J. Heineck

Der Flexor-hallucis-longus-Transfer zum Ersatz der Achillessehne

BACKGROUND Transfer of the flexor hallucis longus (FHL) tendon is a therapeutic option to replace a dysfunctional Achilles tendon in cases of rerupture with large defects, loss of the Achilles tendon after postoperative infection or severe tendinosis. MATERIALS AND METHODS Between January 1994 and December 2005, 35 patients (5 female and 30 male, average age 47 years) were treated with 36 FHL transfers and 25 patients with 26 FHL transfers could be re-evaluated at a mean follow-up time of 79 months (range 20-133 months) after surgery. RESULTS Of the 25 patients, 18 (72%) subjectively rated the result as excellent, 5 (20%) as good, and 1 patient (4%) each as fair and poor. According to the criteria of Trillat and Mournier-Kuhn, 18 patients (72%) were rated excellent, 4 (16%) good and 3 (12%) fair. The AOFAS ankle/hindfoot score at follow-up averaged 91 (range 13-100), the AOFAS forefoot score averaged 95 (range 24-100). CONCLUSIONS FHL transfer to the Achilles tendon provides favorable results in cases of complicated cases with defects, infections or severe tendinosis after Achilles tendon rupture.

[Transfer of the flexor hallucis longus to replace the Achilles tendon: indications, technique and results].

BACKGROUND Transfer of the flexor hallucis longus (FHL) tendon is a therapeutic option to replace a dysfunctional Achilles tendon in cases of rerupture with large defects, loss of the Achilles tendon after postoperative infection or severe tendinosis. MATERIALS AND METHODS Between January 1994 and December 2005, 35 patients (5 female and 30 male, average age 47 years) were treated with 36 FHL transfers and 25 patients with 26 FHL transfers could be re-evaluated at a mean follow-up time of 79 months (range 20-133 months) after surgery. RESULTS Of the 25 patients, 18 (72%) subjectively rated the result as excellent, 5 (20%) as good, and 1 patient (4%) each as fair and poor. According to the criteria of Trillat and Mournier-Kuhn, 18 patients (72%) were rated excellent, 4 (16%) good and 3 (12%) fair. The AOFAS ankle/hindfoot score at follow-up averaged 91 (range 13-100), the AOFAS forefoot score averaged 95 (range 24-100). CONCLUSIONS FHL transfer to the Achilles tendon provides favorable results in cases of complicated cases with defects, infections or severe tendinosis after Achilles tendon rupture.

Traumatische Hemipelvektomie@@@Traumatic hemipelvectomy

ZusammenfassungDie traumatische Hemipelvektomie ist mit ca. 0,6% aller Beckenverletzungen eine sehr seltene Beckenverletzung. Sie ist definiert als Abriss des knöchernen Hemipelvis mit Unterbrechung der großen Gefäß- und Nervenbahnen, oft kompliziert durch urologische oder intestinale Begleitverletzungen. Wie in diesem Fall ist ein typischer Unfallmechanismus der Anprall des ungeschützten Zweiradfahrers an ein entgegenkommendes Kraftfahrzeug, wobei die untere Extremität nach hinten außen und oben weggerissen wird und es zu multiplen Verletzungen der Extremität kommt.Weitere beschriebene Mechanismen sind der Ausriss durch rotierende Maschinenteile und das Überroll- oder Quetschtrauma. Nach zügiger Versorgung durch den Notarzt erfolgte in der Klinik die sofortige Revision, Tamponade und Stabilisierung des Beckenringes. Ein Teilerhaltungsversuch der Extremität wurde mit prothetischem Ersatz der Beckengefäße versucht. Aufgrund fortschreitender ausgedehnter Gewebenekrosen musste die Hemipelvektomie jedoch früh sekundär komplettiert werden. Die Ausscheidungs- und Sexualfunktionen blieben trotz eines transsphinktären Rektumeinrisses erhalten. Die resultierende Lebensqualität ist hoch und der Patient wurde problemlos in sein soziales Umfeld reintegriert.AbstractWith an incidence of only 0.6% of all pelvic injuries, traumatic hemipelvectomy is a rare event. It is defined as open or closed avulsion of one hemipelvis with occlusion or disruption of the main vessels and lengthening or disruption of the nerves, often complicated by urogenital or anorectal injuries. The mechanism of injury in this case is a typical one with extreme abduction and external rotation of the leg, causing sacroiliac joint disruption and symphysis separation. Two other mechanisms described are avulsion when the leg becomes entangled in a piece of machinery or a massive crushing at the groin. After a fast treatment in the field, the patient described was treated with immediate open revision, tamponade and stabilization of the pelvis. Upper leg preservation by reconstruction of the femoral vessels with vascular prostheses was attempted. Because of a broad necrosis of soft tissues, early completion of the hemipelvectomy was performed. The patient recovered well. Miction and bowel evacuation as well as sexual function could be preserved. The resulting quality of life is high and the patient is socially reintegrated without problems.

