Наш опыт лечения ложных суставов плечевой кости с применением химотрипсина узбекский нии травматологии и ортопедии
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^ ТАКТИКА ЛЕЧЕНИЯ УКУШЕННЫХ РАН КИСТИ
НИИ скорой помощи им. Н.В. Склифосовского
Яшина Т.Н., Плохой А.А., Курков Д.В., Афанасьев А.В.
В Москве сохраняется высокий уровень пострадавших от укусов животными. За последние 5 лет зарегистрировано более 4 тысяч обращений в ГКБ № 6.
Даже небольшие по объему повреждения могут приводить к значительным нарушениям функции кисти. Местная обработка ран чрезвычайно важна. Ее необходимо начинать как можно раньше от момента укуса. Она включает санацию раны и окружающих участков кожи мыльным раствором и затем растворами антисептиков, проведение гемостаза, удаление явно нежизнеспособных и некротизированных тканей. Заканчивается обработка наложением повязки с гидрофильной мазью или растворами антисептиков. При показаниях проводится гипсовая иммобилизация в функционально выгодном для кисти положении. Обязательным при лечении укушенных ран кисти является проведение адекватной антибактериальной терапии. Операционная тактика при развитии гнойных осложнений включает вскрытие и санацию гнойного очага, удаление некрозов и секвестров и его дренирование. С учетом функциональной значимости кисти как органа, обеспечивающего трудовую и социальную адаптацию, чрезвычайную важность приобретает вопрос закрытия укушенной раны. После успешного комплексного лечения укушенной раны и купирования перифокальных воспалительных явлений, возникают благоприятные возможности для наложения отсроченных швов и кожной пластики. Наш опыт показывает, что оптимальными сроками для наложения отсроченных швов являются 5–7сутки. Для закрытия укушенных ран используется глухой шов с введением в рану микроирригатора – тонкого дренажа. При наличии дефектов кожи используем кожную пластику местными тканями, свободную или комбинированную. Проводимая тактика лечения позволила предотвратить инфекционные осложнения у 1111 из 1270 пациентов, поступивших на протяжении 2002 года с укушенными ранами кисти. Из 159 больных, оперированных по поводу гнойно-некротических осложнений укушенных ран, у 141 (89,68%) больного в последующем были выполнены операции с наложением швов. Осложнений не отмечено. При нарушениях функции кисти и ее основных захватов были проведены корригирующие операции, в том числе эндопротезирование межфаланговых суставов – у 2 больных, устранение вывихов фаланг пальцев кисти с использованием аппаратов Лазарева–Коршунова и открытое вправление с последующей фиксаций спицами – 10 наблюдений, корригирующие остеотомии – 7 наблюдений, различные способы кожной пластики с целью устранения контрактур и порочных рубцов – 12 наблюдений. Восстановительные операции на сухожилиях – 9 наблюдений. Проводимая тактика лечения при укушенных ранах кисти позволила получить положительные результаты лечения у 89% больных.
^ КЛИНИЧЕСКИЕ АСПЕКТЫ ПРИМЕНЕНИЯ ГРАВИТАЦИОННОЙ ТЕРАПИИ В ТРАВМАТОЛОГИИ И ОРТОПЕДИИ
Самарский государственный медицинский университет
Яшков А.В., Коновалов Д.А., Фридланд Л.Б.
Результативность лечения больных с патологией опорно-двигательной системы на восстановительном этапе во многом определяется адекватным выбором физиотерапевтических средств. Известно, что в патогенезе осложнений большое значение имеет недостаточность кровоснабжения в поврежденном костном сегменте, вследствие повреждения внутрикостных сосудов, выраженной травматизации мягких тканей. В связи с этим поиск эффективных неинвазивных методов коррекции местных гемодинамических нарушений посттравматического генеза с целью оптимизации репаративного остеогенеза актуален и патогенетически обоснован.
