Oliver Gonschorek

Interlocking compression nailing : a report on 402 applications

Abstract Nailing techniques have changed tremendously in recent years. One significant development has been the interlocking compression nail (ICN) which provides active interfragmentary compression. Apart from its beneficial effect in the treatment of acute fractures, allowing early weight-bearing and mobilization of the patient the ICN is useful in many types of revision operations: resection and stabilization of pseudarthroses without cancellous bone grafts, corrective operations of malalignments through a minimally invasive technique, as well as the readaptation of the resection sites in arthrodeses. Between April 1993 and September 1996, 402 consecutive applications of an ICN were followed prospectively to evaluate the practibility and reliability of the system. A special focus was placed on the active compression device. Along with 153 acute fractures, 112 non-unions and 41 cases of malalignment were treated; 96 arthrodeses were performed. Even for difficult courses of healing only a low complication rate was observed, and a remarkably high percentage was managed successfully.

Allogeneic Vascularized Grafting of Human Knee Joints under Postoperative Immunosuppression of the Recipient

Abstract. Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral and tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient’s superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110° flexion.

Endoskopisch assistierte Rekonstruktion der thorakolumbalen Wirbelsäule in Bauchlage

ZusammenfassungDie standardisierte einzeitige dorsoventrale Instrumentation thorakolumbaler Wirbelfrakturen erfordert bislang sowohl bei ventral offenem als auch bei endoskopisch gestütztem Vorgehen eine zeitaufwändige intraoperative Umlagerung von der Bauch- in die Seitenlagerung.Dieser Beitrag beschreibt eine ventrale endoskopisch gestützte Zugangstechnik in alleiniger Bauchlage für die Segmente von Th4 bis L4 über einen 4–5 cm langen Zugang mit einem selbsthaltenden Retraktorsystem. Die Narkosezeiten können bei diesem einzeitig kombinierten Verfahren durch den Wegfall der Umlagerungszeit um etwa 40 min reduziert werden. Die Minimalinzision in Verbindung mit dem Retraktorsystem erlaubt die Verwendung von größtenteils konventionellen Instrumenten und Implantaten und macht die endoskopisch gestützte Operation somit kostengüstiger. Wesentliche Vorteile des offenen und endoskopischen Verfahrens werden miteinander verbunden. Der größte Vorteil der Bauchlagerung liegt in der Möglichkeit des gleichzeitigen dorsalen und ventralen Zugangs zur Wirbelsäule und den damit verbundenen permanenten simultanen Korrekturmöglichkeiten.AbstractIrrespective of an anterior open or endoscopic approach, the combined postero-anterior instrumentation of thoracolumbar fractures requires time consuming intraoperative maneuvres changing the patients position from prone to lateral.A standardised anterior endoscopically assisted approach for the segments Th4 to L4 is described, allowing the patient to remain in prone position, using a 4–5cm incision combined with a retractor system.The approach to the anterior spine in prone position is feasible by using a self holding retractor system for the region from Th4 to L4. Time of anaesthesia for the one stage combined procedure can be reduced by about 40 min, when changing the position of the patient is no longer necessary. The minimal incision in combination with the retractor system allows mainly the use of conventional instruments and implants, which provides reasonable lower costs. The advantages of the open and the endoscopical technique are combined. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is extremly helpful in reduction maneuvres.

Rekonstruktion der ventralen Säule nach thorakolumbalen Wirbelsäulenverletzungen

The morbidity of anterior approaches has significantly influenced the development of therapeutic concepts for the treatment of thoracolumbar spine fractures. Minimally-invasive techniques such as mini-open and endoscopic have enlarged the numbers of anterior reconstruction after spinal fractures in the thoracolumbar region. These minimally-invasive approaches have been facilitated by the development of special implants adapted to the new technique and to the local anatomical requirements.Two multi center studies in Germany (MCSI and II) showed the trend towards minimal invasive procedures and anterior approaches in the German speaking spine centers. Since the first report on thoracoscopic anterior procedures in Germany in 1997 a growing number of spine centers established this method. There is still no evidence based high level literature to substantiate a significant benefit for the patients by anatomical reduction and reconstruction of the anterior spinal column. However, there are some reports on better short outcomes in radiological parameters as well as better clinical results in 5 to 8 year follow-ups.The minimal invasive anterior approach seems to be advantageous for the patients by reducing significantly additive operation morbidity. It has become more important over the last two decades for anterior reconstruction after trauma and posttraumatic malalignment of the thoracolumbar spine.