[Control of diffuse bleeding in unstable pelvic fractures with compression plate packing: presentation of the surgical technique].

Current recommendations on surgical management of unstable pelvic fracture with hemorrhagic shock include reduction and fixation, i.e., with a C-clamp and external fixator, angiographic embolization of injured pelvic arteries, and preferably extraperitoneal packing to control diffuse bleeding from the venous plexus and fracture site. However, the recently reported lethality at 40-60% remains seriously high. One possible reason could be the unsatisfactory efficiency of extraperitoneal packing in the case of a traumatically or surgically opened retroperitoneal compartment. In this paper, a new approach, so-called compression plate packing, is proposed to control diffuse bleeding. In this technique, the essential pressure of the packing on the bleeding site is set up with small fragment plates with screw fixation to the pelvic ring. In two first clinical cases of severe pelvic trauma the hemorrhage could be controlled reliably.

Kontrolle diffuser Blutungen bei instabiler Beckenfraktur mittels Kompressionsplattentamponade

Current recommendations on surgical management of unstable pelvic fracture with hemorrhagic shock include reduction and fixation, i.e., with a C-clamp and external fixator, angiographic embolization of injured pelvic arteries, and preferably extraperitoneal packing to control diffuse bleeding from the venous plexus and fracture site. However, the recently reported lethality at 40-60% remains seriously high. One possible reason could be the unsatisfactory efficiency of extraperitoneal packing in the case of a traumatically or surgically opened retroperitoneal compartment. In this paper, a new approach, so-called compression plate packing, is proposed to control diffuse bleeding. In this technique, the essential pressure of the packing on the bleeding site is set up with small fragment plates with screw fixation to the pelvic ring. In two first clinical cases of severe pelvic trauma the hemorrhage could be controlled reliably.

Ventrale Versorgung einer Fraktur der Halswirbelsäule bei Morbus Bechterew und Struma permagna

ZusammenfassungHalswirbelsäulenfrakturen bei Morbus Bechterew sind seltene Verletzungen. Sie sind häufiger mit neurologischen Ausfällen verbunden als Frakturen der gesunden Halswirbelsäule. In Ihren mechanischen Eigenschaften ähnelt die ankylosierte Wirbelsäule einem Röhrenknochen. Konventionelle Orthesen und Lagerungstechniken gewährleisten aufgrund der Deformität und der Einsteifung oft keine ausreichende Ruhigstellung, und es muss improvisiert werden, um eine schonende Bergung und einen schonenden Transport zu ermöglichen. Bei den meist sehr instabilen Verletzungen besteht die Indikation zur Operation. Die stabilste Versorgung gewährleistet die ein- oder zweizeitige dorsoventrale Fusion. Der dorsale Zugang ist allerdings mit einer deutlich höheren Komplikationsrate behaftet, sodass wir die primäre ventrale Stabilisierung mit langstreckigen winkelstabilen Implantaten favorisieren. Diese kann auch bei schwierigen anatomischen Verhältnissen sicher ausgeführt werden. Bei gutem Schraubenhalt kann dann auf eine zusätzliche dorsale Fusion verzichtet werden.AbstractFractures of the cervical spine in ankylosing spondylitis are rare. The rate of neurological complications is increased compared to fractures of the normal spine. Concerning its mechanical characteristics the ankylosing spine is similar to a long bone. Because of the deformity and the stiffness of the spine conventional orthoses do not provide enough stability and individualized techniques are necessary to perform safe rescue and transport. Because of severe instability an operation is indicated in most cases. The most stable fixation is the combined ventral and dorsal fusion. The dorsal approach is associated with an increased rate of complications, so we favour primary ventral fusion with long interlocking plates. This can be done even in difficult anatomic situations. If the screws can be tightened well, additional dorsal fusion is not necessary.