Экспериментальные исследования на животных, у которых моделировали перелом костей голени, показали, что воздействие повышенной гравитацией кранио-каудального направления способствует активному росту костной ткани в формирующемся регенерате. Была установлена коррелятивная зависимость развития костной мозоли от состояния микроциркуляторного русла. Данные экспериментальных исследований послужили основанием для применения, данного физического фактора в лечебной практике клиники травматологии, ортопедии и экстремальной хирургии Самарского государственного медицинского университета у больных с замедленной консолидацией, несращенным переломом, ложным суставом, начальными признаками деформирующего артроза. На данные способы получены патенты на изобретение № 2145821 и № 2146115, № 2145824 от 2000 года. Они предусматривают одновременное воздействие повышенной гравитации кранио-каудального направления в сочетании с дозированной работой мышц нижних конечностей. Моделировали гипергравитацию с помощью специального стенда для лечения ишемических состояний нижних конечностей. С целью оптимизации остеогенеза, предупреждения развития артрозных изменений после внутрисуставных повреждений гравитационная терапия была применена у 560 больных. Эффективность лечения оценивалась клинически, а также с помощью современных диагностических методов (реовазография, термография, ультразвуковая допплерография, сцинтиграфия, рентгенография, электромиография).
Результаты лечения показали высокую эффективность гравитационной терапии у больных с осложненными переломами голени, бедра, начальными признаками деформирующего артроза. Положительные исходы были получены у лиц с длительными сроками заболевания и отсутствием эффекта от ранее проводимого лечения. Использование нового физиотерапевтического фактора в лечебном комплексе позволило значительно увеличить количество хороших результатов по сравнению с традиционным лечением и уменьшить число неудовлетворительных исходов в 2,5 раза.
^ MANAGEMENT OF ACQUIRED FLATFOOT DUE TO POSTERIOR TIBIAL TENDON DYSFUNCTION
St.Anna Clinic
Christian Sommer
The entity of posterior tibial tendon dysfunction and its relationship to the unilateral adult acquired flatfoot went unrecognized for years. Early in onset the patient complains of painful swelling posterior to the medial malleolus that may radiate to the medial arch. As the tendon dysfunction progresses, a deformity can ensue as a result of midfoot rotation about the talonavicular joint, producing a peritalar lateral subluxation. The medial arch subsequently collapses, allowing for a relative shortening of the lateral column and a painful lateral impingement of the talus and calcaneus. This results in an acquired unilateral flatfoot deformity: a pes planus, valgus et abductus. A clinical description in three stages as described by Johnson 1989 is presented. For each stage, operative and nonoperative treatment options are discussed and different surgical techniques presented.
^ HALLUX VALGUS: PATHOLOGY AND ALGORYTHM FOR SURGICAL DECISION MAKING
St.Anna Clinic
Christian Sommer
Only about 4% of the population develop hallux valgus irrespective to footwear. A much larger group of people are susceptible to the deformity and develop it given the right stimulus, for exaple shoes. Initially, there is valgus deviation of the toe on the metatarsal. This causes the extrinsic flexor and extensor tendons to displace laterally, shifting the sagittal plane forces to a valgus thrust on the toe and thereby causing increasing varus force on the first metatarsal head. Progression of the MP joint subluxation is initially limited by impingement of the tibial sesamoid on the crista of the metatarsal head. Once the crista is eroded, the MP joint becomes less stable and the tibial sesamoid comes to lie under the lateral aspect of the metatarsal head. This movement leads to a rotational torque to the hallux, causing an internal rotation of the first toe.
The operative therapy aims to reduce the intermetatarsal angle I/II and the hallux valgus interphalangeus. Proximal and distal procedures for the first metatarsal are known. Different techniques are discussed and a personal algorythm in decision making is presented.
^ THE AMC-UNIGLIDE EXPERIENCES WITH MINIMAL INVASIV-TECHNIQUE
Fabricius-Klinik Remscheid,Germany
GB
Introduction:
Increasing experiences in determining the indication for UKA and improvements in design and materials of the prosthesis led to better results. The AMC-Uniglide has an unconstrained mobile bearing with congruent area contact. This ensures complete freedom to rotate and slide upon one other with physiologic kinematic and low intrinsic stability.