Compression Nailing of Long Bones

AbstractBiomechanics: The biomechanical concept of compression nailing consists of the use of an intramedullary device that is inserted into the medullary cavity without jamming and that allows a relative movement of the fragments after locking. First, the implant is firmly attached to the distal main fragment, using conventional locking screws at the nail tip. Next, the other main fragment, which contains the nail entry portal, is fixed via a locking screw in a longitudinal slot in the nail. The compression screw is inserted, and produces distraction between the proximal part of the nail and the locking screw in the slot. This distraction results in relative movement between the intramedullary nail and the proximal fragment, compressing the fixed distal fragment against the proximal. Indications: Whether or not compression nailing can be used depends on the axial stability of the fracture or osteotomy. Therefore, simple fracture patterns, nonunions and elective osteotomies are excellent indications. The same is true for fusions of the knee or the ankle joint, providing that there are no major bone defects. Benefits: The chief benefits of compression nailing are controlled fragment apposition, and superior stability, especially to rotational forces, as compared with conventional intramedullary nailing techniques. The favorable biomechanical conditions provided allow early full weight bearing, and ensure a high rate of bony union. With implants and instruments optimized for compression nailing, this technique should widen the scope and enhance the outcome of intramedullary nailing.

Vascularised knee joint transplantation in man: the first two years experience.

OBJECTIVE To describe our early experience with a new technique for restoring destroyed knee joints to give reasonable functional results. DESIGN Observational clinical trial. SETTING Level-1-Trauma centre, Germany. SUBJECTS 5 patients with large bone defects of the knee and loss of the extensor apparatus caused either by serious injury alone, or infection after serious injury. INTERVENTIONS Transplantation of fresh and perfused knee joints with a vascular pedicle from multiorgan donors under immunosuppression. MAIN OUTCOME AND MEASURES Ability to walk, need to remove one transplanted joint. RESULTS Four patients are able to walk, the range of movement being from 50 degrees-120 degrees. The first patient additionally had to be provided with a total knee joint arthroplasty. In the third patient the graft became infected and had to be removed. She finally had an arthrodesis and bone lengthening by the Ilizarov technique. CONCLUSIONS Transplantation of the knee joint may be an alternative to bone lengthening or amputation for patients with total loss of the extensor apparatus.

Reconstruction after spinal fractures in the thoracolumbar region

The morbidity of anterior approaches has significantly influenced the development of therapeutic concepts for the treatment of thoracolumbar spine fractures. Minimally-invasive techniques such as mini-open and endoscopic have enlarged the numbers of anterior reconstruction after spinal fractures in the thoracolumbar region. These minimally-invasive approaches have been facilitated by the development of special implants adapted to the new technique and to the local anatomical requirements.Two multi center studies in Germany (MCSI and II) showed the trend towards minimal invasive procedures and anterior approaches in the German speaking spine centers. Since the first report on thoracoscopic anterior procedures in Germany in 1997 a growing number of spine centers established this method. There is still no evidence based high level literature to substantiate a significant benefit for the patients by anatomical reduction and reconstruction of the anterior spinal column. However, there are some reports on better short outcomes in radiological parameters as well as better clinical results in 5 to 8 year follow-ups.The minimal invasive anterior approach seems to be advantageous for the patients by reducing significantly additive operation morbidity. It has become more important over the last two decades for anterior reconstruction after trauma and posttraumatic malalignment of the thoracolumbar spine.

