Entwicklung der Knieendoprothetik

In this article the evolution beginning with the robotics of total knee arthroplasty to CT-based and kinematic navigation and patient-specific instruments is described. Thereby it is pointed out that in the early 1990s, CT imaging solely for the planning of a knee endoprosthesis was considered as obsolete radiation exposure and this led to the widespread development of kinematical systems.Also a patient specific planning tool based on CAD built acryl harz blocs existed at the time. There is an ongoing process of implanting total knee arthroplasties in a more exact position. Nowadays the new evolution of soft tissue balancing by using a kinematic alignment has put these efforts into perspective.     

Kontroversen der Nierenteilresektion bei Nierenzellkarzinom

Background

The goal of this study was to evaluate how partial nephrectomy is technically performed in Germany, Austria, and Switzerland.

Methods

A one-page anonymous questionnaire was designed to evaluate the indication, the technical procedure, and the follow-up of R1 situation after partial nephrectomy. Furthermore, the size of the hospitals and their catchment areas were recorded. The questionnaire was sent to 341 clinics and a statistical analysis was performed.

Results

The response rate was 69?%. Up to 99?% of the clinics also perform partial resection in T1b tumors. Of those responding, 58?% perform this surgery laparoscopically, and 83?% of the surgeries are performed in warm ischemia. For the follow-up, 29?% suggest imaging within the first 6 weeks. According to this survey, maximum care clinics perform laparoscopic nephrectomy more frequently (p?=?0.003).

Conclusion

The survey of 236 hospitals performing partial nephrectomy shows great variability in the indication, technique, and aftercare of organ-preserving renal tumor surgery. It also shows that a large proportion of tumors >4 cm undergo organ-preserving surgery, many of them minimally invasive. The diverse handling with positive instantaneous section and R1 results suggest the need for further studies concerning long-term follow-up after minimally invasive surgery with R1 situation and renal tumors >?T1a.     

Das dritte Kompartiment bei der Knieendoprothetik

Involvement of the patellofemoral compartment is common in osteoarthritis of the knee but to date there is no consensus as to the most appropriate approach concerning the patella. Both general non-selective resurfacing as well as selective or secondary resurfacing are currently accepted. However, despite abundant studies on the subject no clear conclusions can be drawn from the available evidence. There are arguments in favour of either approach. Accordingly, no strong evidence can be found to support peripatellar denervation. With the advent of new diagnostic modalities for the assessment of knee osteoarthritis, such as single photon emission computed tomography/CT (SPECT/CT), a more selective approach to patellar resurfacing with a potentially improved outcome might become possible.     

Prinzipien der OSG-Arthrodese bei Gelenkinfekt

A chronic empyema of the ankle joint often develops after an open fracture or surgery. In the case of the destruction of the joint due to an infection, an arthrodesis should be performed.Normally we use an external fixator with two bone-nails placed into the calcaneus and two into the tibia. The arthrodesis is distracted and Septopal is permanently implemented. At 4-6 weeks after surgery the Septopal is removed, with distraction being reduced and a cancellous bone-graft taken from the dorsal iliac crest is performed to fill the bony defect. After bone healing, the external fixator is removed and the patient mobilized in a brace. Initially, weight-bearing is limited to 10 kg but is increased gradually to full weight. The brace is used for 6-9 months; later the patient is mobilized in orthopaedic shoes. In difficult cases, also in combination with a malposition which has to be corrected or a lengthening of the lower limb, we use the Ilizarov fixator. From 1993 to 2003 we performed arthrodeses of the ankle joint due to infectious destruction in 107 cases. In 82.2%, the empyema was caused by a fracture of the ankle joint and the following treatment. In 58% of the patients, we saw associated diseases such as obesity, alcohol abuse, diabetes and malposition of the foot. In 55% we found Staphylococcus aureus. In 86%, we used the external AO-fixator, in 14% the Ilizarov fixator. The patient retained the fixator for an average of 128 days. In our study, 92.1% of the 101 patients who had completed therapy showed a good stability an average of 4.5 years after the arthrodesis. In 5% we found partial stability, while three patients had to be amputated. In 57 patients (56.4), an arthrosis of the tarsal bones was found, and 38 patients (54.3%) of the 70 patients who at the time of the arthrodesis were still working could return to work.     

