Critical Soft Tissue Conditions Research Articles

Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

Minimalinvasive operative Korrektur von Kleinzehenfehlstellung

Lesser toe deformities are among the more frequent problems that need operative corrections. Common procedures are an Arthrodesis of the PIP-Joint, a flexor tendon transfer or a resection arthroplasty of the PIP-Joint. Recently, minimally invasive techniques have gained popularity. The main advantage of these techniques is that they are possible even with critical soft tissue conditions due to their less invasive character, a reduced infection rate and a reduction in operative time.Its main disadvantages are a steep learning curve and the need for special equipment like rotating burrs and image intensifiers.In this article, operative techniques are outlined and discussed. Clinical situations which can be solved with minimally invasive techniques are presented.

External fixator: temporary fixation and soft tissue management of the ankle

Joint-spanning transfixation of the ankle joint aims at mostly temporary retention of the reduction, i.e. restoring length and axial alignment and stabilization of the ankle mortise in highly unstable fractures around the ankle and under critical soft tissue conditions. In selected cases, external fixation serves as an additional stabilization also following completed internal fixation or the fracture can be treated in the external fixator. The goal of surgery is to allow quick soft tissue recovery, prevention of redislocation and stabilization of the ankle and adjacent structures. a)Fractures of the tibial pilon; b)very distal, extra-articular lower leg fractures (without the option for pin positioning in the distal fragment); c)highly unstable malleolar fractures with tendency to subluxation and dislocation fractures; d)critical soft tissue conditions around the ankle; e)dislocation fractures of the talus, Chopart and Lisfranc joints (if necessary with additional transarticular transfixation). Missing consent to surgery by the conscious patient, life-threatening general condition by other prioritized injuries. Percutaneous pin placement of the appropriate caliber into so-called safe zones of the tibia, metatarsus and calcaneus, as needed. Additional transfixation of the Chopart and Lisfranc joints with K‑wires as needed. Fixation of the struts with the foot in a neutral position. Besides consideration of biomechanical principles, pin placement must be done in anticipation of the definitive stabilization and future approaches respecting the anatomical structures while achieving maximum stability and soft tissue protection. Following initial transfixation, elevation of the injured leg for soft tissue protection, local cooling and bed rest are indicated. In cases of compartment syndrome and open fractures with temporary soft tissue coverage, second look surgery after 24-72 h is mandatory. For exact fracture analysis and optimal planning of the definitive surgical strategy, the indications for CT imaging should be generously considered. The timing of definitive care depends on the local soft tissue status and the overall condition of the patient. The presence of adislocation at the time of the accident represents anegative prognostic factor for ankle fractures. Higher rates of posttraumatic arthrosis are also found in pilon fractures and trimalleolar fractures, direct cartilage damage and rupture of the syndesmosis. In cases of anatomic reconstruction of the mortice and ankle joint congruence, good to excellent results can be achieved in 75-89%.

The S2-Alar-Iliac Screw for Pelvic Trauma.

Percutaneous sacro-iliac screw osteosynthesis is considered to be standard of care for most posterior pelvic ring fractures. However, special situations require alternative strategies for sufficient stabilization. In these cases, stabilization can often be achieved using posterior instrumentation e.g. using SIPS-screws (spina-iliaca-posterior-superior screws). However, this often leads to implant-related aggravation of the sometimes already critical soft tissue conditions after pelvic trauma. S2-Ala-Ilium screws (S2AI screws) are a suitable alternative. The starting point lies medial of the posterior superior iliac spine below the iliac level. It is almost in line with a potential spinal instrumentation and therefore usually causes fewer soft tissue problems. Although this technique has been widely used in spinal surgery in recent years, its use in orthopaedic traumatology is largely unknown. The possibilities but also the limitations of this technique for the treatment of injuries to the pelvis are illustrated by this retrospective case series.

