than is seen after arthroplasty for a primary fracture. In the case of nonunion of subcapital fractures the results achieved by reconstruction, i.e. bone grafting and internal fixation using plates with fixed-angle blades, are superior to those possible with an anatomical prosthesis. Reverse shoulder arthroplasty gives better results than anatomical prostheses in the treatment of severe tuberosity malunion. The results of reverse shoulder arthroplasty for the sequelae of fractures are also influenced by the integrity of or damage to the soft tissues, the muscles of the rotator cuff (teres minor muscle), and bone. Secondary interventions for the sequelae of fractures of the proximal humerus are complex and involve high rates of complications and revisions.     

Sekundärprophylaxe symptomatischer Karotisstenosen

The SPACE trial compared risk and effectiveness of stent-protected angioplasty (CAS) versus carotid endarterectomy (CEA) in patients with symptomatic stenoses. In the intention-to-treat analysis of the entire study population of 1,214 patients, primary endpoint events (ipsilateral stroke or death occurring between randomization and day 30) occurred in 6.92% of the CAS group and 6.45% of the CEA group. The 95% confidence interval (CI) of the absolute risk difference ranged from –1.94% to +2.87%; therefore, superiority could not be proven. The same was true for the per-protocol analysis. No significant differences between the two treatment groups were found either for the primary endpoint or for any of the secondary endpoints. There were also no differences found regarding short-term prevention. The endpoint of ipsilateral ischemic stroke up to 1 year plus any periprocedural stroke or death occurred in 8.7% of the CAS patients and 7.6% of the CEA patients [odds ratio (OR) 1.16; 95% CI 0.76–1.75]. Following the per-protocol analysis, this endpoint occurred in 8.7% of the CAS patients compared with 6.7% of the CEA patients (OR 1.32; 95% CI 0.85–2.05). Recurrent stenoses, defined as at least 70% following ultrasound criteria, were significantly more common in the CAS group (ITT data: 7.7% vs. 4.1%; OR 1.98; 95%CI 1.19–3.28). Surgery remains the gold standard for treating patients with symptomatic carotid artery stenosis. However, in the hands of an experienced practitioner with a proven low periprocedural complication rate, stenting is an alternative treatment option.