Navigation und Robotronik in der Knieendoprothetik

Trauma und Berufskrankheit - Der breite Einsatz von Robotern und Elektronik in der Fertigung nahezu sämtlicher Gegenstände des Alltagslebens legt die Frage nahe, ob diese Technologien...     

Prinzipien der Antibiotikabehandlung bei periprothetischen Infektionen

Periprosthetic infection is nowadays a rare complication in artificial joint replacement. The infection of joint prostheses is a foreign body associated infection at the site of bone tissue which is difficult to treat with antimicrobial agents. Apart from cases with early, non-established infections, the surgical removal of the foreign material and radical débridement of bone and soft tissue is necessary. The surgical revision is performed preferentially using a one or two stage exchange of the prosthesis. In some cases, only the removal of the prosthesis is necessary. In these cases, a pseudoarthroplasty or an arthrodesis without definitely implanted foreign material is performed. Amputation is carried out if all other forms of revision have failed. All of these surgical procedures are accomplished by antimicrobial therapy, whether systemically administered and/or topically by drug delivery systems. Controlled studies for the comparison of one and two stage exchange procedures are not currently available. For the therapy of periprosthetic infection, an infectious disease specialist who is experienced in this area is needed in addition to an experienced surgical team. Thus, the therapy of these infections should be performed exclusively in centres of competence.     

CT-basierte und CT-freie Navigation in der Knieendoprothetik

ZusammenfassungEinleitung Neben weiteren Faktoren wird der korrekten Wiederherstellung der neutralen Beinachse und einer exakten Implantatlage eine Bedeutung für die Standzeit von Kniegelenkprothesen zugeschrieben. Mit konventioneller Technik treten Fehlimplantationen außerhalb eines angenommenen Sicherheitsbereichs von ±3° auch bei erfahrenen Operateuren in bis zu 30% der Fälle auf. Ziel der Arbeit war die Überprüfung, inwieweit mit zwei grundsätzlich verschiedenen Modulen eines Navigationssystems die korrekte Achsrekonstruktion unterstützt werden kann.Material und Methodik In einer prospektiven Studie wurden unselektiert je 50 Patienten mit einer primären Gonarthrose unter Verwendung der CT-basierten bzw. der CT-freien Applikation des Vector-Vision Navigationssystems (Fa. BrainLAB) versorgt. In allen Fällen wurde das gleiche Prothesenmodell (PFC-Sigma, Fa. Depuy) verwendet. Die beiden Kollektive waren vergleichbar, insbesondere bezüglich der präoperativen Beindeformität. Die Beinachsen wurden prä- und postoperativ mit standardisierten Ganzbeinstandaufnahmen und seitlichen Aufnahmen vermessen.Ergebnisse Eine achsgerechte Implantation mit einer maximalen Abweichung der Beinachse von 3° valgus bis 3° varus konnte bei 46 Patienten (92%) in der CT-basierten Gruppe (A) und bei 48 Patienten (96%) der CT-frei navigierten Gruppe (B) erzielt werden. Auch die Genauigkeit der Lage der Einzelkomponenten war femoral (A=96%; B=94%) und tibial (je 98%) mit beiden Modulen sehr hoch.Diskussion Die Verwendung der beiden Module des Navigationssystems führt zu einer hohen Implantationsgenauigkeit. Vorteile des CT-basierten Systems bestehen in der präoperativen Planungsmöglichkeit. Als Nachteil muss der hohe Ressourcenaufwand gesehen werden. Das CT-freie Modul hat seine Vorteile in der intraoperativen Darstellung der Beinachse, der Gelenkkinematik und der Hilfestellung bei der Weichteilbehandlung. Schnittfehler können mit beiden Applikationen intraoperativ erkannt und korrigiert werden.     

