Korrekturosteotomien des distalen Femur mit retrogradem Marknagel

Deformities of the distal femur are usually corrected by supracondylar osteotomy. In the "classical" procedure the bone cut is performed with an oscillating saw, and internally fixed using a plate. This technique is hampered first by an invasive approach and second by limited corrective options in case of complex deformities. A supracondylar bone cut by focal dome osteotomy or drill osteoclasis in combination with internal fixation by retrograde intramedullary nailing (RN) might be a promising alternative procedure. 12 patients with multidimensional post-traumatic deformities of the distal femur were prospectively enrolled in a study to investigate this new minimal-invasive technique. In all patients a meticulous analysis of leg geometry was done pre- and postoperatively. Details of operative planning, osteotomy and fixation procedure are given as well as the postoperative treatment. 7 corrective osteotomies were one-step procedures, in 5 patients additional lengthening over the RN was performed using unilateral external fixation. The mean follow-up was 15 (range 7-27) months. All of the osteotomies healed in a normal expected time frame. All patients had important functional benefits. In 11 patients the goal of deformity correction was achieved. In one patient the correction in the frontal plane remained insufficient. 6 months after the completion of femoral lengthening osteomyelitis developed in one patient, probably due to a pin-track infection. The infection subsided after early removal of the RN. No further complications were observed. The presented technique is demanding concerning pre-operative planning and surgical realization but it offers a minimal-invasive and promising approach for the correction of multidimensional femoral deformities.     

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE: To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening. DESIGN: Retrospective. SETTING: University hospital. PATIENTS AND METHODS: During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by 相似文献   

应用Orthofix重建外固定架治疗骨缺损

目的 总结应用Orthofix重建外固定架分别利用骨运输术、一期清创 短缩肢体 截骨延长技术以及一期清创 短缩肢体 二期截骨延长技术治疗26例骨缺损的经验，探索肢体安全短缩的限度。方法 在患肢上安放Orthofix重建外固定架。对17例胫骨和2例股骨骨缺损5～22cm者行骨运输术。对5例胫骨干骨缺损小于5cm合并皮肤缺损及感染者和1例股骨干骨缺损4cm合并感染者行一期清创 短缩肢体 延长技术进行治疗。对2例胫骨缺损5cm和1例股骨干骨缺损4cm者合并感染的患者采用先一期清创 部分短缩肢体，术后继续短缩肢体，二期截骨延长恢复肢体的长度。截骨术后10～14d开始延长，每天4次，每天延长1mm。16例胫骨和2例股骨在远、近缺损端相遇后于骨缺损端行清创术和自体骨植骨术。结果 平均随访13个月。骨缺损均得以重建，患肢肢体长度完全恢复，骨折愈合，无感染复发。在5例使用一期清创 短缩 延长法的胫骨缺损和1例行一期短缩 延长法的股骨缺损患者中，3例胫骨和1例股骨短缩至4cm时出现血管危象，立即恢复1cm长度后肢体远端血运恢复。术后第3天开始继续短缩肢体，每天4mm，每天4次。1例术后出现腓总神经麻痹，术后2个月恢复。4例胫骨缺损患者诉膝部疼痛。3例胫骨缺损患者出现马蹄内翻足。2例胫骨缺损患者出现下胫腓分离。结论 应用Orthofix重建外固定架进行骨运输是治疗骨缺损的有效方法，谨慎使用短缩 延长技术。对于软组织有损伤的肢体一期短缩不应超过3cm，可以于术后第2天开始继续短缩，每天短缩4mm，每天4次，每次1mm。     

