Tobias Fehmer

Success rates for initial eradication of peri-prosthetic knee infection treated with a two-stage procedure.

BACKGROUND In Germany, rates of primary total knee arthroplasty procedures and exchange arthroplasty procedures continue to rise. Late-onset peri-prosthetic infection constitutes a serious complication whose management may be dependent upon the spectrum of micro-organisms involved. The aim of this study was to provide a retrospective analysis of the effectiveness of initial eradication measures performed as part of a two-stage procedure. MATERIAL AND METHODS Between 2002 and 2008, a total of 328 patients who had received a first-time diagnosis of chronic peri-prosthetic knee infection following total knee arthroplasty (TKA) subsequently underwent surgery at our clinic. The surgical approach consisted of a two-stage procedure, with the initial procedure consisting of the removal of the prosthesis and radical debridement, followed by insertion of an antibiotic-loaded static spacer. The effectiveness of the procedure was assessed after six weeks, with each patient undergoing a number of clinical and laboratory-based tests, including knee joint aspiration. RESULTS Staphylococcus aureus strains were responsible for 68% (n=223) of the total number of cases of peri-prosthetic knee infection. 19% of cases (n=62) showed evidence of gram-negative bacteria, while MRSA accounted for 15% (n=49) of cases. Six weeks after completion of the above-named treatment regimen, eradication of infection was considered successful in 289 patients (88.1%). Eradication was unsuccessful in 22% of MRSA infections (n=11) and 7% of MSSA infections (n=23). CONCLUSION The treatment regimen outlined in this report is capable of achieving satisfactory results in the management of late-onset peri-prosthetic knee infection, with one exception: patients with infections caused by MRSA showed high failure rates.

Klassifikation von Frakturen im Wachstumsalter

ZusammenfassungDie physiologischen und anatomischen Besonderheiten eines wachsenden kindlichen Skeletts machen eine differenzierte Betrachtung seiner Verletzungen erforderlich. Das kindliche Skelett kann nicht mit dem eines Erwachsenen gleichgesetzt werden. Mit fortschreitender Ossifikation unterliegen die unterschiedlichen anatomischen Regionen eines kindlichen Knochens einem Wandel der biomechanischen Eigenschaften, woraus altersspezifische Verletzungsmuster resultieren. Im Sinne der Gesamtkonzeption dieses Hefts zu Verletzungen im Wachstumsalter soll eine Übersicht über die allgemeine Einteilung kindlicher Frakturen nicht fehlen. Im Bewusstsein um die Existenz umfangreicher und detaillierter wissenschaftlicher Standardwerke werden die gängigen Klassifikationen kindlicher Frakturen nur kurz angeführt, wobei ergänzend auf die Besonderheiten der kindlichen Knochenbiologie hingewiesen wird.AbstractThe physiological and anatomical features of the immature skeleton mean that lesions in it must be considered quite separately from lesions in the adult skeleton. As ossification progresses, the various anatomical regions of the developing bone are subject to changing biomechanic characteristics, leading to childhood-specific injury patterns. Since this issue is dedicated to fractures in childhood, this article takes the form of a short review of classification systems used for common pediatric fractures; there is also a short preface describing the anatomical-biological properties of the skeleton in childhood.

Ilizarov External Frame Technique for Pirogoff Amputations With Ankle Disarticulation and Tibiocalcaneal Fusion

Background: The high rates of wound failure, persisting infection, and nonunion of the tibiocalcaneal arthrodesis are the main reasons why the Pirogoff ankle disarticulation is rarely used for limb salvage. Use of the Ilizarov external frame has increased our fusion rate. The purpose of this study was to review our experience with the use of the Ilizarov external frame as a technique for Pirogoff amputations with ankle disarticulation and tibiocalcaneal fusion. Methods: Twenty-four patients (median age, 57.4 years; range, 29-76 years) underwent a Pirogoff amputation with Ilizarov external frame use between January 2004 and June 2011. The most common indications were gangrene with uncontrollable infection due to Charcot arthropathy or chronic osteomyelitis. Four patients had sustained crush injuries of the foot. All patients were clinically and radiographically followed for a minimum of 12 months. Additionally, 15 patients were evaluated using the Taniguchi rating scale for Pirogoff amputations after a mean follow-up of 44.9 months (range, 12-86 months). Results: In 21 patients (87.5%), a well-healed Pirogoff stump was achieved after a mean external fixation time of 18.1 weeks (range, 12.7-26.6 weeks). Impaired vascular perfusion was found to be the limiting factor for successful wound healing and an overall successful Pirogoff amputation. According to the Taniguchi scale, 67% of the patients achieved good or excellent functional results. Fair (27%) and poor (6%) results were observed only in the diabetic patients. Conclusion: Using the Ilizarov external frame allowed safe fixation and a high success rate, even in neuropathic feet. The frame allowed for immediate weight-bearing and soft tissue control; however, frame-associated complications were common and could result in revision surgery. Level of Evidence: Level IV, case series.