Historische Entwicklung und derzeitiger Stand der Therapie bei posttraumatischen Carotis-cavernosus-Fisteln

Zusammenfassung Grundlagen: Die posttraumatische arterioven?se Fistel zwischen der A. carotis interna und dem Plexus des Sinus cavernosus ist die h?ufigste unter den erworbenen intrakraniellen Fisteln. Pulsierender Exophthalmus, Chemose und auskultierbares Ger?usch lassen rasch an die richtige Diagnose denken. Methodik: Anhand von 44 F?llen wird der Wandel der Therapie von rein chirurgischen Ma?nahmen (Karotisligatur am Hals ohne oder mit gleichzeitiger Klippung der A. carotis interna intrakraniell = Trapping) über Vorl?ufer der endovaskul?ren Verfahren (operativ in die A. carotis interna eingebrachte und zur Fistelstelle vorgeführte Fogarty-Ballonkatheter) zum transfemoralen Fistelverschlu? mittels Absetzballon dargestellt. Die neueste Methode ist die Fistelobliteration unter der Erhaltung der Karotis mit endovaskul?r plazierten, elektrolytisch absetzbaren Platindr?hten, die bei den letzten 10 Patienten angewandt wurde. Ergebnisse: Exophthalmus, Chemose und Tinnitus bildeten sich bei allen au?er 2 Patienten nach der Therapie zurück. Pr?operative Hirnnervendefizite besserten sich in über 70% der F?lle. Einseitiger Visusverlust war in keinem Fall reversibel, w?hrend sich Sehst?rungen in 55% zurückbildeten. 5 perioperative Insulte traten auf, wobei 1 Patientin an den Folgen verstarb. 42 von 44 Fisteln konnten vollst?ndig verschlossen werden. Die A. carotis interna konnte dabei unter Verwendung von Ballons in 60% erhalten werden, w?hrend das bei der Verwendung der Platinspiralen in 90% m?glich war (kombinierte Morbidit?t/Mortalit?t = 11%). Schlu?folgerungen: Eine sichere Behandlung der Carotis-cavernosus-Fistel, unter Erhaltung der A. carotis interna ist heutzutage in einer dafür spezialisierten Therapieeinheit in einem hohen Prozentsatz m?glich.      

Prinzipien der Behandlung spastischer Paresen bei Kindern

Background

In patients with cerebral palsy who are able to walk the source of the problem of spasticity must first be correctly determined. The weakness appears to be the main problem and the first line treatment must concentrate on improvement of strength and bodily control.

Therapy

Spasticity can also compensate for weaknesses. The indications for weakening measures for correction of muscle tonus must therefore be carefully appraised but are part of the repertoire. Orthoses result in stability and correction of deformities. Night braces are in our experience of doubtful value. Biomechanical objectives are a right-angle between the sole of the shoe and lower leg axis (leading edge of the tibia) and full passive and active extension in the knees and hips.

Conclusion

Severely handicapped patients often suffer from hip luxation and scoliosis. Regular control of the hips and spine under loading are necessary. Early interventions, conservative and operative, have a better prognosis than a late correction. In general patients who have a risk for deformities and dysfunction of the musculoskeletal system due to the underlying disease should undergo early orthopedic control.     

Entwicklung der Beinachse im Kindesalter und Therapieoptionen bei kniegelenknahen Fehlstellungen

Krumme Beine sind ein h?ufiger Anlass,Kinder beim Kinderarzt oder Orthop?den vorzustellen. Am h?ufigsten bemerken die Eltern im Kleinkindalter O-Beine sowie einen Innenrotationsgang.Die Beurteilung, ob eine Beinachse noch normal oder pathologisch ist, setzt die genaue Kenntnis der physiologischen Beinachsenentwicklung voraus.Grunds?tzlich sind alle 3 Ebenen des Raums zu beurteilen (Frontal-, Sagittal- und Transversalebene), da in jeder Ebene Abweichungen auftreten k?nnen. Dr.B.Westhoff Orthop?dische Klinik, Universit?t Düsseldorf,Moorenstra?e 5, 40225 Düsseldorf, E-Mail: westhoff@med.uni-duesseldorf.de     