Derotation of post-traumatic femoral deformities by closed intramedullary sawing

Different techniques and devices have been used for correction osteotomies of bones in patients with malalignments. The most frequently used technique for rotational deformities of the femur and tibia is open osteotomy with an oscillating saw and pre-drilled holes with all well-known drawbacks of open surgery. An intramedullary device with an adapted minimal-invasive surgical technique allows intramedullary osteotomy of the bone preserving the surrounding soft tissue. We performed femoral osteotomies with an intramedullary saw followed by static interlocking nailing in 14 patients with post-traumatic rotational deformity in the femur. Twelve patients had an external rotational deformity of the femur ranging between 26 and 63 degrees , one had an additional leg-shortening of about 4 cm. Two patients had internal rotational deformities. In two patients with delayed fracture healing union was achieved within one year without secondary surgery. Post-operative clinical assessment and CT-scans revealed good derotation results with deformities of less than 4 degrees in all cases. No device-related complications were observed. Therefore, we conclude that "closed" osteotomy with an intramedullary saw is a minimal-invasive, safe and reliable option for derotation procedures in the femur.     

Femoral neck lengthening osteotomy after growth disturbance of the proximal femur.

Treatment of congenital dislocation of the hip, Perthes disease, bacterial coxitis, or fractures in childhood may be complicated by vascular insufficiency and subsequent growth disturbance of the proximal femur. The resulting deformity, with a high-standing greater trochanter and a short femoral neck, causes leg length shortening and insufficiency of the hip abductors with a positive Trendelenburg sign and limp. Normal anatomy and biomechanics of the hip joint can be restored by lengthening the femoral neck after two parallel osteotomies of the femur at the the upper and lower border of the femoral neck, followed by distalization the greater trochanter. This femoral neck lengthening osteotomy was first described by the senior author (EM) in 1980. This retrospective study of 37 operated patients with a mean follow-up of 8 years shows good results in 32 patients with little or no preexisting osteoarthritis. Four of five patients with marked degenerative changes underwent a total hip replacement within 1 to 9 years after the osteotomy.     

Osteotomy to lengthen the femur neck with distal adjustment of the trochanter major in coxa vara after hip dislocation

Hip dysplasia and treated dislocations of the hip can lead to deformity of the proximal femur with shortening of the femoral neck and proximal displacement of the greater trochanter. Shortening the femoral neck causes a reduction in the leg length and insufficient performance of the abductors in the hip. Furthermore, the mechanical axis of the knee joint is lateralized. We used a technique involving lengthening the femoral neck and distal transfer of the greater trochanter to restore the normal anatomy and normal biomechanics of the hip joint. We used three osteotomies: one at the greater trochanter, one at the proximal, and the third an oblique osteotomy at the level of the distal femoral neck. In our group of 15 patients with 16 operated hip joints, the results were satisfactory in 14 of the 16 hips. This technique is recommended in young patients with little or no degenerative changes.     

Transiliac leg lengthening: experiences with a modified Salter osteotomy

Transiliac limb lengthening osteotomy is a modified Salter innominate osteotomy which uses a trapezoidal interposition bone graft instead of the usual triangular graft to achieve up to 3 cm of intrapelvic lengthening. It allows correction of certain forms of postural imbalance and pelvic obliquity, as well as allowing an optimal and variable amount of acetabular redirection. This review of 105 patients who have undergone the procedure at our institution revealed the following indications: decompensated scoliosis, 26 patients; acetabular dysplasia with ipsilateral femoral shortening, 34 patients; intrapelvic asymmetry, 7 patients; pure limb length inequality, 38 patients. Intrapelvic lengthening averaged 2.5 cm. Correction of decompensated scoliotic curves averaged 7 degrees reduction in Cobb angle. Improvement in center-edge angle in patients with hip dysplasia averaged 17 degrees. Reduction in size of shoe lift required to balance the trunk in all cases was correlated closely with the intrapelvic lengthening achieved. Complications included two transient neurapraxias (one femoral, one femoral and sciatic), two cases of sacroiliac subluxation (one patient with myelodysplasia, and one patient with polio), three cases of partial graft collapse, and six instances of broken fixation pins, and three deep wound infections. No patient had chondrolysis or avascular necrosis of the femoral head. After average follow-up of nearly 5 years (minimum follow-up 2 years), patients who underwent transiliac limb lengthening osteotomy for correction of postural imbalance for various causes retained satisfactory correction.     

