Spondyloepiphysäre und metaphysäre Dysplasie

Spondyloepiphyseal, metaphyseal and spondylometaphyseal dysplasias are a group of hereditary skeletal diseases, which lead to small stature, axial deformities of the lower extremities and spinal deformities. They differ in pathophysiology, heredity and in their clinical and radiologic appearance. The orthopaedic surgeon treats the spinal manifestations and the axial malalignment of the disease. Among the spinal deformities there are instabilities of the upper cervical spine as well as structural deformities like kyphosis and scoliosis. More frequently, the axial malalignment caused by congenital coxa vara, severe genu varum or genu valgum requires treatment. These deformities are managed by corrective osteotomies of the proximal femur, supracondylar or proximal tibial osteotomies around the knee and by temporary epiphyseodeses. Despite a high recurrence rate requiring repeated surgery the patients report great satisfaction with the treatment results. Well-timed orthopaedic treatment helps avoid or delay the inevitable long-term sequelae of untreated patients such as painful degenerative changes of the spine or early onset of severe osteoarthritis.     

Der renovaskuläre Hypertonus

Arterial hypertension is a major cause of cardiovascular disease, yet it is still underdiagnosed and treated. Although lifelong medical treatment is needed in the case of essential hypertension, the diagnosis of secondary hypertension provides a chance for definitive cure. Thus, differentiation between primary and secondary hypertension is a major medical issue. Approximately 10% of all patients with arterial hypertension suffer from a secondary form, of which about half the cases are of renal origin. Renovascular hypertension is defined as hypertension caused by reduced perfusion of one or both kidneys due to a stenosis in the renal arteries. The latter should be distinguished from renoparenchymatous hypertension, which is caused by a disease of the renal parenchyma and can be either inborn or acquired, affecting one or both kidneys. Therapeutic measures are chosen after considering the cause of the hypertension, the organ status, any comorbidities, and the patient’s overall status. Thus, reduction of risk factors (such as smoking and metabolic abnormalities), medical antihypertensive treatment, and interventional strategies have to be considered.     

Der interdisziplinäre Hybridoperationssaal

Since June 2013 a hybrid operation theatre is used interdisciplinary in the department for surgery of Ulm University. In this operation theatre a floor-based flat panel c-arm, which is mounted on a robotic arm that can be controlled by the surgeon in a sterile environment, is linked to the operating table. Furthermore for the first time it was possible to integrate a navigation system in this setting. The interdisciplinary utilization (trauma, neurosurgery, cardiac and vascular surgery) makes this hybrid operation theatre very time and cost effective. In the orthopedic trauma department this system is mainly used for traumatic and oncologic pelvic and spinal injuries. In these anatomical regions the excellent image quality and large field of view of the robotic flat panel detector based 3D imaging combined with an intraoperative navigation system is a huge advantage. The system can also be used for complex fractures of the extremities. In the future there will be an integration of further imaging modalities and referenced holding devices in this setting.     

Der primäre traumatische Pneumocephalus

Zusammenfassung Bei 1400 Schädelbrüchen fanden wir in einer Häufigkeit von 1,5% einen primären Pneumocephalus. Die Luftfüllung erfolgte zu gleichen Teilen durch Verletzungen der Nasennebenhöhlen und des Felsenbeins und breitete sich vornehmlich im Subarachnoidalraum aus. Bisweilen kam es zur Ventrikelluftfüllung, häufiger zur Darstellung der Falx cerebri. Die Luftfüllung verschwand ebenso wie der selten dabei beobachtete Liquorfluß innerhalb von wenigen Tagen, so daß beim primären traumatischen Pneumocephalus eine Operation nicht angezeigt ist. Die Mortalität ist etwas höher als allgemein bei den Schädelbrüchen, sie liegt jedoch unter der Mortalität der gedeckten Schädel-Hirnverletzungen und ist wesentlich geringer als beim sekundären Pneumocephalus.Die neurologischen Ausfälle bei den über einen langen Zeitraum beobachteten Patienten lassen ebenso wie die erschwerte Wiedereingliederung im Beruf häufig auf ein erhebliches Schädel-Hirntrauma beim Vorliegen eines primären Pneumocephalus schließen.Mit 6 Textabbildungen     

Der angeborene muskuläre Schiefhals

Ohne Zusammenfassung (Mit 20 Abbildungen im Text.)     

Sonographische Diagnostik von metaphysären Wulstbrüchen

Background

Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure involves X-rays of the forearm and wrist. As former studies have shown that these fractures can be visualized using ultrasound, we compared the accuracy of sonographic and X-ray diagnostics.