Editorial zum Themenschwerpunkt Zugänge bei der Knieendoprothetik

Ohne Zusammenfassung     

Indikation und Prinzipien der metabolischen Chirurgie

Bariatric surgery is known to be the most effective and long lasting treatment for morbid obesity and many related conditions, but now mounting evidence suggests it may be among the most effective forms of treatment for metabolic diseases and conditions including type 2 diabetes, hypertension, high cholesterol levels, non-alcoholic fatty liver disease and obstructive sleep apnea. Surgery for severe obesity goes way beyond weight loss. This surgery results in the complete remission or significant improvement of type 2 diabetes and other life-threatening diseases in most patients. The new name metabolic surgery was created and reflects this expanded and evolving view of surgery. Therefore, metabolic surgery is expected to play an ever increasing role in managing these diseases. New research results indicate that metabolic surgery may improve insulin resistance and secretion by mechanisms independent of weight loss, most likely involving changes in gastrointestinal hormones. Many patients with type 2 diabetes experience complete remission within days of metabolic surgery, long before significant weight is lost. This has led to a new concept that metabolic surgery may also be appropriate for diabetic individuals who are of normal weight or only slightly overweight.     

Probleme und Kontroversen in der Behandlung von Sprunggelenkfrakturen

Ankle fractures are the most frequent injuries of a load-bearing joint. Their treatment belongs to the daily routine in trauma surgery. However, despite an increased understanding of the mechanism of injury and relatively straightforward fixation techniques, the medium- to long-term results are often less than satisfactory. The following article therefore explicitly focusses on unsolved problems and controversies in the treatment of ankle fractures in the light of the current literature. These include the therapeutic and prognostic relevance of frequently used classification systems, criteria for the indication for surgery, frequent hazards in internal fixation, the question of whether and how to fix the posterior malleolus, and the detection and treatment of syndesmotic instability. Furthermore, trauma surgeons face the increasing incidence of ankle fractures in the elderly. The presence of osteoporosis, diabetes mellitus and neuropathic osteoarthropathy represents a special challenge.     

Prinzipien chirurgischer Therapiekonzepte der postoperativen und chronischen Osteomyelitis

Infection of the bone is one of the most serious complications in the field of orthopedic and trauma orthopedic surgery. Sufficient treatment protocols not only contain complex surgical procedures but also sophisticated diagnostic tools, proper use of antibiotics, and intensive physical therapy right from the beginning. Even in light of these advanced treatment protocols, which have great impact on both patients and health care systems, persisting infection and residual functional deficits of the extremities are not rare. In cases of early (acute) infection, the main objective is to avoid chronification by diligent surgical interventions. The surgical principle is the meticulous debridement and lavage of the situs. Revision of only the epifascial layers is as inadequate as the simple reopening of the wound without excision of the whole wound including all tissue layers. In cases of chronic soft tissue and bone infection, radical debridement of all infected and scar tissue is also the basic requirement of treatment. Reconstruction of the soft tissue envelope is done by local or free flap surgery. Because of they are better resistant to infection, musculo(cutaneous)flaps are preferred. Bony reconstruction is done by autologous cancellous bone grafting (partial defects), segment transport (full thickness defects), or freely transplanted vascularized bone grafts (large partial defects). Both soft tissue and osseous reconstruction take a relatively long period of time requiring several operations and periods of hospitalization. These have to be discussed and explained to the patients extensively. If the required amount of resection and the capability of reconstruction do not coincide, the surgeon and the patient have to decide whether restoration of function without definitive infection care, symptomatic infection therapy, or amputation is the most proper treatment option according to the patient's everyday needs and lifestyle. Because each treatment protocol is a composition of orthopedic trauma surgeons, plastic surgeons, radiologists, microbiologists, and physical therapists, reliable cooperation and communication is essential.