Treatment of unstable femoral shaft fractures with closed interlocking intramedullary nailing

From 1979 to 1982, 64 femoral shaft fractures in 62 patients were treated by closed interlocking nailing at Harborview Medical Center, Seattle, WA, U.S.A., and Parkland Memorial Hospital, Dallas, TX, U.S.A. Twenty-nine patients sustained multiple system injuries and 29 of the involved extremities (45%) had at least one additional injury. There were 17 (26%) open fractures. Static mode nailing was used to treat 52 fractures; dynamic mode nailing was performed for 12 fractures. Patient follow-up averaged 17 months (range 7-41 months). The average time to union was 13.5 weeks. Normal femoral length within 1 cm was achieved in 97% of cases. Knee range of motion averaged 127 degrees. Complications (9%) included two delayed unions, one nonunion, two cases of shortening or lengthening of more than 1 cm, and one case of malunion with angulation or more than 10 degrees. The delayed unions and nonunions healed after one additional procedure. This study shows that closed interlocking nailing is a safe, effective technique that provides stable fixation in most unstable femoral shaft fractures. This technique represents a major advance in the treatment of difficult femoral shaft fractures that would be poorly suited for standard closed nailing.     

Current concept in dysplastic hip arthroplasty: Techniques for acetabular and femoral reconstruction

Adult patients with developmental dysplasia of the hip develop secondary osteoarthritis and eventually end up with total hip arthroplasty (THA) at younger age. Because of altered anatomy of dysplastic hips, THA in these patients represents technically demanding procedure. Distorted anatomy of the acetabulum and proximal femur together with conjoined leg length discrepancy present major challenges during performing THA in patients with developmental dysplasia of the hip. In addition, most patients are at younger age, therefore, soft tissue balance is of great importance (especially the need to preserve the continuity of abductors) to maximise postoperative functional result. In this paper we present a variety of surgical techniques available for THA in dysplastic hips, their advantages and disadvantages. For acetabular reconstruction following techniques are described: Standard metal augments (prefabricated), Custom made acetabular augments (3D printing), Roof reconstruction with vascularized fibula, Roof reconstruction with pedicled iliac graft, Roof reconstruction with autologous bone graft, Roof reconstruction with homologous bone graft, Roof reconstruction with auto/homologous spongious bone, Reinforcement ring with the hook in combination with autologous graft augmentation, Cranial positioning of the acetabulum, Medial protrusion technique (cotyloplasty) with chisel, Medial protrusion technique (cotyloplasty) with reaming, Cotyloplasty without spongioplasty. For femoral reconstruction following techniques were described: Distraction with external fixator, Femoral shortening through a modified lateral approach, Transtrochanteric osteotomies, Paavilainen osteotomy, Lesser trochanter osteotomy, Double-chevron osteotomy, Subtrochanteric osteotomies, Diaphyseal osteotomies, Distal femoral osteotomies. At the end we present author’s treatment method of choice: for acetabulum we perform cotyloplasty leaving only paper-thin medial wall, which we break during acetabular cup impacting. For femoral side first we peel of all rotators and posterior part of gluteus medius and vastus lateralis from greater trochanter on the very thin flake of bone. This method allows us to adequately shorten proximal femoral stump, with possibility of additional resection of proximal femur. Furthermore, several advantages and disadvantages of this procedure are also discussed.     

