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Meeting abstract : Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2012), 23.10.-26.10.2012, Berlin.
Fragestellung: Die Behandlung langstreckiger Knochendefekte ist eine große Herausforderung. Die Masquelet-Technik zur Behandlung solcher Defekte ist eine zweizeitige Operationstechnik. Zuerst erfolgt die Insertion eines PMMA (Polymethylmethacrylat)-Zementspacers in den Knochendefekt, der die Bildung einer Membran induziert. Diese Membran enthält Wachstumsfaktoren und regenerative Zellen, die möglicherweise die Knochenheilung unterstützen. Nach einigen Wochen wird der Zementspacer entfernt und der induzierte Membranschlauch mit Beckenkammspongiosa aufgefüllt. Im weiteren Verlauf kommt es zu einer kompletten Knochenheilung. Ziele dieser Untersuchung waren die Etablierung der Masquelettechnik am Rattenmodell und die Definition eines Zeitpunkts, an welchem die Membran eine ausreichende Festigkeit sowie einen signifikanten Gehalt von Vorläuferzellen aufweist.
Methodik: Nach Genehmigung der Experimente wurden die Femura von 24 männlichen SD-Ratten osteotomiert. Die Lücke (10 mm) wurde mit PMMA-Zement aufgefüllt und mittels Miniplatte stabilisiert. Parallel wurden den Versuchstieren gleich große PMMA-Spacer subcutan unter die Rückenhaut implantiert. Nach 2, 4, bzw. 6 Wochen (W) erfolgte die Entnahme der Membranen. Ein Teil der Membran wurde für (immun)histologische Untersuchungen aufbereitet (CD34, vWF, van Giesson), ein Teil für die in vitro Kultur. Auswachsende Vorläuferzellen in vitro wurden über CD34 und STRO-1-Färbung nachgewiesen. Statistik: Mediane, Kruskal-Wallis-Test, p<0,05 ist signifikant.
Ergebnisse und Schlussfolgerungen: Im zeitlichen Verlauf nahmen die Vaskularisierung (vWF-positive Fläche [%]: 2 W: 1,8; 4 W:1.6 vs 6 W: 6,4), die Dicke der Membran ([µm]: 2 W: 350 vs 4W: 517, 6 W: 592) und der Bindegewebsanteil ([µm]: 2W: 201 vs 4W: 324, 6W: 404) signifikant zu. Der Hauptanteil elastischer Fasern war auf der dem Zement zugewandten Seite, Vaskularisierung war eher auf der Weichteil zugewandten Seite zu finden. Der Anteil CD34 positiver Zellen nahm signifikant ab (2W: 5%, 4 W: 4% vs 6 W: 1%). Auswachsende STRO-1 positive Zellen konnten nur in zweiwöchigen Membranen nachgewiesen werden. Ältere Membranen wiesen einen zunehmenden Anteil seneszenter Zellen auf. Subcutan induzierte Membranen waren vergleichbar, wiesen jedoch tendentiell eine geringere Dicke und keine STRO-1 positiven Zellen auf.
Mit dieser Studie wurde erstmalig die Induktion einer Membran nach Masquelet im Rattenmodell etabliert. Es konnte nachgewiesen werden, dass der strukturelle Aufbau sowie die zellulären Komponenten zeitlichen Änderungen unterliegen und der Ort der Induktion Einfluss auf die zellulären Komponenten der Membran hat. Junge Membranen (2W) enthielten CD34 und STRO-1 positive Zellen. 4W-Membranen enthielten nur CD34 positive Zellen wiesen aber einen signifikanten Bindegewebsanteil auf, der für eine erhöhte mechanische Stabilität spricht. Ob 2 bzw. 4 Wochen alte Membranen den Knochenheilungsprozess fördern, muss in weiterführenden Studien untersucht werden.
Purpose: Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the “Purdue Pegboard” skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.
Methods: A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), “Disability of Arm, Shoulder and Hand” (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.
Results: Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.
Conclusion: In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.