O-arm®-based spinal navigation and intraoperative 3D-imaging: first experiences

Since the first use of instrument-tracking techniques in the early 1990s, image-guided technologies became a leading topic in all branches of spine surgery. Today, navigation is a widely available tool in spine surgery and has become a part of clinical routine in many centers for a large variety of indications. Spinal navigation may not only contribute to more precision during surgery, but it may also reduce radiation exposure and fluoroscopy time, with advantages not only for the patient but also for the operating room personnel. Different registration algorithms have been developed differing in terms of the type of image data used by the navigation system (preoperatively acquired computed tomography [CT] images, intraoperatively acquired fluoroscopy images) and the way virtual and physical reality is matched. There is a tendency toward a higher accuracy for 3D fluoroscopy-based registration algorithms. The O-arm® represents a new flat-panel technology with the source and detector moving in a 360° arc around the patient. In combination with the Stealth® station system, navigation may start immediately after automated registration with already referenced instruments. After instrumentation, an additional scan may confirm intraoperatively the correct positioning of the instrumentation. The first experiences with the system are described in this paper.

Compression nailing for posttraumatic rotational femoral deformities: open versus minimally invasive technique

Between January 1996 and December 1999, we performed 30 derotational osteotomies with compression nailing in 29 patients. In 18 cases (group 1), we used an intramedullary saw (minimally invasive technique), and in 12 cases (group 2), we used a conventional open technique. Follow-up included clinical, conventional radiological, and computer tomographical assessment. The mean angle of derotation was 28.6±12.3° in group 1 and 27.6±10.7° in group 2. The postoperative mean rotational deviation between left and right side was 7.9±6.7° in group 1 and 6.6±4.4° in group 2. There were five postoperative complications: two delayed unions, two insufficient corrections, and one infection. There was no significant difference between the groups. When using the minimally invasive technique, we recommend the derotation angle to be marked with Schanz screws instead of Kirschner wires, as soft-tissue resistance may lead to bending of these.RésuméEntre janvier 1996 et décembre 1999, nous avons exécuté 30 ostéotomies fémorales de dérotation avec enclouage en compression chez 29 malades. Dans 18 cas (groupe 1), nous avons utilisé un scie intramédullaire (technique mini invasive) et dans 12 cas (groupe 2), nous avons utilisé une technique ouverte conventionnelle. Le suivi à était fait par estimation clinique, radiologie conventionnelle, et tomodensitométrie. L’angle moyen de dérotation était 28,6°±12,3 dans le groupe 1 et 27,6°±10.7 dans le groupe 2. La déviation rotationnelle moyenne postopératoire entre le côté gauche et le côté droit était 7,9°±6.7 dans le groupe 1 et 6,6°±4.4 dans le groupe 2. Il y avait cinq complications postopératoires: deux retards de consolidation, deux corrections insuffisantes et une infection. Il n’y avait aucune différence significative entre les groupes. Quand on utilise la technique mini invasive nous recommandons de marquer les angles de dérotations avec des vis de Schanz plutôt que des broches de Kirschner car la résistance des parties molles peut les courber.

Incomplete cranial burst fracture in the thoracolumbar junction. Results 6 years after thoracoscopic monosegmental spondylodesis

INTRODUCTION Ventral thoracoscopic spondylodesis of the thoracolumbar spine is an elegant treatment strategy. MATERIAL AND METHODS In the years 2002 and 2003 a total of 16 patients with incomplete cranial burst fractures were treated by ventral thoracoscopic monosegmental spondylodesis and were included in this study prospectively. The data acquisition was done preoperatively, postoperatively and after 3, 6, 12 and 18 months. After 6 years a follow-up examination was performed in 13 of these patients (5 men and 8 women, average age 36.3 years, follow-up rate 81%) and 8 patients were treated ventrally only whereas 5 patients were treated dorsoventrally. RESULTS The operative reduction of the kyphotic malalignment was superior in the dorsoventrally treated patients. The persistent gain of monosegmental correction after 6 years seemed to be higher in the patient group treated dorsoventrally. The average physical component summary (PSC) scores were comparable to a control group of the same age and revision surgery was performed in two patients both related to the iliac crest bone graft. CONCLUSIONS The ventral and dorsoventral therapy strategies showed good and very good functional outcomes, respectively. The dorsoventral treatment concept secured a persistent gain of monosegmental correction which seemed to be superior compared to a ventral only therapy strategy.