改良Illizarov技术治疗下肢感染性骨缺损

目的研究改良Illizarov技术治疗下肢感染性骨缺损和肢体短缩的方法。方法感染性骨缺损患者23例,男20例,女3例;年龄21~49岁,平均32岁。股骨7例,胫骨16例。肢体短缩4~17cm,平均9cm。根据Illizarov治疗原则,采用微创截骨,分别采用骨段滑移术修复骨缺损和延长肢体。结果经骨段滑移,骨缺损全部愈合,延长间隙成骨良好,无一例需补充植骨。23例经1~5年随访,所有骨缺损愈合,肢体长度恢复正常,感染无复发。结论骨段滑移技术是治疗下肢大段骨缺损简单而有效的方法,软组织感染创面可在骨段滑移中逐渐缩小并闭合,骨感染可在骨段滑移中逐渐被控制并随骨连接而愈合。     

Ilizarov外固定架治疗胫骨骨缺损及骨短缩

目的探讨应用Ilizarov外固定架治疗胫骨骨不连及骨缺损的方法及临床疗效。方法对19例胫骨骨不连及骨短缩患者（肢体短缩4~17cm,平均9cm）,根据Iuizarov治疗原则,采用微创截骨、直接拉伸延长或骨段滑移术修复骨缺损和延长肢体,在连续硬膜外麻醉下手术置入外固定架。骨不连者调整外固定架使骨断端对合并加压;骨缺损短缩者则做骨段搬移术或直接拉长。定期复查X片,直至骨愈合满意后拆除外固定架。结果本组术后经1～5年随访。所有骨缺损愈合,肢体长度恢复正常或接近正常,感染无复发。结论Ilizalov外固定架技术是治疗胫骨大段骨缺损的有效方法。软组织感染创面可在骨段滑移中逐渐缩小并闭合,骨感染可在骨段滑移中逐渐被控制并随骨连接而愈合。     

Locked nailing of comminuted and unstable fractures of the femur

Forty comminuted or unstable fractures of the femoral shaft were treated by closed intramedullary reaming and locked nailing. Twenty-four fractures were severely comminuted, and the other 16, in the distal or proximal third of the shaft, were classified as unstable. At 12 to 30 months postoperatively all the fractures had healed. Three patients had lateral rotation deformity of 5 degrees to 10 degrees, three had shortening of 1 to 2 cm and two had lengthening of about 1 cm. There were no infections or delayed unions. Closed intramedullary locked nailing can provide stability in fractures of the femoral shaft, irrespective of the degree of comminution and the site of injury.     

Curved osteotomy technique for intertrochanteric varus surgery--an experimental and computer-assisted surgery

PURPOSE: In conventional intertrochanteric varus osteotomy, shortening of the leg and insufficiency of the abductor muscles occur frequently. To avoid these disadvantages, a curved osteotomy is presented. METHOD: 189 intertrochanteric barrel vault and wedge osteotomies were compared. By means of digitized preoperative radiographs the varus osteotomies were planned with a computer program optimising postoperative leg length, bone contact area at the osteotomy site, femoral offset, and abductor muscle length. RESULTS: The average leg shortening was 3.9 mm (range: 0-5 mm) for barrel vault osteotomy and 13.6 mm (range: 8-22.2 mm) for the wedge technique. After correction the mean contact area at the osteotomy sites was 1731.6 mm2 (range: 1087.8-2341.8 mm2) in the barrel vault technique compared with 783.7 mm2 (range: 563.7-1249.6 mm2) in the wedge procedure (p < 0.001, t-test). Adequate femoral offset was achieved in both types of osteotomy. In all curved osteotomies the length of the abductor muscles remained nearly constant in contrast to the wedge procedure. Additional comparative experimental barrel vault osteotomies in 22 human autopsy femora with a high-speed dissecting tool and round jigs revealed a precise application of the preoperative planning. CONCLUSION: The intertrochanteric curved osteotomy provides minimum leg shortening and increased bone contact area. It can prevent an insufficiency of the abductor muscles, because shortening is minimized.     