Background: Surgical complications are associated with a significant burden to patients and hospitals and are increasingly discussed in recent literature. This cohort study reviewed surgery-related complications in a Level I trauma center. The effect of a complication avoidance care bundle on the rate of surgical complications was analyzed. Methods: All complications (surgical and nonsurgical) that occur in our trauma department are prospectively captured using a standardized documentation form and are discussed and analyzed in a weekly trauma Morbidity and Mortality (M&M) conference. Surgical complication rates are calculated using the annual surgical procedure numbers. Based on discussions in the M&M conference, a complication avoidance care bundle consisting of five measures was established: (1) Improving team situational awareness; (2) reducing operating room traffic by staff members and limiting door-opening events; (3) preoperative screening for infectious foci; (4) adapted preoperative antibiotic prophylaxis in anatomic regions with a high risk of infectious complications; and (5) use of iodine-impregnated adhesive drape. Results: The number of surgical procedures steadily increased over the study years, from 3587 in 2015 to 3962 in 2019 (an increase of 10.5%). Within this 5-year study period, the overall rate of surgical complications was 0.8%. Surgical site infections were the most frequently found complications (n = 40, 24.8% of all surgical complications), followed by screw malposition (n = 20, 12.4%), postoperative dislocations of arthroplasties (n = 18, 11.2%), and suboptimal fracture reduction (n = 18, 11.2%). Following implementation of the complication avoidance care bundle, the overall rate of surgical complications significantly decreased, from 1.14% in the year 2016 to 0.56% in the study year 2019, which represents a reduction of 51% within a 3-year time period. Conclusions: A multimodal strategy targeted at reducing the surgical complication rate can be successfully established based on a transparent discussion of adverse surgical outcomes. The combination of the different preventive measures was associated with reducing the overall complication rate by half within a 3-year time period.
Introduction: In an emergency department, the majority of pediatric trauma patients present because of minor injuries. The aim of this study was to evaluate temporal changes in age-related injury pattern, trauma mechanism, and surgeries in pediatric patients. Methods: This retrospective study included patients < 18 years of age following trauma from 01/2009 to 12/2018 at a level I trauma center. They were divided into two groups: group A (A: 01/2009 to 12/2013) and group B (B: 01/2014 to 12/2018). Injury mechanism, injury pattern, and surgeries were analyzed. As major injuries fractures, dislocations, and organ injuries and as minor injuries contusions and superficial wounds were defined. Results: 23,582 patients were included (58% male, median age 8.2 years). There was a slight increase in patients comparing A (n = 11,557) and B (n = 12,025) with no difference concerning demographic characteristics. Significant more patients (A: 1.9%; B: 2.4%) were admitted to resuscitation room, though the number of multiple injured patients was not significantly different. In A (25.5%), major injuries occurred significantly less frequently than in B (27.0%), minor injuries occurred equally. Extremity fractures were significantly more frequent in B (21.5%) than in A (20.2%), peaking at 8–12 years. Most trauma mechanisms of both groups were constant, with a rising of sport injuries at 8–12 years. Conclusion: Although number of patients increases only slightly over a decade, there was a clear increase in major injuries, particularly extremity fractures, peaking at 8–12 years. At this age also sport accidents significantly increased. At least, admittance to resuscitation room rose but without an increase of multiple injured patients.
Introduction: The aim of this article is to show a new concept of indication and application of the MUTARS® RS Cup System in primary and revision hip arthroplasty. This integrated system is applicable for different acetabular cup replacements in patients with acetabular fractures or instable defects, as well as periprosthetic acetabular fractures. The MUTARS® RS Cup System is a cementless revision cup for insertion into the acetabulum with an integrated polyethylene cup, which fits to a regular or bipolar head. This system replaces the conventional approach for acetabular revision with a Burch-Schneider ring, in which a normal polyethylene cup is cemented. This interface with its complications is avoided with this system of a titanium revision cup with integrated polyethylene cup. Steps of preoperative planning and the intraoperative implementation will be highlighted in this article.
Material and methods: This system was applied in 49 patients with 52 MUTARS® RS Cup Implantations in 30 males, 22 females, with an average age of 76,1 years (36,9–94,4 years).