Two-stage revision of infected total knee arthroplasty using a distraction spacer

BACKGROUND The infection of a total knee arthroplasty (TKA) has remained as one of the most devastating potential complications. In this context we developed a new technique that keeps the spacer in distraction during the cementation process to achieve better weight-bearing stability. METHODS We present a case of a 75-year-old male patient, who was treated in our hospital with an infected total knee replacement (TKR) using the distraction spacer. The operative technique includes the removal of the infected prosthesis after radical debridement. Then two carbon rods were inserted overlapping 2-3 cm in the medulla of the tibia and femur. Afterwards an external fixateur with distraction module is attached with two Schanz screws into the distal femur and the proximal tibia. The cementation process was performed under distraction. After hardening of the cement the external fixateur and the Schanz screws are then removed. RESULTS Postoperatively the patient was mobilized with full weight-bearing using an extension splint. The antibiotic therapy was continued for five weeks. After sterile puncture, the reimplantation was performed using a Zimmer-Rotating-Hinge-Knee without any complications. CONCLUSIONS This method allows cement hardening without micromovements and early mobilization with partial full weight bearing and prevents the contraction of the capsule and the ligaments during the prosthesis-free period, preparing the knee for a secondary TKA or an intramedullary arthrodesis with a titanium stem.

Sigmoido-gluteal fistula--a rare complication in clinically asymptomatic chronic diverticulitis.

Abstract Chronic colonic diverticulitis may be associated with typical complications such as local abscesses, stenosis, bleeding, intraperitoneal bowel perforations or fistulas to other organs. Most commonly, fistulas exist between the colon and the bladder; nevertheless, they may also extend to the small intestine, other areas of the colon, ureter, uterus, salpinx, vagina, abdominal wall, portal-and mesenterial venous system, pleura, urachus, biliary system and the hip. We report on a patient with chronic colonic diverticulitis having an unusual sigmoido-gluteal fistula along the sacrum, the piriformis muscle and sciatic nerve. The patient presented with sciatic nerve symptoms and recurrent gluteal abscess formation, but no other clinical symptoms leading to an abdominal pathology. Initially, that fact caused an unsuccessful local treatment under the differential diagnosis of a local gluteal abscess for about a year. Finally, a sigmoid colon resection with end-to-end anastomosis and a proximal diverting stoma was performed. The colostomy was closed electively five months later without any complication.

Primäre Ellenbogenprothetik nach Trauma

ZusammenfassungDie Endoprothetik des Ellenbogengelenks hat bei rheumatoider Arthritis einen festen Stellenwert. Ihre Anwendung im Rahmen der Primärendoprothetik bei Frakturen des Ellenbogens ist nicht in dem Maße etabliert wie bei Brüchen des Schulter- und des Hüftgelenks. Auch die posttraumatischen Diagnosen wie die Pseudarthrose des distalen Humerus oder die posttraumatische Arthrose stellen bisher eine Randindikation für die Ellenbogenprothetik dar. Die vorliegende Arbeit zeigt eine Übersicht über die bezüglich der Anwendungsindikationen und Ergebnisse der Primärendoprothetik des Ellenbogens bei distalen Humerusfrakturen vorliegende Literatur. Zudem werden die Bedeutung und die Einschränkungen der Alloarthroplastik des Ellenbogengelenks für die posttraumatischen Folgeerkrankungen wie Pseudarthrose, Arthrose und Ankylose anhand der verfügbaren Studien reflektiert.AbstractTotal elbow replacement is well established for elbow destruction in rheumatoid arthritis. But its use for primary treatment of elbow fractures is less frequent than such treatment for fractures of the shoulder and hip joint. Posttraumatic conditions such as pseudarthrosis of the distal humerus and posttraumatic arthritis are rare indications for total elbow arthroplasty. This article gives an overview of the present literature regarding the indications and results for primary total elbow arthroplasty for fractures of the distal humerus. We also look at studies dealing with the role and limitations of total elbow replacement in posttraumatic arthritis, pseudarthrosis of the distal humerus, and stiff elbow.