Ventral fusion of a fracture of the cervical spine in ankylosing spondylitis and struma permagna

ZusammenfassungHalswirbelsäulenfrakturen bei Morbus Bechterew sind seltene Verletzungen. Sie sind häufiger mit neurologischen Ausfällen verbunden als Frakturen der gesunden Halswirbelsäule. In Ihren mechanischen Eigenschaften ähnelt die ankylosierte Wirbelsäule einem Röhrenknochen. Konventionelle Orthesen und Lagerungstechniken gewährleisten aufgrund der Deformität und der Einsteifung oft keine ausreichende Ruhigstellung, und es muss improvisiert werden, um eine schonende Bergung und einen schonenden Transport zu ermöglichen. Bei den meist sehr instabilen Verletzungen besteht die Indikation zur Operation. Die stabilste Versorgung gewährleistet die ein- oder zweizeitige dorsoventrale Fusion. Der dorsale Zugang ist allerdings mit einer deutlich höheren Komplikationsrate behaftet, sodass wir die primäre ventrale Stabilisierung mit langstreckigen winkelstabilen Implantaten favorisieren. Diese kann auch bei schwierigen anatomischen Verhältnissen sicher ausgeführt werden. Bei gutem Schraubenhalt kann dann auf eine zusätzliche dorsale Fusion verzichtet werden.AbstractFractures of the cervical spine in ankylosing spondylitis are rare. The rate of neurological complications is increased compared to fractures of the normal spine. Concerning its mechanical characteristics the ankylosing spine is similar to a long bone. Because of the deformity and the stiffness of the spine conventional orthoses do not provide enough stability and individualized techniques are necessary to perform safe rescue and transport. Because of severe instability an operation is indicated in most cases. The most stable fixation is the combined ventral and dorsal fusion. The dorsal approach is associated with an increased rate of complications, so we favour primary ventral fusion with long interlocking plates. This can be done even in difficult anatomic situations. If the screws can be tightened well, additional dorsal fusion is not necessary.

Kontrolle diffuser Blutungen bei instabiler Beckenfraktur mittels Kompressionsplattentamponade@@@Control of diffuse bleeding in unstable pelvic fractures with compression plate packing: Vorstellung der chirurgischen Technik@@@Presentation of the surgical technique

Current recommendations on surgical management of unstable pelvic fracture with hemorrhagic shock include reduction and fixation, i.e., with a C-clamp and external fixator, angiographic embolization of injured pelvic arteries, and preferably extraperitoneal packing to control diffuse bleeding from the venous plexus and fracture site. However, the recently reported lethality at 40-60% remains seriously high. One possible reason could be the unsatisfactory efficiency of extraperitoneal packing in the case of a traumatically or surgically opened retroperitoneal compartment. In this paper, a new approach, so-called compression plate packing, is proposed to control diffuse bleeding. In this technique, the essential pressure of the packing on the bleeding site is set up with small fragment plates with screw fixation to the pelvic ring. In two first clinical cases of severe pelvic trauma the hemorrhage could be controlled reliably.

Der Flexor-hallucis-longus-Transfer zum Ersatz der Achillessehne@@@Transfer of the flexor hallucis longus to replace the Achilles tendon: Indikation, Technik und Ergebnisse@@@Indications, technique and results

BACKGROUND Transfer of the flexor hallucis longus (FHL) tendon is a therapeutic option to replace a dysfunctional Achilles tendon in cases of rerupture with large defects, loss of the Achilles tendon after postoperative infection or severe tendinosis. MATERIALS AND METHODS Between January 1994 and December 2005, 35 patients (5 female and 30 male, average age 47 years) were treated with 36 FHL transfers and 25 patients with 26 FHL transfers could be re-evaluated at a mean follow-up time of 79 months (range 20-133 months) after surgery. RESULTS Of the 25 patients, 18 (72%) subjectively rated the result as excellent, 5 (20%) as good, and 1 patient (4%) each as fair and poor. According to the criteria of Trillat and Mournier-Kuhn, 18 patients (72%) were rated excellent, 4 (16%) good and 3 (12%) fair. The AOFAS ankle/hindfoot score at follow-up averaged 91 (range 13-100), the AOFAS forefoot score averaged 95 (range 24-100). CONCLUSIONS FHL transfer to the Achilles tendon provides favorable results in cases of complicated cases with defects, infections or severe tendinosis after Achilles tendon rupture.