Aseptic loosening of total ankle replacement : One-stage revision ankle arthroplasty

To revise one or both loosened prosthesis components, to achieve postoperative pain relief, and preserve ankle range of motion. Aseptic loosening of the tibial and/or talar ankle prosthesis components without substantial bone defect of the tibial or talar bone stock. General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g. Charcot arthropathy), substantial nonreconstructable osseous defects with or without cysts on the tibial and/or talar side, non-compliance, patients with primary total ankle replacement (TAR) using intramedullary fixation (stem fixation), patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking, unrealistic patient expectations, patients with high activity in sports. Exposure of the ankle joint using the previous incision (anterior or lateral transfibular approach). Mobilization and removal of loosened prosthesis component. Careful debridement of bone stock at bone-prosthesis interface. Determination of prosthesis component size. Implantation of definitive prosthesis components. Wound closure in layers. Asoft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts at postoperative day1 with 15 kg partial weight bearing using astabilizing walking boot or cast for 6weeks. Following clinical and radiographic follow-up at 6weeks, full weight bearing is initiated gradually. Between January 2007 and December 2012 aone-stage revision TAR was performed in 14patients with amean age of 52.7± 12.0years (29.8-70.5years). The indication for revision surgery was aseptic loosening of one or both prosthesis components. The mean time between the initial TAR and revision surgery was 5.9± 2.9years (2.0-11.5years). In 2patients atibiotalocalcaneal arthrodesis was performed due to painful aseptic loosening of revision TAR. In all patients asignificant pain relief was observed.

Versorgung knöcherner hinterer Kreuzbandausrisse über einen minimal-invasiven dorsalen Zugang

Reduction and fixation of bony avulsions of the posterior cruciate ligament (PCL) through a minimally invasive dorsal approach to restore stability of the knee joint. Prevention of soft tissue damage through a minimally invasive procedure and achieving early functional rehabilitation by stable osteosynthesis. Bony tibial avulsions of the PCL and simple posteromedial tibial fractures. Infections in or around the knee, critical soft tissue conditions and lack of patient compliance. OPERATION TECHNIQUE: Supine position, skin incision mediodorsal over the head of the medial gastrocnemius muscle. After dissection of soft tissue and superficial fascia the medial gasteocnemius muscle is retracted to the lateral side, nerves and vessels of the popliteal fossa are thereby protected. Incision of the posterior capsule from the tibial attachment, exposure of the fracture and the PCL, reduction of the fracture, fixation with two drill wires and definitive fixation with two cannulated screws. In case of multifragment fracture a suture anchor is used for fixation. Partial weight bearing of 10-20kg for 4-6 weeks and limitation of knee flexion up to 90° for 4 weeks. Between November 2010 and November 2011 three patients were treated with the new minimally invasive posteromedial approach to fix bony avulsions of the PCL. In two cases an osteosynthesis with two screws was performed and in the other patient a comminuted avulsion fracture was fixed with a suture anchor. In the latter patient the posterolateral corner was additionally augmented according to Larson with an autologous semitendinosus tendon. No intraoperative or postoperative complications could be observed. In all three patients an excellent fracture reduction without steps or gaps could be achieved. In two cases an early functional treatment protocol and in one case (suture anchor fixation plus augmentation of the posterolateral corner) a special postoperative PCL rehabilitation protocol was used. Good clinical results with stable knee joints could be achieved in all cases. The minimally invasive dorsal approach for the treatment of bony avulsions of the PCL was demonstrated to be safe and simple with a low complication rate.