Evaluating the microbial pattern of periprosthetic joint infections of the hip and knee

Purpose. Periprosthetic joint infection (PJI) is a devastating complication that leads to enormous economic and health care complaints from affected patients. The aim of this study is to identify the causative pathogens responsible for PJI, evaluate temporal trends concerning the pathogen pattern and identify potential risk factors for PJI. Methodology. This was a retrospective study analysing a total of 937 patients suffering PJI of the hip or knee joint between 2003 and 2011. Results. In total, 394 patients (42.0 %) with total knee arthroplasty (TKA), 477 patients (50.9 %) with total hip arthroplasty (THA) and 64 patients (6.8 %) receiving a dual‐head prosthesis had to be hospitalised due to PJI. In two cases (0.2 %), a simultaneous infection of TKA and THA occurred. The mean age of the study cohort was 70.85±11.68 years. The mean body mass index (BMI) was 28.53±5.7. According to the Charlson comorbidity index, 2.99 % of the patients were classified as severity Grade 1, 13.98 % Grade 2, 40.02 % Grade 3 and 43.0 % Grade 4. Staphylococcus aureus (MSSA), methicillin‐resistant Staphylococcus epidermidis (MRSE), methicillin‐resistant Staphylococcus aureus (MRSA), coagulase‐negative Staphylococcus (CoNS), Streptococcus, and Enterococcus were the pathogens mainly responsible. An increase in high‐resistance pathogens, such as MRSE, extended‐spectrum beta‐lactamase bacteria (ESBL), ampicillin‐resistant Enterococcus, Acinetobacter spp. and vancomycin‐resistant Enterococcus (VRE), was found during the study period. Only MRSA showed a declining tendency in a regression model. Conclusion. Patients suffering PJI present a certain risk profile with many comorbidities, e.g. high age and obesity. The observed microbiological pattern demonstrates the rise of high‐resistance pathogens.

The posttraumatic proximal cross-union of the forearm in childhood: what is recommended?

The posttraumatic proximal cross-union of the forearm in childhood is a rare complication after radial head, neck or proximal forearm fractures and elbow dislocations. There is no standardized treatment. Several surgical procedures with or without interposition techniques are described in the literature. The aim of this study was to analyze all children with cross-unions who underwent surgery over the last 15 years. From 1998 to 2013, 8 children with a posttraumatic proximal cross-union of the forearm (Type 3 according to Vince and Miller) received surgical treatment with resection of the cross-union or radial head. Mean age at the time of initial trauma was 9.0±2.56 years (range 6-14 years), age at the time of surgery was 11.9±3.09 years (range 7-16 years). Mean time of resection of the crossunion was 23.2 months. Follow-up time was 10.6 months (range 1-36 months). Five patients had a resection of the cross-union without any interposition techniques, in 2 cases with an additional arthrolysis of the elbow. One patient had an interposition of a local fascia flap. In 2 cases, a primary excision of the radial head, six and seven years, respectively, after trauma, was performed. All patients, except one, had non-steroidal antiinflammatory drugs therapy after surgery. A post-operative irradiation was performed in 3 cases. The mean postoperative range of motion for pronation/supination was 36/0/53°. Controversy remains about the best procedure to adopt for posttraumatic cross-union in childhood. After analysis of our data and the literature, we recommend the resection of the crossunion within 6-24 months of occurrence without necessarily using any interposition techniques. All patients reported an improvement with regard to ordinary activities. In cases of long-term cross-union for several years with ankylosis of the elbow and bony deformities of the proximal radius, an excision of the radial head as salvage procedure is recommended.

Versorgung medialer Schenkelhalsfrakturen im Alter

ZusammenfassungAufgrund der demografischen Bevölkerungsentwicklung sehen wir uns mit einer jährlichen Zunahme medialer Schenkelhalsfrakturen betagter Patienten konfrontiert. Im vorliegenden Beitrag werden die Behandlungsmodalitäten der Frakturen des koxalen Femurendes geriatrischer Patienten insbesondere mittels Duokopf- und Totalendoprothese anhand der vorliegenden Literatur und unter Betrachtung der für die Therapie der Schenkelhalsfraktur des Erwachsenen vorliegenden Leitlinien der Deutschen Gesetzlichen Unfallversicherung (DGU) diskutiert. Auch die Frage der Verwendung zementierter oder zementfreier Schäfte bei der endoprothetischen Versorgung dieser Verletzungen wird aufgegriffen und reflektiert.AbstractDue to demographic changes in the population, we are facing an annual increase in femoral neck fractures in geriatric patients. The paper discusses the treatment modalities of hip fractures in this patient group, with particular regard to bipolar and total hip alloarthroplasty according to the current literature and taking the existing guidelines of the German statutory accident insurance (DGU) into consideration. We also discuss the use of cemented or cementless stems in the endoprosthetic care of these fractures.