Michael Wich

Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review

Objective To determine whether total hip arthroplasty is associated with lower reoperation rates, mortality, and complications, and better function and quality of life than hemiarthroplasty for displaced fractures of the femoral neck in older patients. Design Systematic review and meta-analysis of randomised trials, quasirandomised trials, and cohort studies. Data sources Medline, Embase, Cochrane register of controlled trials, publishers’ databases, and manual search of bibliographies. Study selection Randomised controlled trials, quasirandomised trials, and cohort studies (retrospective and prospective) comparing hemiarthroplasty with total hip arthroplasty for treating displaced femoral neck fractures in patients aged more than 60 years. Data extraction Relative risks, risk differences, and mean differences from each trial, aggregated using random effects models. Analyses were stratified for experimental and non-experimental designs, and two way sensitivity analyses and tests for interaction were done to assess the influence of various criteria of methodological quality on pooled estimates. Data synthesis 3821 references were identified. Of the 202 full papers inspected, 15 were included (four randomised controlled trials, three quasirandomised trials, and eight retrospective cohort studies, totalling 1890 patients). Meta-analysis of 14 studies showed a lower risk of reoperation after total hip arthroplasty compared with hemiarthroplasty (relative risk 0.57, 95% confidence interval 0.34 to 0.96, risk difference 4.4%, 95% confidence interval 0.2% to 8.5%), although this effect was mainly driven by investigations without concealed treatment allocation. Total hip arthroplasty consistently showed better ratings in the Harris hip score (three studies, 246 patients, weighted mean difference 5.4, 95% confidence interval 2.7 to 8.2) after follow-up periods of 12 to 48 months. The standardised mean difference of different scores from five studies was 0.42 (95% confidence interval 0.24 to 0.61), indicating a medium functional advantage of total hip arthroplasty over hemiarthroplasty. Total hip arthroplasty was associated with a slightly higher risk of dislocation (relative risk 1.48, 95% confidence interval 0.89 to 2.46) and general complications (1.14, 0.87 to 1.48). Conclusion Single stage total hip arthroplasty may lead to lower reoperation rates and better functional outcomes compared with hemiarthroplasty in older patients with displaced femoral neck fractures. However, heterogeneity across the available trials and distinct subgroup effects preclude definitive statements and require further research in this area.

Management of a Long Segmental Defect at the Proximal Meta-Diaphyseal Junction of the Tibia Using a Cylindrical Titanium Mesh Cage

This case report describes a Gustilo Anderson type IIIB tibia fracture associated with extensive segmental bone loss at the proximal meta-diaphyseal junction associated with a tibial plateau fracture and an avulsion of the tibial tubercle. After the tibial plateau fracture was stabilized using cannulated lag screws, the shaft fracture was stabilized using a statically locked intramedullary nail in combination with a cylindrical titanium mesh cage and cancellous bone graft. The soft tissue defect was covered with local flaps. Immediate full weight bearing was initiated, and early functional recovery was achieved. At the final follow-up, plain radiographs demonstrated excellent limb alignment, and bony healing with computed tomography examination revealed bony ingrowth through the cage. This technique may be a reasonable alternative in the treatment of segmental bone loss of long bones.

Resorbable screws versus pins for optimal transplant fixation (SPOT) in anterior cruciate ligament replacement with autologous hamstring grafts: rationale and design of a randomized, controlled, patient and investigator blinded trial [ISRCTN17384369]

BackgroundRuptures of the anterior cruciate ligament (ACL) are common injuries to the knee joint. Arthroscopic ACL replacement by autologous tendon grafts has established itself as a standard of care.Data from both experimental and observational studies suggest that surgical reconstruction does not fully restore knee stability. Persisting anterior laxity may lead to recurrent episodes of giving-way and cartilage damage. This might at least in part depend on the method of graft fixation in the bony tunnels. Whereas resorbable screws are easy to handle, pins may better preserve graft tension. The objective of this study is to determine whether pinning of ACL grafts reduces residual anterior laxity six months after surgery as compared to screw fixation.Design/ MethodsSPOT is a randomised, controlled, patient and investigator blinded trial conducted at a single academic institution. Eligible patients are scheduled to arthroscopic ACL repair with triple-stranded hamstring grafts, conducted by a single, experienced surgeon. Intraoperatively, subjects willing to engage in this study will be randomised to transplant tethering with either resorbable screws or resorbable pins. No other changes apply to locally established treatment protocols. Patients and clinical investigators will remain blinded to the assigned fixation method until the six-month follow-up examination.The primary outcome is the side-to-side (repaired to healthy knee) difference in anterior translation as measured by the KT-1000 arthrometer at a defined load (89 N) six months after surgery. A sample size of 54 patients will yield a power of 80% to detect a difference of 1.0 mm ± standard deviation 1.2 mm at a two-sided alpha of 5% with a t-test for independent samples.Secondary outcomes (generic and disease-specific measures of quality of life, magnetic resonance imaging morphology of transplants and devices) will be handled in an exploratory fashion.ConclusionSPOT aims at showing a reduction in anterior knee laxity after fixing ACL grafts by pins compared to screws.

