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Vogel C, Reumann MK, Menger MM, Herath SC, Rollmann MFR, Lauer H, Histing T, Braun BJ. [Non-unions of the upper extremities]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02095-w. [PMID: 38829545 DOI: 10.1007/s00104-024-02095-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 06/05/2024]
Abstract
The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.
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Affiliation(s)
| | - Marie K Reumann
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Maximilian M Menger
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Steven C Herath
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Mika F R Rollmann
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Henrik Lauer
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Tübingen, Deutschland
| | - Tina Histing
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Benedikt J Braun
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
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Reumann MK, Hillrichs H, Menger MM, Herath SC, Rollmann MFR, Stuby F, Histing T, Braun BJ. [Nonunions after intertrochanteric and subtrochanteric femoral fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:356-363. [PMID: 38224360 DOI: 10.1007/s00113-023-01402-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION The overall frequency of proximal femoral fractures means that we are repeatedly confronted with failed healing and implant failure, despite a relatively low nonunion rate especially in intertrochanteric fractures (< 5%). The aim of this paper is to present our approach to treating these nonunions of the proximal femur and discuss the treatment results. MATERIAL AND METHODS Between 2009 and 2023, patients with nonunion of the proximal femur were retrospectively identified and analyzed. Age, gender, time to revision, the Weber-Cech classification of pseudarthrosis and radiographic imaging before and after revision were analyzed. RESULTS A total of 66 patients were analyzed. The mean age was 58 years (range 25-88 years). The overall healing rate was 88% with a mean consolidation time of 8 months (range 2-29 months). The main osteosynthesis procedures were plate osteosynthesis (n = 45, of which 44 were blade plates), and nail replacement (n = 12). Other procedures included augmentative plate osteosyntheses (n = 4), isolated cancellous bone graft (n = 2), nail dynamization (n = 2), and the use of a dynamic hip screw (n = 1). DISCUSSION The analysis of our treatment data as well as the current literature, revealed a trend towards intramedullary revision procedures. Implants that can be used to correct the CCD angle, such as the blade plate, remain a predictable option to achieve correction, especially in nonunions with an increased degree of varus. Particularly in the subtrochanteric region, fractures can also be treated in a targeted manner by a combination of mechanical and biological methods with a reamed nail change to a larger caliber implant.
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Affiliation(s)
- Marie K Reumann
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Hauke Hillrichs
- Klinik für Unfallchirurgie, Orthopädie und Allgemeinchirurgie, BG Unfallklinik Murnau, Murnau, Deutschland
| | - Maximilian M Menger
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Steven C Herath
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Mika F R Rollmann
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Fabian Stuby
- Klinik für Unfallchirurgie, Orthopädie und Allgemeinchirurgie, BG Unfallklinik Murnau, Murnau, Deutschland
| | - Tina Histing
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Benedikt J Braun
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinik Tübingen, Eberhard Karls Universität Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Hackl S, Eijkenboom A, Militz M, von Rüden C. [Diagnostic and therapeutic work-up of infected tibial nonunion]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:96-102. [PMID: 37812233 DOI: 10.1007/s00113-023-01371-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The failure of bone fracture healing is one of the major complications of fracture treatment, especially of the tibia due to its limited soft tissue coverage and high rate of open injuries. Although implant development is constantly progressing and modern surgical techniques are continuously improving, infected tibial nonunion plays a decisive role in terms of its variable clinical presentation. OBJECTIVE This article provides guidelines for the successful surgical treatment of infected tibial nonunion. MATERIAL AND METHOD Strategies are presented to identify infection as a cause of failure of fracture healing and to achieve infection and bone healing. RESULTS A significant amount of tibial nonunions primarily thought to be aseptic ultimately turn out to be infected nonunions. CONCLUSION The treatment of infected tibial nonunion requires extensive clinical, radiological and laboratory diagnostics as well as a profound biomechanical and biological understanding of the bone situation. This is the only way to achieve rapid osseous healing with as few revision interventions as possible.
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Affiliation(s)
- Simon Hackl
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Alexander Eijkenboom
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Matthias Militz
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Weiden, Deutschland
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Lotzien S, Baron D, Rosteius T, Cibura C, Ull C, Schildhauer TA, Geßmann J. Medial augmentation plating of aseptic distal femoral nonunions. BMC Musculoskelet Disord 2023; 24:554. [PMID: 37407946 DOI: 10.1186/s12891-023-06675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/27/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants. METHODS We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D). RESULTS Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection. CONCLUSIONS According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.
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Affiliation(s)
- Sebastian Lotzien
- Department of General and Trauma Surgery, Ruhr University Bochum, Bürkle-de-La-Camp-Platz 1, 44789, Bochum, Germany.
| | - Darius Baron
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Charlotte Cibura
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Christopher Ull
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle- de- La- Camp Platz 1, 44789, Bochum, Germany
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Grunert M, Hackenbroch C, von Lübken F. [Update on non-unions 2022 : Imaging diagnostics, classification and treatment algorithms]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:589-601. [PMID: 35796818 DOI: 10.1007/s00113-022-01201-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Fracture healing is a complex regenerative process. An unconsolidated fracture that will not heal without further surgical intervention is called non-union. The causes are multifactorial. Diagnostic imaging is a central pillar and provides insights into the morphology and biology of the fracture as a basis for optimal surgical treatment decisions. AIM Knowledge of fracture healing, targeted radiological and nuclear medical diagnostics, and interdisciplinary standardized classification are of high importance for optimal treatment. METHODS In this article, the proven and modern diagnostic procedures are presented, an overview of the currently used scoring and classification models is given and the optimal therapeutic approach based on the extended "diamond concept" is addressed. A possible diagnostic and therapeutic approach is shown using an algorithm. CONCLUSION For successful treatment of pseudarthrosis, targeted radiological and nuclear medical diagnostics with old established but also newest methods, such as dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and hybrid imaging, are necessary. An exact classification of non-unions using additional classification models makes it possible to determine and carry out the optimal surgical treatment at an early stage.
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Affiliation(s)
- Michael Grunert
- Klinik für Nuklearmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
- Klinik für Nuklearmedizin, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Carsten Hackenbroch
- Klinik für diagnostische und interventionelle Radiologie und Neuroradiologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
- Klinik für Radiologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Falk von Lübken
- Klinik für Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
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