Methods

From January 2007 to May 2008, a total of 93 patients aged between 0 and 12 years with forearm trauma were initially examined using a 7.5-Mhz linear transducer. After diagnosis, axis deviation and treatment were fixed and standard X-rays were taken. The results of the two diagnostic procedures were compared. The examiners were doctors in training or consultants and underwent no specific training.

Results

We found 77 fractures in 64 patients (50 radius, 1 ulna, 13 radius and ulna). The sensitivity of ultrasound diagnostics was 94% and the specificity 99% compared with X-ray diagnosis. Mean axis deviation differences were 1.8° (radius) and 0.7° (ulna).

Conclusion

Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis. Patients with inconclusive findings should undergo X-ray diagnosis.     

Nagelung metaphysärer Frakturen

Nailing of metaphyseal fractures demands thorough preoperative planning. The trauma surgeon has to take the specific morphology of the fracture, the individual anatomy of the broken bone, and the design and characteristics of the selected implant into consideration. The fracture has to be precisely reduced and the reduction controlled during nail insertion. The reduction technique and reduction aids must be chosen preoperatively. The nail has to be introduced with care and brought to its correct and ideal position. Only after successful proximal and distal interlocking can the nail become the central weight bearing implant, which holds the fracture stable and reduced. In the following contribution, the specific problems of reduction and nail fixation of metaphyseal fractures of the proximal humerus, proximal and distal femur, and proximal and distal tibia together with the needed reduction and fixation aids are presented.     

Der muskuläre Schiefhals und seine Behandlungserfolge

Ohne ZusammenfassungMit 2 Textabbildungen (4 Einzelbilder)An Hand der Bearbeitung von Fällen aus der Orthopädischen Universitätsklinik (Hüfferstiftung) Münster (Direktor: Prof. Dr. O. Hepp).     

Der primäre Verschluß von Gaumenspalten

Ohne Zusammenfassung Mit 5 Textabbildungen     

Frühfunktionelle Ergebnisse einer Kurzschaftprothese des Hüftgelenks mit metaphysär-intertrochantärer Verankerung

Total hip arthroplasty has become one of the most successful standard procedures in orthopedic surgery. With a more frequent use in young and active patients bone saving procedures become more important. The goal is to save good bone stock for the revision procedure. One example of conservative femoral implants is the Mayo-stem with reported long term results. The stem design allows a metaphyseal intertrochanteric multipoint fixation for primary fixation. The surgical technique is simple. Using a transgluteal approach, the medial preparation of the femoral neck decreases significantly the irritation of the abductor tendons. In a prospective-randomized study, the early functional results with the Mayo-stem were significantly better than the results achieved with a cement-free standard stem. The Mayo-stem may not be indicated for every hip situation. Its use, however, in cases with normal anatomy contributes to save autologeous bone. Therefore, this short stem is a sensible alternative to standard stems.     

Primäre und früh-sekundäre Endoprothetik nach Brüchen des Hüftgelenks

Trauma und Berufskrankheit - Die Endoprothetik nach Acetabulumfrakturen stellt eine alternative Therapieoption zur Osteosynthese dar. Sowohl beim älteren als auch beim jungen Menschen ist es...     

Primäre und früh-sekundäre Endoprothetik nach Brüchen des Hüftgelenks

Endoprosthesis after acetabular fractures represents an alternative therapy option to osteosynthesis. In both elderly and young people it is essential to exactly define the indications for both procedures and to demarcate them from each other.     

Endovaskuläre Kühlung oder Oberflächenkühlung?

Introduction

Time course, time necessary to achieve the target temperature and stable maintenance, as well as a controlled rewarming period are important factors influencing the outcome of patients after successful cardiopulmonary resuscitation.

Methods

After successful cardiopulmonary resuscitation a total of 49 patients were cooled via an endovascular or external cooling device to a target temperature of 33°C. Relevant cooling parameters, such as time between admission and initiation of cooling, achievement of target temperature and stable maintenance of cooling therapy, were compared between both groups.

Results

In the endovascular cooling group the target temperature was reached significantly faster (154±97 min vs. 268±95 min, p=0.0002) and showed stable and controlled maintenance of cooling therapy (deviation from target temperature: 0.189±0.23°C vs 0.596±0.61°C, p=0.00006). The rewarming phase was better controlled and length of ICU stay was shorter in the group with endovascular cooling (8.8±3 vs. 12.9±6 days).

