The midterm restriction of the quality of life should be evaluated and correlated with the objective radiological results in patients with the special tibial plateau fracture of type Moore V. From 2003 to 2012, 36 patients with 38 fractures were registered in a retrospective cohort study. Injury mechanism, surgical treatment, complication rate, and radiological results after a mean follow-up of 37 months and the quality of life (NRS, IKDC-form, and EQ-5D-score) after 68 months were analyzed. There were 27 men and 9 women (mean age 50.8 years) in 30 cases with high impact injury. External fixator was used in 24 cases primarily, single plate fixation was used in 12 cases, and double plate fixation was used in 25 cases. All early complication (21%) could be cured. Mean NRS was 4.53, IKDC-score was 50.46, and the EQ-5D was 7.47. The quality of life was quoted to 44% of the output value before the injury. Osteoarthritis was seen in 36 cases; severe in 19 cases and 4 requiring endoprostheses. Loss of reduction and deviation of axis were seen in 13 and 3 patients, respectively. The tibial plateau of type Moore V is a severe injury resulting in the midterm reduction of the quality of life. There is a correlation of subjective and objective results.

Sind Krepitationen unter der Haut nach penetrierenden Verletzungenein ein harmloses benignes subkutanes Emphysem oder eine gefährliche Infektion mit gasbildenden Bakterien (Gasbrand durch Clostridium perfringens, krepitierende Zellulitis durch anaerobe Streptokokken oder koliforme Anaerobier)?

Versorgung periprothetischer Frakturen durch Implantation eines sonderangefertigten, retrograden Hohlnagels, der über die Prothesenspitze gestülpt und mit dieser verklemmt wird.

Treatment of periprosthetic fractures by implantation of a specially constructed, retrograde hollow nail which fits over the tip of the prosthesis and becomes locked on it.Periprosthetic femoral fractures with firmly anchored prosthesis shaft after total hip arthroplasty of types B1 and C according to the Vancouver classification.Loosened prosthesis (type B2/B3) and trochanteric fractures (type A). Broken or damaged prosthesis, florid inflammation and soft tissue injuries in the operation field, contracted knee joint, advanced deformation in the knee joint and distal femur, enclosed prosthesis and general contraindications.In a supine position the periprosthetic fracture is exposed via a lateral access. For cemented prostheses the cement is removed around the tip of the prosthesis (at least 2-3 cm) and medullary cavity. Arthrotomy with flexion of the knee joint and marking of the nail entry point. Drill the medullary cavity, retrograde introduction of the nail, visually fit the nail over the tip of the prosthesis and lock the nail with the prosthesis. If necessary use additional spongiosaplasty or also placement of additional cerclages depending on fracture type and size of the defect zone. Lock the nail distally. Use intraoperative radiological imaging to control correct positioning and length of the nail. Close the wound layer by layer with placement of suction drainage devices and dressing.Partial loading for 6 weeks with a subsequent pain-adapted loading gradient until full loading is possible. If selective partial loading is not possible, a decision must be made in individual cases as to whether the intraoperative findings allow immediate full loading.From 2004 to 2011 a total of 25 periprosthetic femoral fractures in 25 patients were treated in 2 locations using specially constructed slotted hollow nails. Within the framework of a retrospective study 20 of these patients (16 female and 4 male; average age 77.2 [72-84] years) were clinically and radiologically re-examined on average 19.3 (7-31) months postoperatively. No postoperative bleeding, wound healing disorders and infections. In all patients there was a loading stable consolidation of the fracture in the correct femoral axis, length and rotation with no evidence for radiological signs of loosening of the prosthesis or dislocation of the nails. In one case there was loosening of the prosthesis which had obviously occurred during the operative procedure. After consolidation of the fracture it was necessary to exchange the prosthesis for a long shafted prosthesis. A comparable situation to the preoperative degree of mobility was found in 12 out of the 20 patients, a moderate deterioration in 5 patients, a substantial residual impairment in 2 patients and an improvement of the situation in 1 patient.

Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.

Treatment of cartilage defects poses challenging problems in human and veterinary medicine, especially in horses. This study examines the suitability of applying scaffold materials similar to those used for human cartilage regeneration on equine chondrocytes. Chondrocytes gained from biopsies of the talocrural joint of three horses were propagated in 2D culture and grown on two different scaffold materials, hyaluronan (HYAFF®) and collagen (BioGide®), and evaluated by light and electron microscopy. The equine chondrocytes developed well in both types of materials. They were vital and physiologically highly active. On the surface of the scaffolds, they formed cell multilayers. Inside the hyaluronan web, the chondrocytes were regularly distributed and spanned the large scaffold fibre distances by producing their own matrix sheath. Half-circle-like depressions occasionally found in the cell membrane were probably related to movement on the flexible matrix sheath. Inside the dense collagen scaffold, only single cells were found. They passed through the scaffold strands by cell shape adaptation. This study showed that the examined scaffold materials can be used for equine chondrocyte cultivation. Chondrocytes tend to form multilayers on the surface of both, very dense and very porous scaffolds, and have strategies to span between and move in large gaps.