Bioresorbable Pins and Interference Screws for Fixation of Hamstring Tendon Grafts in Anterior Cruciate Ligament Reconstruction Surgery: A Randomized Controlled Trial

Background Biodegradable cross-pins have been shown to provide higher failure loads than do screws for fixation of hamstring tendons under laboratory conditions. Purpose To compare the clinical results of biodegradable pins (RigidFix) and interference screws (BioCryl) for fixation of hamstring grafts in arthroscopically assisted anterior cruciate ligament reconstruction. Study Design Randomized controlled trial; Level of evidence, 1. Methods To test the hypothesis of a difference of 1.0 ± 1.2 mm in anterior knee laxity between the two fixation options, 54 patients were randomly assigned to groups via a block randomization scheme and sealed envelopes. All patients underwent standardized hamstring graft reconstruction and had similar postoperative aftercare by an accelerated rehabilitation protocol. Measures assessed at baseline and after 1 and 2 years of follow-up included (1) the side-to-side difference in anterior laxity (KT-1000 arthrometer), (2) Short Form 36 physical and mental component scores, and (3) the International Knee Documentation Committee form scores. Results After 1 and 2 years, 26 and 21 patients in the BioCryl group and 28 and 24 patients in the RigidFix group were available for follow-up examination. No significant difference was noted in instrumented anterior translation between BioCryl and RigidFix fixation: 1 year, 0.11 (95% CI, —0.60 to 0.82; P = .7537); 2 years, 0.33 (95% CI, —0.43 to 1.08 mm; P = .3849). Also, there were no significant differences in the mean physical and mental component scores and International Knee Documentation Committee form scores and in overall complication and surgical revision rates. A pin dislocation was classified as the sole procedure-specific serious adverse event. Conclusion Bioresorbable pins do not provide better clinical results than do resorbable interference screws for hamstring graft fixation in anterior cruciate ligament reconstruction surgery.

Functional outcomes and health-related quality of life after robot-assisted anterior cruciate ligament reconstruction with patellar tendon grafts

During a short period of time, surgical robots had been propagated for automated tunnel placement in anterior cruciate ligament (ACL) reconstruction. Clinical outcome data are currently unavailable. Between 2000 and 2003, 152 patients underwent ACL replacement with the assistance of the Computer Assisted Surgical Planning and Robotics system (CASPAR, OrtoMaquet, Germany) at our hospital. After minimal invasive pin placement in both the tibia and femur, computed tomography was used to register anatomical landmarks and to plan graft tunnel alignment. The robot was used to drill tibial and femoral tunnels in an outside-in fashion according to pre-operative planning. There was one procedure-specific Serious Adverse Event (i.e., an intraoperative transection of the posterior cruciate ligament). After IRB approval, all patients were invited for a follow-up examination. Data from 100 patients (35 women, 65 men, mean age 35 [SD 11] years, median follow-up 61 [range 42–77] months) form the basis of this report. Side-to-side differences in anterior laxity were measured with the KT-1000 arthrometer. Patient-centered outcomes included the Lysholm-Score, the lower extremity functional scale (LEFS), and the Short Form 36 (SF36). The mean KT-1000 side-to-side difference was 0.89 [95% confidence interval (CI) 0.52–1.26] mm. Eight and five patients had a positive Lachman and pivot shift test, respectively. The Lysholm-Score averaged 86 (95% CI 83–89) points. Excellent, good, fair, and poor outcomes were reported by 38, 32, 20, and 10 patients. The LEFS averaged 85 (95% CI 82–88) points. The mean SF36 Physical Component Score was 48.4 (95% CI 46.5–50.3), indicating residual deficits compared to the population norm. All tibial graft tunnels did not cross the Blumensaat line, but were placed slightly anterior to the optimal center of 42% reported in previous studies. Compared to literature data, robot-assisted ACL reconstruction with BTB grafts may lead to higher knee stability, but poorer functional outcomes. The immense additional efforts with the procedure did not pay off in a benefit to patients.