Corrective Osteotomy of the Distal Femur by Retrograde Nailing

Abstract Objective: Correction of deformities of distal femur by a supracondylar dome or drill hole osteotomy in combination with a retrograde intramedullary nailing as an alternative to the classic technique of osteotomizing with an oscillating saw and internally fixating with a blade plate. In addition, leg length discrepancies can be corrected by the use of a unilateral distraction fixator after correction of axial and torsional deformities. Indications: Multidimensional deformities of the distal femur. Deformities of the distal femur with shortening > 1.5 cm. Deformities of the distal femur in the presence of length discrepancy and torsional deformity of the lower leg. Distal femoral deformities that may later need to be treated with a total knee replacement. Contraindications: State after local bone or soft tissue infections. A condylar bone stock insufficient for purchase of screws for intramedullary locking. Surgical Technique: Knee arthroscopy. Determination of the entry point and direction of insertion of the intramedullary nail in the frontal and sagittal plane. Insertion of the nail up to the level of osteotomy, placement of Schanz screws proximal and distal to the planned osteotomy for later assessment of the degree of correction. Either dome os teotomy or drill hole osteotomy. Correction of axial and torsional malalignments. Advancing of nail and static locking. Optional: for intended callus distraction, mounting of a unilateral distraction fixator. Results: Follow-up after 29 (4–45) months of 18 patients, seven with callus distraction. The goal of correction was reached in 17 patients. Three nonunions and one osteomyelitis healed after surgical revision. The following is a reprint from Operat Orthop Traumatol 2003;15:363–86 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Operat Orthop Traumatol 2003;15:363–86 DOI 10.1007/s00064-003-1084-5     

Orthopedic management in children with fibrous dysplasia of bone]

The method and results of treatment in 9 children with fibrous dysplasia of bone and 3 children with Albright syndrome are presented. Curettage and filling of the defect with autologous and/or lyophilized grafts failed in all 5 attempted cases. Due to pathological fracture or deformity Rush nailing combined with multilevel osteotomies has been performed within 5 femoral bones and 4 tibial bones. Healing was undisturbed, neither fracture nor deformity recurred. Valgus osteotomy has been done in 2 children with pseudoarthrosis of the femoral neck. In one case osteotomy healed, in another bony union is not completed yet but the neck-shaft angle remained unchanged. In authors' opinion curettage and grafting proved ineffective; Rush nailing rendered good results in both fracture and deformity treatment.     

Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint

Instability of the hip joint in the young adult is a difficult problem. Patients with an unstable hip secondary to any aetiology usually have loss of bone from the proximal femur or shortening of the limb or both. In this study we report our results in the treatment of the unstable hip joint in young adults by pelvic support osteotomy using the Ilizarov method. From 1997 to 2004, 25 patients (17 females and 8 males) with an unstable hip joint were treated in the Orthopaedic department of Mansoura University Hospital, Egypt. Their mean age was 22.4 years (range: 19 to 35). The main complaints were pain, leg length discrepancy, limping, and limited abduction of the hip. All patients underwent valgus extension osteotomy in the proximal femur and distal femoral osteotomy for lengthening. The average follow-up ranged from 2 to 7 years. All hips were pain free at follow-up. The Trendelenburg sign became negative in 20 patients. There was no limb length discrepancy and alignments of the extremity were re-established. Five patients had a lurch gait. Valgus extension osteotomy has provided stability of the hip joint and maintained some motion of the hip joint. By using the Ilizarov technique, we could prevent the valgus effects created by the valgus extension osteotomy while achieving lengthening of the femur through the distal osteotomy in the femur.     