Material and Methods:
Minimal-invasive technique
30 patients with minimal-invasive AMC-Uniglide implantation technique were compared with 30 conventional implanted AMC“s and 30 total knee replacements in regard to rehabilitation and accuracy of implantation.
361 AMC-Uniglides
361 consecutive patients were investigated after AMC-Uniglide implantation. The mean duration of follow-up was 5.5 (2.3-12.5) years. Patients were reviewed using the American Knee Society Rating System. The roentgenographic analyses were performed with the American Knee Society Evaluation System.
Results:
Minimal-invasive technique
The comparison of 30 minimal-invasive UKA with 30 conventional UKA and 30 total knee replacements show an advantage of minimal invasive technique with regard to a reduced time of rehabilitation. The accuracy of implantation was comparable between the conventional and the minimal-invasive technique.
361 AMC-Uniglides
Ninety-five percent of patients had no pain or slight pain at the latest follow-up, ninety-two percent had good or excellent clinical outcome. Three knees were revised for mobile bearing dislocation after medial UCA and three for lateral mobile bearing dislocation after lateral UCA. Five revisions because of component loosening were performed and there was one case of deep infection.
Conclusion:
The clinical results of the investigated patients demonstrate that the AMC-Uniglide is a successful concept with a safe anchorage of the prosthesis and a good durability of the mobile bearings. An advantage of minimal invasive technique with regard to a reduced time of rehabilitation was found. The accuracy of implantation was comparable between the conventional and the minimal-invasive technique.
Key Words
Unicompartmental knee arthroplasty– AMC-Uniglide - minimal-invasive
^ DOES SURFACE REPLACEMENT OF THE HIP PREVENT BAD RESULTS?
Orthopädische Klinik Universitätsklinikum Carl Gustav Carus
Guenther K.P., Witzleb W.C.
Introduction:
Hip resurfacing has always been an attractive strategy since it offers considerable advantages like: minimal bone loss, preservation of the epi- and metaphyseal femur; more physiological loading; reproduction of normal biomechanics and proprioception; minimal risk of dislocation and better conditions for revision surgery. Unfortunately historic hip resurfacings failed because of the failure of the implant materials. After the renaissance of the metal on metal bearings since 1986 in the mid 90ies modern resurfacings were developed, which based on that tribology. The question is whether the cementless cup and the metal on metal bearing of these devices can better the bad long time results of the historic resurfacings.
Method:
An assessment of short to mid-term clinical and radiological results of 276 McMinn Birmingham Hip Resurfacings (BHR) implanted in 238 patients between 1998 and 2002 with a follow-up of 1 to 5 years (mean 2 years) is presented. The 105 women and 133 men were in average 50 years (16-69) old. 38 patients were implanted on both sides.
Results:
Secondary arthritis predominated the presenting pathologies in our series with a high percentage of CDH cases (60%). The mean Harris Hip Score rose from 51 points preoperatively over 83 points already after 12 weeks to 90-92 points after one year postoperatively.
We did not found any migration or osteolysis radiologically except one case of a septic cup loosening. Altogether we had to revise 7 hips in cause of different complications: one early infection; two late infections, one with septic cup loosening; one nerve palsy; two missing implantations; one femoral neck fracture; one impingement of the iliopsoas tendon and two cases of ectopic ossification’s. 4 times the device had to be revised, what results in a revision rate of 1.4%.
Discussion:
The main problems of the historical hip resurfacings lay for certain in the too thin-walled and thus too elastic polyethylene cups and the metal or ceramic on polyethylene bearing. In our opinion these disadvantages are improved with the modern metal on metal Hip Resurfacings because of the cementless press fit cup, the low wear metal on metal bearing and the saver implantation technique. So we would advise this procedure young and active patients despite the missing long time experiences also mainly because the bad long time results of conventional THR in this patient population.