The role of education in improving trauma care: can we do better?

It has been shown that the half-life of our medical knowledge has a period of 5 years. That means that half of our current knowledge will be outdated by 2020. But it is not only the volume of information we have to deal with it is the fact that groundbreaking news which should change our daily practice could appear every day and we need to keep informed. This shows the need and importance of medical education to keep physicians up-to-date to an ever-changing world of science, techniques and technical equipment. In the last 20 years new electronic equipment and new media has entered the educational world and was implemented into nearly all of our learning processes. For example 20 years ago if we had to deal with a rare medical disease in one of our patients we had to go into the library to get a look into the volume of a medical textbook, copy the relevant chapter and then discuss it with our colleagues in the hospital. Nowadays the latest science on the same subject is only a few clicks away on open access, medical databases and online publishing platforms and discussions can take place with experts online all over the world [1–4]. Has this changed the way orthopaedics and trauma surgeons learn to day? Only to a certain degree, we still have not taken advantage of the new capabilities we can use nowadays for enhancing the learning processes. We attend conferences and listen a lot to good or poor lectures, we read abstracts, very rarely whole articles and we once in a while book to attend a cadaver course for hands on experience. To improve trauma care in our institutions we face three main tasks:

Wissenschaftliche Aspekte der Zusammenhangsbegutachtung

ZusammenfassungDie Zusammenhangsbegutachtung gehört zu den verantwortungsvollsten Aufgaben der am berufsgenossenschaftlichen Heilverfahren beteiligten Ärzte. Praktisch jede Problemstellung lässt sich klar und einfach lösen, wenn man die Fragen „1. War der angeschuldigte Unfall geeignet, den Körperschaden hervorzurufen?“ und „2. War der Unfall rechtlich wesentlich?“ chronologisch bearbeitet. Die kritische Würdigung der wissenschaftlichen Literatur ist Voraussetzung für eine fundierte Abwägung konkurrierender Kausalitäten. Am Beispiel des so genannten posttraumatischen Zervikalsyndroms nach „HWS-Distorsion“ lässt sich gut belegen, dass der aktuelle klinisch-epidemiologische Kenntnisstand nur im Einzelfall die Einschätzung einer Eignung erlaubt, da die Effektstärke demografischer und sonstiger Variablen als überwiegend einzuschätzen ist und die geforderte rechtliche Wesentlichkeit des Ereignisses im Regelfall für die Betrachtung der langanhaltenden und häufig erst später auftretenden Symptome, nicht erfüllt wird.AbstractRendering an expert opinion on the causal relationship between an accident and late consequences for the victim’s health is one of the most responsible tasks undertaken by physicians engaged in treatments approved by the employers’ liability insurance associations. Practically any problem can be solved, providing two questions are dealt with in order: (1) Was the documented event sufficient (in terms of time, force, and direction) to cause the alleged physical harm? and (2) Was the event (in a legal sense) of such a relevance that its importance for the health deficit exceeds a specific threshold? Physicians need a good knowledge of the current medical literature to be able to address these questions properly. In the case of whiplash-associated disorders, recent clinical and epidemiological data rarely allow confirmation of adequacy that the accident was sufficiently serious to cause neck pain, and almost never, to justify any assumption of causality.

Operative interne Stabilisierung von Beckenringfrakturen in Abhängigkeit von der Klassifikation

ZusammenfassungDie Behandlung der Beckenringfrakturen hat in den letzten Jahrzehnten einen deutlichen Wandel in der therapeutischen Konzeption erfahren. Stand früher die konservative Behandlung mit oft unbefriedigenden funktionellen Ergebnissen im Vordergrund, ist heute die operative Therapie der instabilen Beckenringfrakturen mit interner Osteosynthese etabliert und als Standardverfahren anzusehen. Dabei muss das Ziel jeder osteosynthetischen Versorgung in der anatomischen Reposition und belastungsstabilen Fixation des instabilen Beckens liegen, da allein dies eine frühzeitige Mobilisation erlaubt und die Rate an posttraumatischen Fehlstellungen, Instabilitäten und Pseudarthrosen mit konsekutiven chronischen Schmerzzuständen und Invalidität minimiert.AbstractThere has been a significant change in the treatment of the disrupted pelvic ring in the last few decades. Nonoperative treatment of disrupted pelvic ring fractures often led to unsatisfactory results (patients were treated with slings and traction) such as malrotation of the hemipelvis, malunion or nonunion, pain, neurologic dysfunction, or genitourinary dysfunction. The therapeutic approach shifted to widely accepted standards of internal fixation based on the general format of the AO group or the often-used Tile classification. The concept of operative treatment of the disrupted pelvic ring is based on correct anatomical reduction and partial or half weight bearing of the pelvic ring after internal fixation. Only internal fixation allows the early mobilization of the patient and reduces the rate of major chronic disabilities (malrotation, malunion or nonunion, pain, neurologic dysfunction, or genitourinary dysfunction).