INTRODUCTION:The operative treatment of a congenital trigger thumb comprises splitting the A1 pulley under conditions of hand surgery. One complication is cutting through the A2 pulley. In this case a bowstring phenomenon will result.CASE REPORT:We report about the reconstruction of the A2 pulley by using a transosseous fixed tendon strip for a now 7-year-old boy with an impressive bowstring phenomenon with profound impairment of thumb function and power after surgery of a trigger thumb at the age of 2 years.DISCUSSION:The iatrogenic splitting of the A2 pulley during the operative treatment of a congenital trigger thumb and the treatment of the resulting bowstring phenomenon are not sufficiently reflected at the literature. In adulthood, several different methods of pulley reconstruction are described.CONCLUSION:In our opinion this technique is a safe and easy option to reconstruct the A2 pulley without expensive fibre anchors and enables a broad replacement without compromising extension tendons. Also outdated bowstring phenomenons are sufficiently stabilised. A good hand function with full preservation of finger flexibility and power is ensured as well.

Periprothetische Femurfrakturen nach Revisionskniegelenkendoprothetik werden mit zunehmender Häufigkeit beobachtet. Ein 59-jähriger Patient zog sich nach einer solchen in der Anschlussheilbehandlung im Rahmen eines Sturzes bei der Physiotherapie eine periprothetische Oberschenkelschaftfraktur zu. Die Behandlung erfolgte nach exakter präoperativer Planung mittels computertomographischer Messung der Größen- und Längenverhältnisse sowie Herstellung eines individuellen Implantats durch offene Reposition und Aufpfropfen eines Femurnagels auf den Prothesenstiel. Der Patient wurde postoperativ unter schmerzadaptierter Vollbelastung mobilisiert, nach 12 Wochen war es zur knöchernen Konsolidierung bei schmerzfreier Vollbelastung gekommen. Die In-situ-Kopplung einer Endoprothese mit einem geschlitzten Hohlnagel stellt eine wertvolle Behandlungsoption bei periprothetischen Frakturen dar.

Bei zunehmender Zahl an Revisionsoperationen nach einer Kniegelenkendoprothetik ist eine steigende Inzidenz periprothetischer Femurfrakturen zu beobachten.

Introduction: The positioning-related compartment syndrome of the lower leg after long-duration operations in the lithotomy position represents a rare complication. The aim of this retrospective study was to draft recommendations to avoid this rare complication by reviewing the cases with positioning-related compartment syndromes in our own patient data.Patients/Material and Methods: From January 1996 to February 2009, 3 women and 1 man with an average age of 38 years (24 to 55 years) were treated with a medial and lateral dermatofasciotomy with opening of lower leg loges due to a clinically manifested compartment syndrome of the lower leg after long-duration operations in the lithotomy position.Results: In all 4 patients a dermatofasciotomy with opening of the lower leg compartments could avoid considerable secondary damage of the limb. A long-duration lithotomy position in connection with obesity, a low positioning of the head as well as nicotine abuse are only some of the risk factors contributing to the development of a positioning-related compartment syndrome. An epidural anaesthesia bears the risk of a protracted diagnosis.Conclusion: The positioning-related compartment syndrome represents a rare but considerable complication after long-duration operations in the lithotomy position. It is a clinical complication and the inducing and exponentiation risk factors as well as the clinical symptoms should be known by the treating team. If the operation time is expected to be longer than 3 hours, we recommend written information to the patient concerning this complication. Consequent postoperative controls of risk patients are obligatory. An epidural anaesthesia bears the risk of a protracted diagnosis. In the case of suspected compartment syndrome we recommend early dermatofasciotomy in order to avoid irreversible damage to the limb.

PURPOSEThe rhizarthrosis is the most common degenerative joint disease of the hand. Incidence is detected around 10 %. For the treatment of rhizarthrosis different conservative and surgical methods are available. As many publications deal with the outcome of different surgical procedures. However there are no experiences in possibility of resuming an extreme exposure of the hand by athletic activities and the relevant timeframe between surgical treatment and the resumption as well as which of the competing surgical procedures you should suggest the patient.CASE REPORTA female 46-year-old tennis player went to hospital in January 2005 with rhizarthrosis in stage 3 according to Eaton of the dominant right hand with pain during rest and exertion in the right basal joint. She was treated with trapeziectomy and interposition of a pyrocarbon spacer. Since the last clinical and radiological check in spring 2009, the patient is completely free of complaints and has resumed to play tennis 1 - 2 hours per day at tournament level. The correct position of the pyrocarbon spacer is radiologically verified while the joint space in the carpo-metacarpal joint is constant.CONCLUSIONThe trapeziectomy with interposition of an pyrocarbonspacer is a worthfull alternative compared to other established operative techniques. The demonstrated casuistic proves that this treatment matches both the high and multiaxial stress on the first ray of athletes. Four dislocations in the examined collective and the price of the implant of 930 Euro has to be discussed critically.