Results and discussion: The system shows a good operative feasibility, as well as a reliable handling and safe method for stable treatment of non-reconstructable acetabular fractures or acetabular incongruencies and instabilities.
Objective: Skin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time.
Methods: We conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally.
Results: After liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application.
Conclusion: The fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.
Introduction: Stem cell transplantation is one of the most promising strategies to improve healing in chronic wounds as systemic administration of endothelial progenitor cells (EPC) enhances healing by promoting neovascularization and homing though a high amount of cells is needed. In the following study, we analysed whether local application can reduce the number of EPC needed achieving the same beneficial effect on wound healing.
Material and Methods: Wound healing after local or systemic treatment with EPC was monitored in vivo by creating standardized wounds on the dorsum of hairless mice measuring wound closure every second day. Systemic group received 2 × 106 EPC i.v. and locally treated group 2 × 105 EPC, locally injected. As control PBS injection was performed the same way. Expression of CD31, VEGF, CD90 and, SDF-1α was analysed immunohistochemically for evaluation of neovascularisation and amelioration of homing.
Results: Local (7.1 ± 0.45 SD) as well as systemic (6.1 ± 0.23 SD) EPC transplantation led to a significant acceleration of wound closure compared to controls (PBS local: 9.7 ± 0.5 SD, PBS systemic 10.9 ± 0.38 SD). Systemic application enhanced CD31 expression on day 6 after wounding and local EPC on 6 and 9 in comparison to control. VEGF expression was not significantly affected. Systemic and local EPC treatment resulted in a significantly enhanced SDF-1α and CD90 expression on all days investigated.
Conclusion: Local as well as systemic EPC treatment enhances wound healing. Moreover, beneficial effects are obtained with a tenfold decrease number of EPC when applied locally. Thus, local EPC treatment might be more convenient way to enhance wound healing as number of progenitor cells is limited.
Introduction. Cancellous bone is frequently used for filling bone defects in a clinical setting. It provides favourable conditions for regenerative cells such as MSC and early EPC. The combination of MSC and EPC results in superior bone healing in experimental bone healing models. Materials and Methods. We investigated the influence of osteogenic culture conditions on the endothelial properties of early EPC and the osteogenic properties of MSC when cocultured on cancellous bone. Additionally, cell adhesion, metabolic activity, and differentiation were assessed 2, 6, and 10 days after seeding.
Results. The number of adhering EPC and MSC decreased over time; however the cells remained metabolically active over the 10-day measurement period. In spite of a decline of lineage specific markers, cells maintained their differentiation to a reduced level. Osteogenic stimulation of EPC caused a decline but not abolishment of endothelial characteristics and did not induce osteogenic gene expression. Osteogenic stimulation of MSC significantly increased their metabolic activity whereas collagen-1α and alkaline phosphatase gene expressions declined. When cocultured with EPC, MSC’s collagen-1α gene expression increased significantly. Conclusion. EPC and MSC can be cocultured in vitro on cancellous bone under osteogenic conditions, and coculturing EPC with MSC stabilizes the latter’s collagen-1α gene expression.