Internal fixation of fractures of the proximal humerus with the MultiLoc nail

Anatomical reduction of two- to four-part fractures of the proximal humerus using indirect reduction techniques. Intramedullary fixation with a short humerus nail. Restoration of a stable bone-implant construct that enables early functional after-treatment. Displaced and unstable two- to four-part fractures of the proximal humerus. Fractures of the proximal humerus extending in the humeral diaphysis (use a long nail). Ipsilateral combined lesions of the proximal humerus and the humeral diaphysis (use a long nail). Poor physical and/or mental status. Critical soft tissue conditions in the area near the surgical site. Local soft tissue infection. Pre-existing severe osteoarthritis of the shoulder joint; severe shoulder stiffness. Head-split fractures of the humerus head that cannot be reduced. Exposure of the fracture using an anterior acromial approach and determination of the correct nail entrance point. Anatomic fracture reduction using indirect reduction techniques. Stable fixation using an intramedullary MultiLoc® nail. Determination of the proximal locking configuration depending on the fracture morphology. Distal locking with angle-stable option. POST-OPERATIVE TREATMENT: Post-operative radiographs for documentation of the surgical result and implant position. Use of an arm sling for 7-10days. Active and passive exercises of the shoulder joint starting on day1. Shoulder abduction limited to 60° for 2weeks. Subsequent abduction to 90° until the 4th week. Subsequent active mobilisation without restrictions. Weight bearing and sporting activities after 3months. Radiological evaluation after 2, 6 and 12 weeks. During a 6-month period, 160 patients were documented in a prospective clinical multicentre study. According to the AO classification, there were 36% A-type fractures, 41% B- and 23% C-type injuries. A 6-month follow-up was available for 17patients. The mean age of these patients was 67years. One patient had an A-type fracture. There were ten B- and six C-type fractures. At the time of follow-up, the mean Constant score was 66points. Radiographically, all fractures had healed. Intra-articular screw penetration and loss of reduction were both observed once.

Minimal-invasive Osteosynthese von Kalkaneusfrakturen

Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration. Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders typeII, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients. Impossible percutaneous reduction and fixation. Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously. Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day2, patients are mobilized with partial weight bearing for 6-8weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes. Between 1998 and 2008, 68patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37patients with intraarticular fractures (Sanders typesIIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2years postoperatively, the average was 5years postoperatively. Subjectively, 33 of 35patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64-100) at a mean of 5years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.

Minimally Invasive Plate Osteosynthesis of the Distal Fibula With the Locking Compression Plate: First Experience of 20 Cases

The aim of this study was to evaluate the clinical feasibility and the possible complications associated with minimally invasive plate osteosynthesis of the distal fibula. Regional county hospital. All patients with Orthopaedic Trauma Association 42, 43, 44 fractures of the distal tibia requiring plate fixation of the distal fibula were included in this cohort study. A consecutive series of 701 internally fixed fractures of tibia and ankle yielded 20 fibular fractures treated with this technique. Fractures were treated with the minimally invasive plate osteosynthesis technique using an angular stable screw-plate system for the fibula. Clinical and radiologic outcomes at 24 months. Seventeen fractures healed without complication at an average of 9 weeks. Three aseptic nonunions were recorded: one in a pilon fracture (Orthopaedic Trauma Association 43-C3) and one in a distal lower leg fracture (Orthopaedic Trauma Association 43-A3), both with severe closed soft tissue injury (as a result of a crush mechanism). The third one was in an ankle fracture dislocation (OTA 44-C1) with delayed treatment and inadequate reduction of the simple fibula fracture. Although this technique is comparable to minimally invasive plate osteosynthesis in the tibia or femur, it appears to be more difficult as a result of small bone size. As a result, we reserve this technique for selected complex fractures of the distal fibula with critical soft tissue conditions.

Ein modifizierter posterolateraler Zugang für die operative Versorgung von Tibiakopffrakturen

