Osteosynthesen hüftgelenknaher Frakturen

With increasing numbers of primary anterior cruciate ligament (ACL) reconstructions the number of patients who need revision ACL reconstruction is likely to increase as well. Revision surgery after ACL reconstruction is challenging and requires a thorough workup before considering revision surgery. As scientific data are sparse the approach to these patients has to be orientated mainly toward clinical decision criteria. First, ACL-dependent causes have to be differentiated from ACL-independent causes of failure. If ACL-independent pathologies have been ruled out a re-rupture of the transplant has to be differentiated from transplant insufficiency. The patient history as well as a thorough physical examination will give decisive hints about a traumatic re-rupture or a recurrent instability, which generally needs further evaluation using imaging techniques. The purpose if this article is to review the diagnostic process as well as therapeutic considerations and to summarise the author’s treatment algorithm when approaching recurrent pain and instability in failed ACL reconstruction.     

Behandlungsstandards bei osteoporotischer hüftgelenknaher Fraktur

Background

Due to demographic changes fractures in elderly patients with osteoporosis are becoming increasingly more important. The demands placed on an adequate therapy are high due to the disrupted bone metabolism.

Causes and localization

In most cases the weakened osteoporotic bone breaks in situations involving minor trauma but the increased risk of falling and the not uncommon presence of muscular atrophy in the elderly also play an important role. Typical localizations of such bone breaks are the spine, the lower arm near the wrist, the upper arm near the shoulder and most commonly the upper femur near the hip joint.

Therapy

An operative approach is almost always indicated and should be carried out within 24 h in patients with no serious contraindications, as an extended preoperative time interval has many disadvantages with an increased morbidity and mortality. The aim of treatment is to establish a load stable osteosynthesis which allows a functional follow-up treatment with rapid mobilization of patients. Among the many procedures which could be suitable for treatment of osteoporotic proximal femoral fractures, the biomechanical superiority of dynamic implants has been proven. Early mobilization and intensive physiotherapy are the core issues in follow-up treatment. Despite optimal treatment complications can still occur.     

Das Manteltransplantat zur Defektrekonstruktion nach Resektion maligner Knochentumoren an der unteren Extremität

We treated 11 patients with primary sarcoma and 1 patient with enchondroma of the femur or tibia. Bridging the osseus defect we used an intercalary allograft shell and contralateral fibula as described by Capanna et al. [7]. The median bone defect after resection of the tumor was 15.7 (9.0-28.5) cm, average follow up was 29.2 (13-56) month. Anastomosis of the autologous fibula was successful in 8 cases. There were 3 cases necessitating later amputation. The other cases showed good clinical (Enneking-score) and radiological (ISOLS-score) results. These results indicate the described technique as a suitable method for defect reconstruction with good functional outcome.     

Beckenteilresektion (innere Hemipelvektomie) und endoprothetischer Ersatz bei hüftgelenksnahen Tumoren

Objective

Treatment of tumors of the pelvic girdle by resection of part or all of the innominate bone with preservation of the extremity. Implantation and stable fixation using a custom-made megaprosthesis to restore painless joint function and loading capacity. The surgical goal is to obtain a wide surgical margin and local tumor control.

Indications

Primary bone and soft tissue sarcomas, benign or semi-malignant aggressive lesions, metastatic disease (radiation resistance and/or good prognosis).

Contraindications

Limited life expectancy and poor physical status, extensive metastatic disease, persistent deep infection or recalcitrant osteomyelitis, poor therapeutic compliance, local recurrence following a previous limb-sparing resection, extensive infiltration of the neurovascular structures and the intra- and extrapelvic soft tissues.

