Metadiaphysäre Femurdefektrekonstruktion mit kortikalen Strut-Allografts bei periprothetischen Knochendefekten

Objective

Biological augmentation and stabilization of high-grade bone defects with structural allografts from donor femur halfs.

Indications

Severe bone defects with aseptic loosening of hip prosthesis, periprosthetic femoral fracture or non-union, possibly even in cases of a healed infection.

Contraindications

Local or systemic infection.

Surgical technique

The two modeled strut allografts are temporary fixed epiperiostal anterolateral and -medial with wire cerclages, while protecting the vascular supplying linea aspera of the femur. With the thus stabilized femur, the leg can be placed in the four-position in order to prepare the medullary canal of the revision prosthesis. Finally, the uncemented revision prosthesis is hammered in under successive tightening of the wire cerclages. With this “cracking technique”, stem is stabilized and the grafts have repositioning, augmentative, and supportive function.

Postoperative management

Partial weight-bearing postoperatively for 12 weeks. X-ray control during surgery, 10 days postoperatively, after 6 and 12 weeks and every 1–2 years.

Results

In four different studies, 123 patients were stabilized from December 1991 to June 2011 due to an extensive periprosthetic femoral bone defect and/or periprosthetic fracture, refracture, or non-union with strut allografts. After an average follow-up of 3.8 years (range 0.3–11 years), the average Harris Hip Score was 80.8 (range 44–100). During this time, there was 1 refracture, 103 stable stems, 20 fibrous stable stems, 9 patients with low graft resorption, and 122 patients with radiographic healing of the strut allografts based on classification according to Emerson et al. (Clin Orthop Relat Res 285:35–44, 1992).     

The effect of cement augmentation and anteromedial plating on proximal humerus allograft reconstruction

Background

Limb salvage following the resection of tumor from the proximal part of the humerus, poses many challenges, and there is no consensus regarding the best reconstructive technique after proximal humerus resection. The aim of this study was to evaluate the effect of anteromedial placing of the plate in the absence of deltoid muscle and cement augmentation on the functional outcome, complication rate and survival of proximal humerus allograft reconstruction.

Die metaphys?r verankerte Prothese bei posttraumatischer und prim?rer Omarthrose

Objective

??Bone-saving?? prosthesis designs, e.g., metaphysary fixed implants, are becoming increasingly common in primary arthoplasty of the glenohumeral joints. In primary omarthrosis, this is an accepted procedure. This study shows and evaluates the short-term clinical outcome of posttraumatic omarthrosis patients in comparison with primary omarthrosis patients after ??Eclipse?? implantation.

Patients and methods

From August 2006 to December 2009, a total of 115 metaphysary fixed, stemless shoulder prostheses were implanted for primary omarthrosis (n?=?96) or posttraumatic omarthrosis (n?=?19). All the 115 patients were registered prospectively and examined 6 and 12 months postoperatively. In addition to the radiological studies, the Constant Murley score (CMS) and patient satisfaction were evaluated

Results

Both groups differed significantly in the pre- and postoperative CMS. Implantation of the Eclipse prosthesis led to a highly significant increase in the CMS. There was also a significant increase of the range of motion (ROM) in the posttraumatic group. One year after implantation, 87.5% (n?=?83) of the primary omarthrosis group were ??very satisfied?? or ??satisfied??. In the posttraumatic group, this value was 78.9% (n?=?15). There was 1 early complication (hematoma) and 5 sequelae [2 secondary cuff insufficiencies, 1 luxation with insufficiency of the subscapularis muscle, and 2 glenoid loosenings (2.3 and 3 years after implantation)]. A single complication for the posttraumatic group was reported: one of the two reported secondary cuff insufficiencies.

Conclusion

The implantation of a stemless fixed prosthesis leads in the posttraumatic situation as well as in primary omarthrosis to an identical increase of the CMS. It is a good prosthesis design with rare complications. It is possible to implant the prosthesis independent of the diaphysis of the humerus and malposition of the humeral head.     

Distal humeral hemiarthroplasty: indications,results, and complications. A systematic review

Background

Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening.

Methods

The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded.