Prothetische Versorgung posttraumatischer Koxarthrosen

ZusammenfassungZunehmende Mobilität und Freizeitaktivitäten in jeder Altersgruppe unserer Gesellschaft haben die Unfallzahlen mit Verletzungen des proximalen Femurs deutlich ansteigen lassen. Nach primärer Rekonstruktion gelenkbeteiligter Strukturen entwickelt sich im weiteren Verlauf eine nicht unerhebliche Anzahl von Koxarthrosen auf dem Boden von Osteonekrosen oder Fehlstellungen. Die damit verbundenen Einschränkungen haben dazu geführt, dass auch bei jungen Erwachsenen der Hüftgelenkersatz durch Hüftendoprothesen durchgeführt wird.Aufgrund der Voroperationen zeigen sich in diesen Fällen deutlich erschwerte Ausgangsbedingungen, die das Risiko der intraoperativen Komplikationen wie z. B. Schaftsprengungen oder Fehllagen der implantierten Hüftendoprothesen erhöhen. Als Standardtherapien zur Versorgung der posttraumatischen Koxarthrose stehen heutzutage die zementierte und die zementfreie Hüftendoprothetik zur Verfügung. Im Rahmen der nichtzementierten Hüftendoprothetik hat sich die computerassistierte, roboterunterstützte und/oder navigierte Hüftendoprothetik zu einer etablierten Methode der Behandlung posttraumatischer Koxarthrosen entwickelt.Durch die spezifische Vorbereitung sind die anatomischen Veränderungen exakt zu bestimmen und durch den Fräseinsatz des Roboters eine an der Ausgangsanatomie orientierte Wiederherstellung möglich.AbstractThe incidence of severe injuries involving the proximal femur has increased rapidly in the last few decades.Following primary reconstruction posttraumatic arthrosis of the hip will develop in some cases.Recent developments in total hip replacement surgery have led to a wider range of indications in the case of younger subjects.Exact preoperative planning is extremely difficult, which might lead to a higher complication rate (e.g., displacement of the implanted prosthesis, fractures of the proximal femur), as documented in the available literature.Cemented and uncemented implantation of hip prostheses are well-known standard procedures in the treatment of posttraumatic arthrosis of the hip. In the case of uncemented implantation, computer-guided, robot-assisted procedures have become increasingly well established. The preoperative preparation allows precise determination of the cortical situation, while robot-assisted surgery allows the precise execution of the preoperative plan.

Epiphyseolysis capitis femoris im Adoleszentenalter nach fraglichem Trauma

Die akute Hüftkopflösung wird häufig als Folge eines äußeren Ereignisses angesehen. Als Ursache im Sinne der Entstehung im Rahmen der Lehre von der Bedingung der wesentlichen Kausalität (SGB VII) muss dies jedoch meist anders beurteilt werden. Als konkurrierende Ursachen erscheinen hierbei zum einen die Krankheitsanlage, d. h. die hormonellen und strukturellen Veränderungen, die zu einer oftmals auch spontanen Lösung der Epihysenfugen führen, und zum anderen die äußeren Einwirkungen (Unfallgeschehen), die der versicherten Sphäre zuzurechnen sind. Dabei handelt es sich in der Mehrzahl der Fälle um Ereignisse, die nach ihrer Art und Intensität nicht geeignet sind, eine traumatische Hüftkopflösung hervorzurufen. Obwohl der positive Zusammenhang in der haftungsbegründenden Kausalität gegeben ist, erscheint das gegenständliche Ereignis, das zeitnah zur klinischen Manifestation der Epiphyseolysis capitis femoris steht, in der Regel durch eine normale Verrichtung des alltäglichen Lebens ersetzbar zu sein.Acute slipping of the upper femoral epiphysis is usually attributed to trauma sustained in an accident. Under the terms of the causal investigation required by the SGB (German Code of Social Law) VII, the force involved in an accident is hardly ever of a type or intensity that would lead to slipping of the femoral head. Hormonal and structural effects of genetic disorders are so marked, in contrast, that the effects of any trauma are quite slight in comparison.