Surgical technique

Levels of osteotomy are defined preoperatively by a CT-controlled manufactured three-dimensional 1:1 model of the pelvis. Using these data, the custom-made prosthesis and osteotomy templates are then constructed by the manufacturer. The anterior (internal, retroperitoneal) and posterior (extrapelvic, retrogluteal) aspects of the pelvis are exposed using the utilitarian incision surgical approach. The external iliac and femoral vessels are mobilized as they cross the superior pubic ramus. The adductor muscles, the rectus femoris and sartorius muscle are released from their insertions on the pelvis and the obturator vessels and nerve are transected. If the tumor extends to the hip joint, the femur is transected at a level distal to the intertrochanteric line to ensure hip joint integrity and to prevent tumor contamination. A large myocutaneous flap with the gluteus maximus muscle is retracted posteriorly. The pelvitrochanteric and small gluteal muscles are divided near their insertion in the upper border of the femur. To release the hamstrings and the attachment of the sacrotuberous ligament, the ischial tuberosity is exposed. After osteotomy using the prefabricated templates, the pelvis is released and the specimen is removed en bloc. The custom made prosthesis can either be fixed to the remaining iliac bone or to the massa lateralis of the sacrum. The released muscles are refixated on the remaining bone or the implant.

Postoperative management

Time of mobilization and degree of weight-bearing depends on the extent of muscle resection. Usually partial loading of the operated limb with 10?kg for a period of 6?C12?weeks, then increased loading with 10?kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination, and radiographic studies.

Results

Between 1994 and 2008, 38?consecutive patients with periacetabular tumors were treated by resection and reconstruction with a custom-made pelvic megaprosthesis. The overall survival of the patients was 58% at 5?years and 30% at 10?years. One or more operative revisions were performed in 52.6% of the patients. The rate of local recurrence was 15.8%. Deep infection (21%) was the most common reason for revision. In two of these cases (5.3%), a secondary external hemipelvectomy had to be performed. There were four cases of aseptic loosening (10.5%) in which the prosthesis had to be revised. Six patients had recurrent hip dislocation (15.8%). In four of them a modification of the inserted inlay and an implantation of a trevira tube had to be performed respectively. Peroneal palsy occurred in 6?patients (15.8%) with recovery in only two. There were 4?operative interventions because of postoperative bleeding (10.5%). The mean MSTS score for 12 of the 18?living patients was 43.7%. In particular, gait was classified as poor and almost all patients were reliant on walking aids. However, most patients showed good emotional acceptance.     

Modulare Defektrekonstruktion beim Pfannenwechsel mit Abstützschale und metallischen Augmenten

Objective

Restore primary center of rotation and reconstruct extensive bone defects in hip revision surgery with a modular off-label implant combined with antiprotrusion cage and metal augment, thus, achieving improved hip function.

Indications

Large segmental acetabular defects with nonsupportive columns (Paprosky type 3a and 3b) in cup loosening or Girdlestone situation. In case of pelvic discontinuity posterior column-plating is possible.

Contraindications

Persisting hip infection and severe systemic disorders impairing achievement of secondary stability through bony integration of metal augment.

Surgical technique

Posterolateral (if dorsal column plating) or other approach. Remove loose implant and granulation tissue with sufficient exposure of bleeding bone. Size acetabular defect with trial components of augment and appropriate antiprotrusio cage. Fixation of selected metal augment with screws. Fill additional acetabular defects with morsellized bone graft. Open a slot into the ischium to fix the distal flange of the cage. If necessary, bend both flanges according to patient’s anatomy. Enter the ischium with distal flange and gradual impaction of the antiprotrusio ring. Final stabilization of the ring with several screws aiming at the posterior column or the acetabular dome. Inject cement between ring and augment to stabilize the construction and avoid metal wear. Final cement fixation of a polyethylene liner or a dual-mobility cup into the antiprotrusio ring. In pelvic discontinuity with major instability osteosynthesis of the dorsal column can be performed prior to cementation.

Postoperative management

Prophylaxis of periprosthetic infection, DVT and heterotopic ossification. Physical therapy with partial weight bearing (20 kp) for 6 weeks; in discontinuity initial wheel chair mobilization.

Results

Since 2008, 72 off-label implantations of a combined antiprotrusio cage and a Trabecular Metal? Augment were performed. A total of 44 patients (46 operations) were investigated at 38.8 (36–51) months postoperatively. In all, 36 patients had a bone defect according to Paprosky type 3a/b and in 3/4 patients with pelvic discontinuity additional osteosynthesis was performed. The WOMAC score increased from 39.8 (8.7–75) points preoperatively to 57.9 (16.7–97.9) points at follow-up. Migration or failure of implant components was not observed. In 11?% of dislocations and 11?% periprosthetic infections surgical revision was necessary.     