Results

For non-fracture indications, good to excellent results were achieved in 76.5 % of patients with a mean arc of motion of 62° at mean follow up of 46.3 months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4 % of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2 months. One third of the patients experienced a complication but only 1.7 % experienced loosening of the prosthesis.

Conclusion

Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.     

Primäre Alloarthroplastik des frakturierten Ellenbogens beim hochbetagten Patienten

Aim of study

Inadequate treatment of distal intra-articular fractures of the humerus results in painful restriction of movement or malarticulation. Especially in geriatric patients with osteoporosis, stable osteosynthesis can be difficult. Primary total endoprosthetic replacement of the cubital joint could offer an alternative.

Material and methods

In 12 patients with a distal intra-articular fracture of the humerus a cemented semi-constrained Coonrad-Morrey prosthesis was implanted. Patient were followed-up after an average of 13 months and assessed according to the Mayo score.

Results

In 6 patients additional computerized tomography was carried out. Minimally invasive Kirschner wire osteosynthesis resulted in immediate postoperative loss of correction due to osteoporosis. As with the external distraction-compression apparatus the ulnar pinholes can form a predetermined breaking point and fixation in a long-arm cast is recommended. The mean Mayo score was 90.5 points and mean range of motion in extension/flexion was 84.5°.

Conclusion

In elderly patients primary endoprosthetic treatment of a distal intra-articular fracture of the humerus with a semi-constrained cemented prosthesis may offer an alternative to osteosynthesis thus enabling creation of a mobile, painless and stable cubital joint.     

Die Humeruskopfmehrfragmentfraktur – Versorgung mit einer Humeruskopfprothese?

Background

Proximal humerus fractures are one of the most common fractures in elderly patients. In the treatment of complex proximal humerus fractures, primary hemiarthroplasty is still discussed controversially. The present study was undertaken to evaluate the results of primary hemiarthroplasty in the treatment of proximal humerus fractures with a modular prosthesis (EPOCA, Fa. Argomedical, Gifhorn, Germany).

Material and methods

A prospective study of 24 patients with complex humerus fracture (NEER: IV/4, V/4, VI/4, and head split fracture) was performed from August 2000 to December 2002. Mean age was 75.6 years (range: 52–92); 18 patients were seen for follow-up after 0.5 and 1 year, respectively. The Constant-Murley score (max. 100 points) and the UCLA Rating System (max. 35 points) were calculated for functional assessment of the operated shoulder.

Results

Fifteen patients (83%) were pain free 1 year after the operation. The Constant-Murley score improved from 52 (±17) to 56 (±18) at the second follow-up after 1 year. On the contralateral side a score of 86 (±10) was assessed (p<0.05 vs operated side). Correspondingly, shoulder function according to the UCLA Rating System improved [25 (±4); 27 (±5)].

Conclusions

Osteoporotic bone of older patients often may not permit stable internal fixation of complex proximal humerus fractures. In these situations primary hemiarthroplasty is the treatment of choice.     

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

Objective

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures.

Design

A retrospective clinical trial.

Setting

Department of Orthopaedics, Tianjin Medical University General Hospital.

Patients

Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates.

Intervention

The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied.

Main outcome measurements

Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed.

Results

After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %).

Conclusions

The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.     

Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate

Objective

Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated.

Indications

Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing.

Contraindications

Loosening of prosthesis. Local infection. Osteitis.

Surgical technique

Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis.

Postoperative management

Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist.

Results

In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.     

Silver-Coated Megaprosthesis of the Proximal Tibia in Patients With Sarcoma

Background

Proximal tibia arthroplasty is associated with high rates of infection. This study is the largest one that has compared the infection rates with titanium vs silver-coated megaprostheses in patients treated for sarcomas.

Proximal fractures of the humerus in patients older than 75?years of age: should we consider operative treatment?

Background

Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.

Materials and methods

In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.

Results

Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).

Conclusion

This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.

Level of evidence

According to OCEBM Working Group, Level IV.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.     

Prothetik bei proximalen Humerusfrakturen

Background

The purpose of this present study was to review the functional and radiological results of patients with complex fractures of the proximal humerus who were treated with an anatomical shoulder prosthesis.