Corrected by: ErratumHandchir Mikrochir Plast Chir 2009; 41(06): 378-378DOI: 10.1055/s-0029-1245116

PURPOSE:The aim of this work was to point out the meaning of pyrocarbon spacer as replacement of the trapezium in case of rhizarthrosis.PATIENTS/MATERIAL AND METHOD:32 Patients (20 female, 12 male) provided in our department between January 2005 and June 2008 with pyrocarbon spacer as replacement of the trapezium as a result of a radiologic as well as clinical documented rhizarthrosis. To rate the therapy a clinical and radiological examination was done and the score of Buck-Gramcko was used. Because of a complication in two patients the spacer was taken out and a suspension arthroplasty was done. Those two patients were not considered in the study.RESULTS:80% good and very good results according to the score of Buck-Gramcko, 13.3% of satisfactory and 6.7% bad results were obtained. Dislocation of the implant is the main complication of the presented procedure.CONCLUSION:With the presented procedure it is possible to achieve in the majority of the treated patients good and very good results. 4 dislocations in the examined collective and the price of the implant of 930 Euro has to be discussed critically.

Zur Wiederherstellung von Knorpeloberfläche und geschädigtem subchondralem Knochen steht die Knorpel-Knochen-Transplantation (KKT) zur Verfügung. Hierbei werden Knorpel-Knochen-Zylinder aus einer weniger belasteten Region des Gelenks in das Areal des Knorpelschadens transferiert. Das Operationsverfahren basiert auf dem Prinzip der Pressfit-Verankerung des in der Regel aus dem medialen oder lateralen kranialen Anteil des Patellagleitlagers gewonnenen Transplantats mit nachfolgender zuverlässiger Einheilung im knöchernen Lager.

Osteoporosis is a metabolic bone disease characterized by reduced bone quality and quantity. As a consequence, patients are at risk for fractures, subsequent immobility, and higher mortality especially among elder patients. Because of the high incidence of complications and the associated financial burden for the health system, new parameters for diagnostic and therapeutic purposes are urgently needed. In this regard, research focused on vitamin K as a biochemical bone marker has provided promising results. Vitamin K represents an important enzyme-cofactor for the posttranslational modification and activation of several proteins involved in bone metabolism. Vitamin K has been proven to be a valuable diagnostic as well as therapeutic parameter especially in osteoporosis. Patients with osteoporosis have been shown to have decreased levels of vitamin K. Further, regular intake of vitamin K may increase bone mineral density (BMD), thereby lowering the fracture risk. Yet vitamin K alone may not sufficiently indicate the mineral status of the bone. However, the usefulness of a combination of several biochemical bone markers as improved surrogate markers of bone metabolism has been shown recently. Therefore, this review will focus on the significance and importance of vitamin K for bone metabolism. Beyond this, aspects on the current and prospective use of vitamin K as well as other newly developed biochemical bone markers will be discussed. (C) 2008 Elsevier Inc.

Osteochondral transplantation is a treatment option for restoring lesions of the cartilage surface and the underlying subchondral bone. For this technique, osteochondral cylinders are taken from less loaded regions of the knee joint and brought into the defect. It is based on press-fit implantation of osteochondral cylinders that are harvested from the mediocranial or laterocranial aspect of the patellofemoral joint with subsequent stable bony integration of the transplant.Indications for osteochondral transplantation must consider clinical, radiological, and magnetic resonance aspects, and concomitant pathologies of the joint should be eliminated. Isolated grade III and IV cartilage lesions in the load-bearing area of the medial or lateral femoral condyle are considered to be ideal indications for osteochondral transplantations. Further indications are retropatellar defects and lesions of the medial aspect of the talus. The technique is established for defects from 1 cm(2) to 3 cm(2).At this time, osteochondral transplantation is the only surgical method to achieve long-term coverage of the defect with hyaline cartilage. Donor site morbidity at the patellofemoral joint needs to be discussed because, particularly after the harvest of several cylinders, pain syndromes can develop. Therefore, the technique should be limited to two cylinders with a maximum diameter of 12 mm and one further cylinder with a smaller diameter.

Aim: Elastic stable intramedullary nailing (ESIN) is the therapy of choice in pediatric forearm shaft fractures. It requires increased intraoperative image intensifier times and radiation load.Method: We performed a retrospective analysis of 78 operative procedures from a five-year period. In 16 cases the image intensifier times of the distinct steps of the operation were investigated prospectively.Results: Average duration of the surgical procedure was 36.9 (18-144) minutes. Average radiation time was 59.5 (8-222) seconds. In educational operations, the duration of surgery was significantly longer than in procedures performed by experienced surgeons, but radiation times only were increased tendentially. In those procedures investigated prospectively, 53.1% of the image intensifier time was used for fracture passage.Conclusion: In ESIN of forearm shaft fractures, intraoperative image intensifier times of less than 2 minutes can be expected. Low intraoperative radiation times are a mark of quality. They serve for radiation protection of the patients, surgeons and OT staff.

Der erhöhte Bedarf an intraoperativer Durchleuchtungszeit bei intramedullären Osteosynthesetechniken ist von der Verriegelungsnagelung der Erwachsenen her bekannt und akzeptiert. Angaben über den Bildwandlereinsatz bei der elastisch stabilen intramedullären Nagelung (ESIN) bei Kindern und Jugendlichen liegen dagegen kaum vor.