Die geriatrische Frührehabilitation nach hüftgelenknahem Oberschenkelbruch

Background

Modern strategies for postoperative care of patients with hip fractures include early discharge from the acute care hospital to inpatient interdisciplinary rehabilitation facilities. Whether these programs are effective for the patients and improve their long-term outcomes or if they simply transfer costs, with a reduction of the inpatient days in the acute care hospital, is currently under discussion.

Patients and methods

This prospective study included 282 patients with hip fracture admitted to our trauma center were included into the prospective study. The mean patient age was 86±8 (65–110) years. All patients were treated operatively. After a mean of 12±9 days, the patients underwent inpatient interdisciplinary geriatric rehabilitation for a mean of 27±13 (4–103) days. The primary outcome measure was their activities of daily living (Barthel index) before, at the end of rehabilitation, and 1 year after trauma. In addition, patient-related variables were correlated with the Barthel index.

Results

With discharge from the acute care hospital, the Barthel index was 42±20 points and it increased during rehabilitation to 65±26 points. One year later the Barthel index was 67±28 points. Ninety percent of patients improved their Barthel index during rehabilitation. Within 1 year, 40% of patients deteriorated in their activities of daily living. Fifty one percent of patients were reintegrated back to their homes. Patients who lived at home before trauma and were reintegrated back to their homes had a significant higher Barthel index (75±24) 1 year after trauma than patients who were living in a nursing care facility before the trauma (Barthel index 52±27). The variables of age, level of cognition, and type of fracture had no influence on the long-term outcome. An extension of rehabilitation above the mean time period did not improve the sustainable clinical outcome.

Conclusion

Postoperative inpatient rehabilitation programs enhance short-term activities of daily living. In particular, patients who lived at home before the trauma and were reintegrated back home benefited in perpetuity from geriatric rehabilitation. A policy for early discharge to geriatric rehabilitation is associated with extension of overall hospital stay. This association along with the related increased health care costs should be weighed against the sociofunctional effectiveness of these programs.     

Komplikationsmanagement nach ästhetisch-plastisch chirurgischer Operation im Ausland

We report about a 37-year-old female patient who presented to our department with hypertrophic, painful and unaesthetic scars after abdominoplasty and mastopexy operations abroad. Extremely low prices for aesthetic operations abroad motivate patients to be operated on by, in some cases, uncertified plastic surgeons. These operations are linked to the risk of being operated on again in their native country and having to partly bear the costs of the reoperation due to legal regulations. A well-founded physician-patient relationship and state of the art surgical standards are based on an ensured qualified aftercare for as long as necessary and a trustful relationship.     

Beckenfrakturen und hüftgelenknahe Verletzungen

Trauma und Berufskrankheit - Aufgrund der gesetzlichen Begriffskriterien ist die Bemessung der Minderung der Erwerbsfähigkeit (MdE) mit den Entwicklungen auf dem allgemeinen Arbeitsmarkt und...     

Stimm- und Sprachübungen nach Kehlkopfausrottung

Ohne Zusammenfassung     

Zur Resektion beim perforierten Magen- und Zwölffingerdarmgeschwür

Zusammenfassung Wir halten uns auf Grund unserer Erfahrungen für berechtigt, auch im Zustande der Perforation in den geeigneten F?llen die Eesektion auszuführen, die bei der operativen Behandlung des Magen- und Zw?lffingerdarmgeschwürs wohl allein eine Radikaloperation darstellt und angestrebt werden mu\.     

Krüppelfürsorge und krüppelanstalten nach ihrem

Ohne Zusammenfassung     

Über Beugekontrakturen nach Resektion kindlicher Kniegelenke

Ohne Zusammenfassung     

Ergebnisse der Resektion zur Ausschaltung nach Finsterer aus klinischer und röntgenologischer Sicht

Zusammenfassung Bericht über die Besonderheiten der hier geübten Operationstechnik bei der Resektion zur Ausschaltung nachFinsterer. Auf Grund der guten Früh-und Spätergebnisse (klinische und röntgenologische Nachuntersuchung von 30 Patienten) wird die R.z.A. bei strenger Indikationsstellung für eine wertvolle Operationsmethode gehalten.Mit 3 Textabbildungen