Patients and methods

Between 1999 and 2005 a total of 61 patients were treated with an anatomical trauma prosthesis after an acute fracture.

Results

Thirty-eight patients (31 women and 7 men) with a mean age of 72 (range, 31–85) years could be followed-up. The absolute Constant score averaged 57.7 of 100 (range, 32–86) points by a mean of 86 (range, 60–129) months. Postoperative active elevation averaged 105 (range, 50–180)° and active abduction averaged 96 (50–180)°. Tuberosity resorption was found in 52% (20/38) at final follow-up. The outcome was significantly better in patients with healing of the tuberosities (p?=?0.02).

Conclusion

With the use of an anatomical trauma prosthesis the reduction of the pain level is excellent while the gain in function is only slight. The bony union of the tuberosities in an anatomical position is essential to achieve good results.     

A multicenter experience with infected abdominal aortic endograft explantation

Objective

Endovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome.

Der Anbindungsschlauch zur Weichteilrekonstruktion nach Megaprothesenimplantation

Objective

To restore function and an active range of motion, and stabilize the joint after joint resection.

Indications

Restoration of a joint capsule following reconstruction of a defect using a proximal humerus and femur prosthesis. Reattachment of tendons and muscles.

Contraindications

Acute or chronic infection. Status after cured infection.

Surgical technique

The attachment tube (Implantcast, Buxtehude, Germany) is attached to the joint capsule (proximal humerus and femur replacement) or directly to the prosthesis (for proximal tibial replacements) using nonresorbable Ethibond? sutures (Johnson &; Johnson Medical, Norderstedt, Germany). Bone anchors are used, if the joint capsule has been completely resected. The body of the prosthesis, which has previously been attached to the shaft, is then pulled distally through the tube, and a (bipolar) head or humerus cap is placed on top of it. In the proximal humerus and femur replacement, proximal slitting of the tube may be helpful to reposition the prosthesis under vision. Following repositioning, fixation of the tube is completed ventrally and the slits previously made in the tube are sutured. Fixation of the tube to the prosthesis is carried out either with Ethibond? sutures placed around the tube, or??for a proximal humerus and tibia replacement??it is possible to attach suture material to the prosthesis through eyelets.

Postoperative management

Further treatment basically depends on the location of the mega-endoprosthesis used.

Results

Macroscopically and microscopically, fibroblasts migrate into the tube??s mesh, so that attachment of the soft tissue takes place. As of yet, no cases of luxation have occurred when the tube is used in combination with a bipolar head, and with fixed-implant cups the risk of luxation can be reduced using tripolar cup systems. In patients with a proximal tibial replacement, active straightening of the knee joint can be restored in most cases, although some limitation on active extension is still possible depending on the extent of the tumor resection.     

Two-stage revision for infected total knee arthroplasty: our experience with interval prosthesis

Introduction

To review our practice of performing two-stage revision for infected total knee arthroplasty using articulating interval prosthesis and to compare the incidence of the recurrence of infection and re-operation rate in patients undergoing two-stage revision as planned with the group of patients who choose not to proceed to the second stage.

Method

This study is a retrospective review of 60 consecutive patients undergoing a two-stage revision for infected total knee arthroplasty using articulating interval prosthesis. All cases managed by a single surgeon using a uniform peri-operative protocol, and short-course parenteral antibiotic therapy.

Result

Thirty-four patients (57 %) (Group 1) underwent the two-stage revision as planned. However, twenty-six patients (43 %) (Group 2) opted not to have a second-stage procedure as the first-stage and interval prosthesis had eradicated the infection, resolved the pain and achieved good functional outcome. There were five cases of recurrent infection in the 60 patients (8 %) at a mean follow-up 5 years. In those completing the two-stage revision, two patients had recurrent infection. Of the patients who retained the interval prosthesis, there were three recurrent infections. There was no statistically significant difference between the groups in terms of recurrence of infection or re-revision.

Conclusion

Two-stage revision with interval prostheses represents a safe and reliable method of treating infected knee prosthesis; however, there may be a role for one-stage revision in selected cases.