Open reduction and internal fixation of posterolateral tibial plateau fractures. Tibial plateau fractures involving the posterolateral quadrant. Critical soft-tissue conditions. Tibial plateau fractures which do not involve the posterolateral quadrant. 90 degrees side positioning on the contralateral side, skin incision along the fibular head, exposure of the peroneal nerve, lateral arthrotomy and exposure of the joint, dissection of the popliteal cavity between the lateral head of the gastrocnemius muscle and soleus muscle. Blunt preparation between popliteus muscle and soleus muscle under preservation of the popliteal artery and vein. Sharp dissection of the soleus muscle from the dorsal parts of fibula and tibia until the peroneal nerve at the fibular neck enters into the muscle. Exposure of the posterolateral tibial head. The dorsal joint capsule and the popliteal corner are prevented from any soft-tissue damage. Visual control of fracture reduction by viewing in the joint gap through lateral arthrotomy. Reduction of the fracture from dorsal with pointed reduction forceps. A conventional or locking radius T-plate can be pinched off with lateral cutters and anatomically bent for fracture fixation and is dorsally fixed at the tibial plateau. 10 kg partial weight bearing for 6-8 weeks. Limited range of motion 0-0-90 degrees for 6 weeks. In a period of 2 years, seven patients with posterolateral tibial plateau fractures received open reduction and internal fixation by using the modified posterolateral approach. The patients were examined at follow-up between 12 and 24 months after surgery. Six patients were free of pain with full range of motion and stable knee joints. Radiologically, a good fracture reduction was achieved in six cases. In one patient with a posterolateral comminuted dislocation fracture, a small fracture step and a gap could be observed. No approach-related complications were found.

Osteosynthese der Frakturen der Vorderwand und des vorderen Pfeilers des Azetabulums über einen ilioinguinalen Zugang

Restoration of the congruence of the hip joint. Correction of gaps or steps in the articular surface, especially in the main weight-bearing area of the acetabular dome. Correction of femoral head subluxation. Restoration of joint stability in order to enable early postoperative mobilization. Fractures of the anterior wall and/or column that are characterized by intraarticular gaps or steps of > 1 mm in the area of the main weight-bearing dome of the acetabulum. Fractures complicated by subluxation or dislocation of the femoral head. Poor general physical condition and/or dementia. Critical soft-tissue conditions in the area near the surgical approach. Local soft-tissue infection. Preexisiting severe osteoarthritis of the hip joint. Exposure of the fracture through an ilioinguinal approach. Reduction of a subluxated femoral head. Reduction of the anterior column and/or wall. Correction of articular gaps, steps and areas of joint impression. Internal fixation using small-fragment reconstruction plates, if required in combination with additional screws. Postoperative radiographs for the documentation of the surgical result and implant position (exclusion of intraarticular implants). Postoperative computed tomography, if indicated. Active and passive exercises of the hip joint starting on day 1. Hip joint flexion limited to 90 degrees . Prophylaxis of thrombosis until full weight bearing, starting preoperatively. Mobilization without weight bearing or 15 kg partial weight bearing for 8-12 weeks. Progressive weight bearing over a time period of 4-6 weeks. Radiologic evaluation after 2, 6, and 12 weeks as well as after 6, 12, and 24 months. Excellent and good functional results are observed in 73-85% of the isolated anterior column fractures. The anterior wall fracture is a seldom injury. Functional results are worse in comparison to the other simple fracture types. Good or excellent results can only be observed in two thirds of cases. This observation is related to the fact that anterior wall fractures often occur in elderly patients with osteoporotic bone.

Temporary vertical transarticular-pin fixation of unstable ankle fractures with critical soft tissue conditions

Unstable ankle fractures are demanding injuries to treat. Open reduction and internal fixation are accepted as standard care, however, in patients with severe soft tissue damage or serious medical conditions, this approach may not always be advisable. Closed reduction with temporary fixation using vertical transarticular pins is one method to maintain joint alignment until an open technique is possible. Fourteen patients (median age: 59.5 years) with unstable ankle fractures, including three type-2 open fractures, were included in the study. Open reduction and fixation was delayed because of severe soft tissue damage, and a temporary transarticular pin fixation using two Kirschner wires was performed. After a median of 8.4 days, an open reduction and internal fixation was carried out in all patients. No complications related to the temporary arthrodesis were observed during the acute phase, and follow-up at 24 months revealed no damage to the articular surface attributable to the pin insertion. The median Olerud-score was 33.43, but three patients showed signs of early post-traumatic arthritis which we felt were due to the initial fracture. We conclude that closed reduction and temporary fixation using vertical transarticular pins of unstable ankle fractures is a safe method of maintaining joint alignment until a definitive open approach is feasible.