^ THIS CAN BE AVOIDED
Iyer orthopaedic centre
Iyer Vishwanath, Shivashankar B
Introduction: Locked nailing has become the standard modality for the treatment of diaphyseal fractures of long bones. However, indiscriminate use, without following the basic principles can give rise to complications, which can be avoided.
Material and methods: Examples of complications that the author has come across in dealing with routine trauma, are displayed. Why the complication occurred, how it could have been avoided and how to manage further have been described. The complications displayed are mainly for fractures of leg bones lower fourth and one femur nailing. This is very basic and does not deal with complications, likely to occur, with more advanced usage of locked nailing. Conclusions: If one follows the basic principles of locked nailing, complications can be minimum and success can be hundred percent.
^ SOLAPUR SLEEVE, AN USEFUL INSTRUMENT IN LOCKED NAILING
Iyer Orthopaedic centre
Iyer, Shivashankar
Introduction: Interlocking intramedullary nailing has become the preferred and standard method of treatment of diaphyseal fractures of the femur and tibia in most centers in the world, except in exceptional circumstances. With the availability of C arm closed nailing is the rule. The skin incisions are becoming smaller and it has become really a keyhole surgery.
Material and methods: We are describing the use of an instrument like a sleeve, 10 cm long, 1mm thick and 13mm wide. One end has a handle to hold and the other beveled. This acts as a soft tissue protector and helps in the keyhole surgery. We in over 100 prograde nailing and in 56 supracondylar nailing procedures have used this Sleeve. There were no special difficulties encountered
Discussion and Results: In the conventional method of interlocking nailing of femur, the entry incision is usually long to split the glutei and expose the trochanter The usual soft tissue protector is not deep enough to reach up to the trochanter. The flexible reamers, which are introduced to enlarge the medullary cavity, are not covered all around, with the possibility of friction burns, or occasionally, entanglement of soft tissues in the reamer. All this is avoided with the use of this Solapur Sleeve. The bevel facilitates the easy insertion.
Conclusions: The advantages of small incisions, like less postoperative pain, speedier postoperative mobilization and finally the cosmetic acceptance are made possible by usage of this Solapur Sleeve and the keyhole surgery
^ ACL REVISIONS
Praxisklinik 2000
Lais M.
Injuries of anterior cruciate ligaments (ACL) are very common. The success rate for ACL reconstructions is between 80 and 90 percent. A small number of patients have unsatisfactory results.
The reasons for operative revisions are pain, instability, deficit in extension / flexion or swelling. In a lot of cases different reasons are responsible.
Failures can be divided in:
• technical errors (non anatomic tunnel placement, inadequate graft fixation, Graft fixed in lax position, , inadequate graft material, Synthetics)
• untreated lesions (meniscus- / cartilage problems, failed meniscus refixation, axial malalignment, medial / lateral instabilities)
• biological errors (Arthrofibrosis, Infection)
• traumatic failures ( re-injurie, re-rupture)
• rehabilitation (unreliable patient, aggressive rehabilitation).
The treatment for failed ACL reconstructions is a complex procedure. The results of revision ACL surgery are not as good a primary ACL reconstruction. Preoperatively you need a careful analysis of the functional disability. The distinction between pain and instability is very important. You should outline the realistic expectations.
Steps in planning the operation.
• determine the cause of failure
• patient history
• examination (instability, pain, effusion, extension / flexion deficit, malalignment)
• x - raxy (weight baring) narrowing joint space, non anatomic tunnel
• placement)
• MRI (meniscus, cyclops Syndrom)
• patient information about operation (graft options, cartilage treatment, correction of malalignement)
If a revision ACL surgery is required you should know the used graft material, the location and size of the previous tunnels and the fixation device. Some cases need removing the old screws, carry out a bone grafting and do the reconstruction in a second operation. Other surgeries require a realignment .
We use only autocrafts (Quadriceps tendon, Patellar tendon, Semitendinosus / gracilis tebndon double or quadrupled). We have no experiences with Allografts (Patellar tendon, Achilles tendon, synthetics).