Meeting Abstract (DGU 2003) 67. Jahrestagung der Deutschen Gesellschaft für Unfallchirurgie 89. Tagung der Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie 44. Tagung des Berufsverbandes der Fachärzte für Orthopädie Fragestellung Ziel dieser prospektiven Untersuchung ist die Analyse der Funktion und des Outcomes nach distaler Radiusfraktur in Abhängigkeit von Frakturtyp, Therapieform und Begeleitverletzungen. Berücksichtigt wurden diesbezüglich insbesondere auch neuere Implantate wie die volaren winkelstabilen Titanplatten und dorsale low profile Implantate. Methodik Innerhalb von 2 Jahren (01/01 bis 12/02) wurden insgesamt 150 Radiusfrakturen bei 145 Patienten (82 Frauen; 63 Männer) mit einem Durchschnittsalter von 51,8 (17-93) Jahren operativ versorgt. Die operative Versorgung erfolgte in 56,7 % der Fälle mittels volarer Plattenosteosynthese, davon wurde bei 60 % eine winkelstabile Platte eingesetzt. Die übrigen Frakturen wurden durch eine dorsale Platte (8%) bzw. durch Materialkombination Spickdraht/Schrauben und/oder Fixateur externe stabilisiert. Die radiologische und klinische Nachuntersuchung erfolgt frühestens 1 Jahr nach operativer Versorgung. Zusätzlich wird anhand eines Fragebogens der DASH - Score bestimmt. Ergebnisse Nach der AO-Klassifikation fanden sich in 47,7 % Typ A-, 8,6% Typ B- und 55,6% Typ C-Frakturen. Dabei fand sich bei 53,1 % eine relevante Begleitverletzung (Bandverletzungen 14,3 %; Handwurzelfrakturen 3,9 %; distale Ulnafrakturen 10,4%; TFC/Proc. styloideus ulnae 70,1%). Von den 25 bisher untersuchten Patienten (15 Frauen, 10 Männer; Durchschnittsalter: 55,3 Jahre; NU nach: 14 Monaten) waren 32% Typ A-, 20% Typ B- u. 48% Typ C-Frakturen. Die Greifkraft betrug 87,7 % und das Bewegungsausmaß 83,6 % im Vergleich zur Gegenseite. Der durchschnittliche standardisierte DASH-Score betrug 22,6 Punkte (0: optimale Funktion). Bei den mit volarer Platte stabilisierten C-Frakturen (9 der nachuntersuchten Patienten) fand sich ein DASH-Score von 41 Punkten. Die Greifkraft betrug 67,5% und das Bewegungsausmaß 79,6% im Vergleich zur Gegenseite. Bisher konnte weder bei der konventionellen, noch der winkelstabilen Plattenosteosynthese ein radiologischer Korrekturverlust nachgewiesen werden. Bei den Frakturen ohne lokale Begleitverletzungen waren Greifkraft (91% vs. 79,8%), Bewegungsausmaß (89,5% vs. 83,4%) und DASH-Score (16,8 vs. 26,1) besser als bei den Frakturen mit Begleitverletzungen. Schlussfolgerung Bei korrekter Reposition und Stabilisierung, wird der Outcome nach distaler Radiusfraktur neben dem Frakturtyp wesentlich durch die Begleitverletzung mitbestimmt. Daraus resultiert dass eine Verbesserung nur durch eine Optimierung der Therapie der Begleitverletzungen erreichbar ist.
Introduction: Microsurgery courses, taught external to surgical training programs, are essential for acquiring the high level of technical skill required for clinical proficiency.
Methods: The Frankfurt microsurgery course is a 5-day, intensive course that teaches arterial and venous anastomosis using end-to-end, end-to-side, one-way-up, continuous-suture, and vessel graft techniques. During the course, the instructor records the level of skill (in-course data) achieved by each trainee by assessing anastomosis completion and patency. Demographic information is also collected. Post-course trainees are invited to complete an online survey (post-course data) to get their opinions of the courses’ effectiveness.
Results: The in-course “skill achievement” and post-course “course effectiveness” data are presented below. In-course data: 94.8 and 59.9% of participants completed patent end-to-end arterial and venous anastomoses, respectively, while 85.4% performed a patent end-to-side anastomosis. 96.1 and 57.1% of participants who attempted arterial and venous anastomoses using the one-way-up technique were successful, as were 90.9% of those attempting continuous-suture technique. Patent venous grafts were performed by 54.7% of participants.
Post-course data: All respondents indicated significant improvement of their microsurgical skills after taking the course. 66.7% of respondents considered the full-time presence of the instructor to be the most valuable aspect of the course. All respondents would highly recommend the course to colleagues.
Conclusion: The microcourse significantly increased trainees’ clinical microsurgery skills, confidence, and the number of clinical cases they perform. Of all the anastomosis techniques taught, venous anastomosis and grafting were the most difficult to learn. The presence of a full-time experienced instructor was most important.