Conclusion

Endovascular cooling offers the possibility to reach the target temperature significantly faster and a stable maintenance of therapeutic hypothermia. It is capable of a more controlled rewarming period and shortens the length of ICU stay.     

Der Metall-Metall-Hybridoberflächenersatz des Hüftgelenks

Worldwide the employment of surface replacements using metal-on-metal components as an option, particularly for the young and active patient, has gained broad acceptance. Part of the attraction for hip resurfacing is its conservative nature as a prosthetic solution for hip arthritis. It is anatomical, replicating the normal hip and limb length, preserving proximal femoral bone, and is a truly minimally bone invasive approach with excellent outcome of joint function. The purpose of this article is to show the data of 1,000 Conserve(c) Plus hybrid metal-on-metal prostheses in a consecutive study of 1,140 patients with a follow-up of 5.6 years. The current Kaplan and Meier survival estimates of the prosthesis, using any conversion to total hip replacement as the end point, were 98.1% at 3 years [95% confidence interval (CI): 96.8-98.9%], 96.7% at 4 years (95% CI: 94.8-97.8%), and 95.2% at 5 years (95% CI: 93.0-96.8%). The mean postoperative Harris hip score was 93.3. The current state of metal-on-metal surface replacement is positive. The new generation of hip resurfacing has a lot of improvements. The purpose of this review of the procedure is to point out the definite improvements from earlier designs using polyethylene as well as to highlight the overall results and durability achieved by one surgeon's extensive experience and to assess the results from other series and centers. We also want to point out the areas where further investigation is needed.     

Der Oberflächenersatz am Hüftgelenk

Resurfacing arthroplasty is regarded as an attractive method, especially for the young patient who needs a hip replacement. However, the high expectations regarding this new technique in THR must first be met. Earlier experiences with similar forms of surface replacement have led to high revision rates with early aseptic wear induced component loosening and neck fractures. Technical progresses in production techniques for metal-on-metal articulations with minimized wear have enabled the introduction of new surface replacements for the hip joint. Long-term results of these resurfacing arthroplasties are still due. Femoral neck fractures and femoro-acetabular impingement are possible early complications which require revision. The implantation of these systems requires a high degree of operative skill and experience on the part of the surgeon. Approach dependent trauma to the musculature and endangering of the blood supply to the femoral head is balanced with the positive effect of the preservation of femoral bone stock and better options in case of revision. Whether the younger patient with a higher activity profile and an increased chance of implant loosening actually profits from the resurfacing arthroplasty will be determined in the future.     

Der diabetische Fuß – eine interdisziplinäre Aufgabe

Ohne Zusammenfassung     

Behandlung metaphysärer Femurpseudarthrosen durch Retrogradnagelung

We report on the therapy of two hypertrophic, metaphyseal nonunions of the distal femur by retrograde nailing. Two patients with an old nonunion were successfully treated only by interlocking the retrograde nail according to the principle of transfixation. Both cases illustrate that an angular stable fixation might be critical to bony consolidation in the metaphyseal region. If toggling of the nail within the medullary cavity is limited by interlocking at appropriate positions, retrograde intramedullary nailing will provide angular stable fixation.     

Intraartikuläre Bupivacaingabe bei Hüftgelenkarthroskopie

The effect of intra-articular bupivacaine on postoperative pain following arthroscopy has been intensively studied for the knee joint but no data are currently available for the hip joint. The aim of the present prospective, randomized and double-blind study was to evaluate a possible effect of intra-articular bupivacaine on postoperative pain intensity following hip arthroscopy. A total of 26 patients were included: 13 received 20 ml of 0.25% bupivacaine through the trocar at the end of surgery and 13 patients received 20 ml of 0.9% NaCl as placebo. Postoperative pain intensity was assessed using a visual analogue scale (VAS) at 0.5 h, 4 h, 8 h, 12 h, 16 h and 20 h, at rest and during movement of the joint and on the basis of additional piritramide requirements. Furthermore, a mean VAS was calculated as the arithmetic mean of all VAS scores assessed over the whole study period. In the bupivacaine group, a significantly lower mean VAS was recorded at rest (17.5 vs 27.5, p=0.05) and during movement of the hip joint (23 vs. 46, p=0.001). The additional piritramide consumption tended to be higher in the placebo group. In conclusion, intra-articular bupivacaine following arthroscopic hip surgery reduces pain in the postoperative period mainly during movement and thus may possibly allow earlier mobilization.