The rehabilitation for a revision ACL reconstruction is less aggressive than the initial operation. In the most cases a successful result can be expected.
^ A NEW CEMENTLESS GLENOID COMPONENT
ATOS-Klinik
Lichtenberg S, Habermeyer P
Introduction: Cementing techniques for polyethylene glenoid components lead to a high rate of radiolucency and even loosening.The design objective of this new glenoid component was to develop a cementfree socket system,fixing the socket without reaming or drilling,producing great primary stability so as not to leave any additional bone defects in the socket.
Material and Methods: The glenoid component consists of a 2 mm titanium metal-back with an anatomically convex back surface,which is screwed cementless against the socket by means of a cage screw 13 mm in diameter and 12 mm long.The cage screw is screwed into the spongeous bone so that the central bonecylinder remains.The cage screw allows bone ingrowth.The PE inlay is only 4 mm thick so that the entire socket component is only 6 mm high.An anatomical study on 10 scapulae was performed as well a cyclic loading test.In a prospective phase 1 clinical study from 1998 to 2000 we implanted 51 glenoid components.The radiological and functional outcome was assessed at 6 wks, 3 mon, 6 mon, and annually.
Results: The anatomical and radiological trials have shown that the glenoid component could be fixed securely in every size of the cadaver glenoid.Cyclic loading (1000000) in craniocaudal and in a-p direction (Fp= 400N) did not alter the prosthetic component.The postoperative x-ray examinations revealed a correct pressfit placement without any signs of radiolucency,loosening or dislocation in 50 cases.In 1 case the cage screw showed a misalignement leading to a revision.
Conclusion: This newly developed cementless glenoid offers the possibility of bone ingrowth and osteointegration.Furthermore no reaming of the subchondral bone is necessary which reduces glenoid bone loss.The anatomical and biomechanical tests for quality control display an excellent mechanical durability of the prosthetic components.
^ RESULTS OF TREATMENT AT PATIENTS AFTER TOTAL HIP REPLACEMENT WITH USE OF AN ESTIMATION OF QUALITY OF LIFE
The Volgograd State medical University, faculty of traumatology and orthopaedy, hospital №4 Volgograd
Lomtatidze V.E., Lomtatidze E.Sh., Kim N.I., Volchenko D.V., Potselujko S.V., Groshev J.V., Kruglov M.I., Popov D.P.
The purpose: to carry out a comparative estimation of quality of life and a functional condition of a hip joint at patients with traumas and diseases of hip before and after THR.
Problems: to select group of patients with traumas and diseases of hip by which it was carried out THR; to estimate quality of life by means of questionnaire EQ-5D; to estimate a functional condition on system Harris.
Materials and methods: 50 patients were included in research with traumas and diseases of hip joint. The middle age of the patients was 55,1 years (SD = 12,4 from 33 to 76 years). For an estimation of quality of life questionnaire EuroQuol-5D (EQ-5D) was used (the estimation on five basic sections was made: mobility, self-service, a pain, mood, daily activity), for a functional condition - system Harris.
Results: are investigated period was from 6 to 18 months, average value of quality of life on EQ-5D before the operation has made 0,53 (the maximal value 1,00), average value on Harris Hip Score 42,3 points (the maximal value of 100 points). After six months period the value EQ-5D - 0,75, on Harris Hip Score - 79 points, during the period from 12 to 18 months the average value EQ-5D has made 0,81, on Harris Hip Score of 81,9 points. The greatest differentiation in life quality estimation was marked in sections pain / discomfort and mobility. There is a correlation between the system of a functional condition estimation on Harris Hip Score and an estimation of quality of life on EQ - 5D is received.
Conclusions: 1) the estimation of life quality of patients with traumas and diseases of hips can be used, as addition to the standard methods of patient examination;
2) The analysis of the received data allows to apply the most effective approach to hip joint and a choice of a implants design;
3) Parameters of quality of life will help to optimize and lower expenses for expensive operative interventions.