Proximal femoral osteotomy as an adjunct in cementless revision total hip arthroplasty

Cementless total hip replacement techniques are increasingly used in revision arthroplasty. A major challenge is to achieve implant stability in a femur distorted by a failed arthroplasty. Five patients with aseptic loosening of cemented primary or revision total hip replacements complicated by significant proximal femoral disease, four with marked angular deformity of the femur and one with a subtrochanteric nonunion, were treated successfully with cementless revision arthroplasty combined with proximal femoral osteotomy. At follow-up examination, all femoral and trochanteric osteotomies had healed and D'Aubigne and Postel scores for pain, function, and range of motion had improved. All porous prostheses demonstrated radiographic features consistent with bone ingrowth fixation. No progressive stress shielding has been observed. Concomitant femoral osteotomy to correct anatomic deformity, in association with cementless total hip arthroplasty, results in union of the osteotomy and restoration of hip function.     

Limb lengthening and deformities corrections with the femoral Albizzia nail

The albizzia femoral nail allows for lengthenings up to 10 cm. It can be used in achondroplastic patients. Multiplane corrections can be addressed with a special nail (3D-Albizzia) if multiple osteotomies are performed (e.g. for proximal and distal femoral varus). A derotation and a flexion/extension osteotomy can also be associated. IM nailing is suitable for patient with previous external fixators. Surgical planning should be careful. The operation is currently performed percutaneously, with a 1 to 2 cm skin incision for nail insertion, and a 6 mm incision for distal femoral dome osteotomies. CPM machine is applied in recovery room and rehabilitation resumes on day 1, allowing more than 120 degrees of knee flexion by day 1. Ratcheting for gradual lengthening is begun on day 5 at a rate of 1 mm/day. Muscle stretching and strengthening are maintained for one year. In bilateral cases, a preoperative strengthening program is set. A 120 degrees knee range of motion can be maintained all during lengthening. Intramedullary lengthening allows for maintaining muscle and soft tissue suppleness which protects from hyperpressure over joints and from long-term muscle waisting. The Albizzia is currently a good tool once the surgeon get used to its physiotherapy aspect. Previously reported general anaeshtesia for getting the ratcheting is barely needed, when the technique has been done percutaneously and when the full range of knee motion is recovered on day 1 and maintained thereafter.     

Limb lengthening in children with osteogenesis imperfecta]

The authors operated on 7 children (5 girls, 2 boys) suffering from osteogenesis imperfecta (oi) type I according to Sillence classification, with lower limbs discrepancy. We elongated 10 segments (7 femurs and 3 tibias). Mean age at operation time was 14.7 years (13-17 years). The mean leg length discrepancy was 9.3 cm (4-18 cm), and shortening of one bone was 6.5 cm (4-9 cm). We used Ilizarov technique twice in tibial lengthening. We used Wagner technique in one tibial elongation and in 7 femur elongation. Except for one tibia, in the remaining cases there was Rush rod inserted intramedullary in the bone being elongated. During tibial elongation we fixed lateral malleous by screw. The osteotomy was performed in proximal metaphysis of the 5 femurs and 3 tibias, and in distal femurs in two cases. The elongation was 1 mm for day, with frequency 4 x 1/4 mm. The mean bone lengthening achieved was 5.5 cm (2-9 cm); the mean lengthening of the limb was 7.9 cm (2-18 cm). The mean time of elongation was 2.8 months (2-5 months). Elongation index was 26 days for 1 cm of lengthening. The mean time of fixator removal was 9.2 months (4-13 months). Healing index was 58 day/1 cm (overall number of days for 1 cm lengthening). The complications occurred in all the patients. Although the risk of numerous complication is high, lower limbs lengthening in children with type I osteogeneis imperfecta is possible to perform and allows equalizing discrepant limbs or, at least reducing the difference.     

Acute correction of lower limb deformity and simultaneous lengthening with a monolateral fixator

We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys. The mean maximum correction in any one plane was 23 degrees (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0). Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. For logistic regression analysis the patients were binary coded into two groups; those with a good outcome (BHI < or = 45 days/cm) and those with a poor outcome (BHI > 45 days/cm). Various factors which may influence the outcome were then analysed by calculating odds ratios with 95% confidence intervals. This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect. Those patients with a maximum angulatory correction of less than 30 degrees in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater.