Abstracts - Chirurgie Kongress

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migration of the helical blade into the femoral head and even cutting through into the Acetabulum by repeated physiological forces only. The classic cut out is missing. Further biomechanical studies have to show if there are forces that allow this penetration by micromovements between the nail and the helical blade. 103.2 PFNA-Klingenwechsel mit Verbundosteosynthese als Therapieoption beim Cut-Out der PFNA- Schenkelhalsklinge M. Randazzo, T. Köstler, V. Neuhaus, M. Turina, O. Schöb (Schlieren) Objective: Der Cut-out der Schenkelhalsklinge durch die Kompakta des Femurkopfes ist eine bekannte Komplikation nach osteosynthetischer Versorgung von pertrochantären Femurfrakturen mittels PFNA. In der Regel erfolgt die operative Revision dieser Komplikation mit Explantation des Osteosynthesematerials und Implantation einer Hüftendoprothese. Anhand von 3 Fallbeispielen zeigen wir eine alternative Operationsstrategie mittels Wechsel der Schenkelhalsklinge. Methods: Von April 2006 bis August 2008 behandelten wir 67 Patienten mit pertrochantären Femurfrakturen mittels PFNA. Bei Auftreten eines Cut out der Schenkelhalsklinge erfolgte ein Klingenwechsel mit Zementaugmentation. Die Auswertung erfolgte anhand der ersten postoperativen Röntgenbilder sowie der klinischen und radiologischen Nachkontrollen 6 Wochen postoperativ. Results: 4 Patienten (5,97%) erlitten nach durchschnittlich 42,3 Tagen einen Cut out der Schenkelhalsklinge, welcher mittels Schenkelhalsklingenwechsel verbunden mit einer Zementaugmentation versorgt wurde. Das Patientenalter betrug 62, 60, 86 und 80 Jahre, darunter 3 Frauen und 1 Mann. Der postoperative Verlauf gestaltete sich bei allen Patienten problemlos. Die mittlere Hospitalisationsdauer betrug 16 Tage. In der klinischen und radiologischen Kontrolle 6 Wochen postoperativ wies ein Patient belastungsabhängige Hüftschmerzen auf. Conclusion: Eine Neuplatzierung der Schenkelhalsklinge beim PFNA mit Verbundosteosynthese scheint eine mögliche Alternative bei der Komplikation des Cut out darzustellen. Der kurzfristige Followup zeigt in unseren Fällen ermutigende Resultate. Der Langzeitverlauf wird uns allerdings erst zeigen, in wie weit die Knochenheilung durch die Zementapplikation beeinflusst wird und ob der Knochenzement zu einer Femurkopfnekrose führt. 103.3 Evaluation of anterior minimally invasive surgery (AMIS ® ) with unipolar hip hemiarthroplasty for displaced femoral neck fractures in the elderly E. M. Arn, A. Schierz, C. Meier, (Zollikerberg) Objective: Hip hemiarthroplasty (HA) is a standard treatment for femoral neck fractures in the elderly. Most commonly, surgery is performed via a lateral or posterior approach both being associated with considerable disadvantages. Minimally invasive HA via an anterior approach may overcome some of these problems. AMIS ® is a technique which combines a minimally invasive anterior approach with a special mobile leg positioner and approach-specific instruments. It was the aim of this study to evaluate the learning curve of the AMIS ® procedure for HA. Methods: Prospective consecutive case series. Since 07/2008 the AMIS ® procedure has been the standard technique for femoral neck fractures in the elderly (>=70 years) in our department. All AMIS ® procedures were performed by one of two experienced trauma surgeons. HA via a lateral transgluteal approach (n=5) was only performed when none of the surgeons familiar with this technique was available. Evaluation included operating time, quality of stem implantation, intraoperative blood loss, the amount of postoperative wound drainage collection and complications related to the surgical technique. Results: Twenty-two patients underwent HA within the first 6 months of the study (mean age 86y, range 72-100y). Uncemented HA was performed in 18 cases (mean operating time 81 min, range 50-130 min), 4 patients received cemented HA (mean operating time 103 min, range 95-110 min). Intraoperative blood loss was 460 mL (range 200-900mL). Compared to preoperative planning 19 out of 22 stems were implanted with identical length +/- 5mm. Mean length discrepancy was 3mm (2-7mm). Mean postoperative wound drainage was measured 470mL (range 130-730mL). One iatrogenic fissur of the greater trochanter with secondary displacement after a repeated fall and one postoperative hematoma required surgical revision. One patient fell two days after surgery sustaining a periprosthetic fracture which was successfully treated non-operatively. No other procedure-related complication was observed. Conclusion: According to our experience, the AMIS ® technique is safe with reliable stem implantation right from the start. With proper teaching and instruction the AMIS ® technique can be learned and performed with a steep learning curve and immediate good results making it an attractive potential standard technique for the treatment of femoral neck fractures. 103.4 Operative strategy for the treatment of dislocation type fractures of the proximal tibia (Moore type II, medial) P. Potocnik, R. Jenni, C. Sommer (Chur) Objective: In 1980 Moore introduced a new classification for dislocation type fractures caused by high energy mechanisms. The most common medial Moore type II fracture is an entire condyle fracture with the avulsion of the median eminence. It is usually associated with a posterolateral depression of the tibial plateau and an injury of the lateral meniscotibial capsule. This uniform injury of the knee is increasingly observed in the recent years after skiing injuries due to the high speed carving technique. The aim of this study is to describe the injury pattern, our operative approach for reconstruction and outcome. Methods: Retrospective analysis of our patients with this injury from 2001 to 2007. All fractures were stabilised postprimarily. The surgical main approach was strictly medial. Exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. The posterolateral impaction was adressed directly through the main fracture gap. Small fragments were removed, larger reduced and preliminarily fixed with separate K-wire(s). The posteromedial part of the condyle was then prepared for main reduction and application of a buttress T-plate in a posteromedial position, preserving the pes anserinus and MCL. In addition an anteromedial arthrotomy through the same main approach was performed for reduction and PDS-suture-fixation of the anterior eminence (ACL and anterior horn of lateral meniscus). Follow-up after 1-8 years radiologically and clinically. Results: We treated 19 patients with 20 fractures. Median age 42.3 (24-76). Follow-up: 15p (74%). All fractures healed without secondary displacement or infection. Osteoarthritis: none to moderate: 14p, severe: 1p. All patients judge the result as good to excellent. 10 returned to full previous sport activity. Lysholm score: 94.1. Tegner Activity Score: 4.7. Pain: 6 completely painfree, 9 with some pain during heavy weight bearing. Giving-way: 1p. All have a minimum flexion of 100°. Conclusion: In our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. With our strategy we achieved good results in nearly all patients. The described larger medial approach allows to adress most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). 103.5 Long term results and posttraumatic ankle arthrosis in osteosynthesis of the posterior malleolus using a dorsolateral approach J. Forberger, B. Martens, P. Sabandal, M. Dietrich, C. Spross, A. Platz (Zürich) Objective: The importance of stable anatomical reconstruction of the joint surface in ankle fractures is well described in literature. Ankle fractures which include the posterior malleolus also have a significant restricted functional outcome. The objective of this analysis is to observe the functional outcome in long term follow up and ankle arthrosis after plate fixation of the “Volkmann triangle” by using a dorsolateral approach. Methods: From January 2003 to December 2005 all patients treated by plate-osteosynthesis for the posterior displaced tibial fragment were consecutively included into this single institution study. In long term follow up functional outcome was controlled by using the modified Weber protocol and the standardised foot and ankle questionnaire from the American Association of Orthopaedic Surgery (AAOS), which include the foot and ankle core scale, as well as the shoe comfort score. Standardized x-rays were analysed by two independent investigators. The arthrosis where classify in four stages. Results: During the time period 51 Patients (36 female, 15 male) were consecutively included into the study. Median age was 55 years (range 19-83). According to the AO-classification there was one fracture classified 44-A3, 39 44-B3, 8 44-C1 and 3 as 44-C2. The involvement of the articular surface was 23% (10% to 48%). Clinical and radiological follow up was performed 42 months (27-64) after operation. No displacement of the “Volkmann triangle” was seen. The foot and ankle core scale shows a median of 95 (range 47 to 100). The shoe comfort score a median of 100 (range 50 to 100). A median of 7.5 points (5-14) was documented using the modified Weber-protocol. We have seen 12 cases without arthrosis, 18 patients had a middly arthrosis, one patient with a moderately arthrosis and 6 patients with severe arthrosis. One of these patients with severe arthrosis underwent ankle arthrodesis. We have seen no significant decrease in ROM and no worsening in all scores in the annually sales controls. Conclusion: The dorsolateral approach allows the direct anatomical reposition and plate-fixation of a displaced posterior malleolus by little local complications and. Despite the fact of radiological findings of arthrosis leads the direct anatomical reconstruction using the dorsolateral approach to good functional and subjective outcome in long term follow up. 103.6 Radiologischer und klinischer Outcome bei intraartikulären Calcaneusfrakturen nach Versorgung mit 2.0/2.7 mm AO Minifragmentplatten J. Müller, J. Rosenkranz, R. Babst (Luzern) Objective: Postoperative Wundheilungsstörungen sind die häufigste Komplikation der osteosynthetischen Versorgung von intraartikulären Calcaneusfrakturen. Um das Risiko von Wundheilungsstörungen zu vermeiden benutzten wir in unserer Serie wenig auftragende 2.0 und 2.7 AO Minifragmentplatten. Damit stellte sich die Frage ob diese Versorgung die notwendige Stabilität bietet. Methods: Im Zeitraum 1998-2004 wurden 62 Patienten mit 70 intraartikulären Calcaneusfrakturen osteosynthetisch versorgt. Zur Nachkontrolle erreichten wir 47 Patienten mit 53 Frakturen (Nachkontrollquote 87%). Die Klassifizierung der Frakturen erfolgte nach Essex-Lopresti, Saunders und der OTA- Klassifikation. Die radiologischen Nachkontrollen erfolgten 6, 12 Wochen und 1 Jahr postoperativ. Gemessen wurde der Böhler Winkel im postoperativen Verlauf und im Vergleich zur Gegenseite. Die klinische Bewertung beinhaltete den AOFAS Ankle-Hindfoot Score, SF 36 und validierter VAS zum Zeitpunkt der Jahreskontrolle. Results: In der 6 Wochen Kontrolle zeigte sich ein signifikanter Korrekturverlust des Böhlerwinkels von durchschnittlich 28° (St 8°) postoperativ auf 24° (St 9°). Zum Zeitpunkt der Jahreskontrolle betrug der Böhlerwinkel 22°. Klinisch schnitten Patienten in allen Scores besser ab wenn ihr Böhlerwinkel >= 20° war. Tiefe Infekte traten bei 2 Fällen auf (3.8%), Wundheilungsstörungen wurden bei 9 Patienten (17%) beobachtet. Conclusion: Bei osteosynthetischer Versorgung von intraartikulären Calcaneusfraktur mit 2.0/2.7 mm AO Minifragmentplatten konnten wir einem signifikanten sekundären Repositionsverlust, welcher mit dem klinischen Ergebnis korreliert, feststellen. swiss knife 2009; special edition 69
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Abstracts - Chirurgie Kongress

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