Übersetzt aus dem Englischen:

Lernen Sie die chirurgische Technik zur Tibiakopf-Fraktur: 360-Grad-Zugang, anteriore Vorgehensweise (Stufe 2), variable Winkel proximale Tibiaplatte (DePuy-Synthes) mit schrittweisen Anweisungen auf OrthOracle. Unsere E-Learning-Plattform enthält hochauflösende Bilder und eine zertifizierte Fortbildung (CME) des chirurgischen Verfahrens zur Tibiakopf-Fraktur: 360-Grad-Zugang, anteriore Vorgehensweise (Stufe 2), variable Winkel proximale Tibiaplatte (DePuy-Synthes).

Wie bei vielen Traumata im Erwachsenenalter haben Tibiakopf-Frakturen eine bimodale Verteilung. Bei jüngeren Patienten resultieren diese Verletzungen aus hochenergetischen Mechanismen wie Stürzen aus großer Höhe oder Verkehrsunfällen, während sie in der älteren Bevölkerung häufiger durch einfache Stürze verursacht werden.

Tibiakopf-Verletzungen wurden von Schatzker auf der Grundlage von Röntgenaufnahmen in 6 Typen eingeteilt. Typen 5 (bikondylär) und Typ 6 (bikondylär mit vollständiger Trennung der Gelenkfläche von der Tibiaschafthülle) stellen die hochenergetischen Verletzungen dar. Eine neuere Klassifikation von Luo, basierend auf CT-Scans, unterteilt den Tibiakopf in 3 Säulen, medial, lateral und posterior, und hilft, die chirurgische Vorgehensweise bei der Fraktur je nach genauer Frakturkonfiguration zu leiten.

Die Mehrheit der Tibiakopf-Frakturen betrifft die laterale Seite und kann mit dem Standard anterolateralen Zugang mit Meniskusanhebung angegangen werden. Für Frakturen mit medialer oder posteriorer Beteiligung sind weitere Zugänge möglich, darunter direkter medialer, postero-medialer, direkter posteriorer oder sogar posterolateraler Zugang. Die Fixierung bikondylärer Tibiakopf-Frakturen über einen einzelnen anterioren Mittellinien-Schnitt wird heutzutage im Allgemeinen vermieden, da hierfür eine umfangreiche Weichteildissektion erforderlich ist und die damit verbundenen Wundprobleme.

Original Intro:

Posterior Cervical Laminoplasty (Bioplate cranial fixation system) and Excision Of C5 nerve sheath tumour

Learn the Posterior Cervical Laminoplasty (Bioplate cranial fixation system) and Excision Of C5 nerve sheath tumour surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Posterior Cervical Laminoplasty (Bioplate cranial fixation system) and Excision Of C5 nerve sheath tumour surgical procedure.

Spinal nerve sheath tumours (NST), also known as peripheral nerve tumours, are uncommon growths that develop in the covering (sheath) of nerves within the spinal canal or along peripheral nerves branching from the spine. These tumours can occur in different parts of the body but are particularly relevant when they affect the spine.

The two primary types of benign nerve sheath tumours are Schwannomas and neurofibromas. Malignant peripheral nerve sheath tumours are an aggressive and invasive cancer that develop in about 8-13% of patients with NF1. They can also occur sporadically and are associated with a poor prognosis.

Managing spinal nerve sheath tumors often requires a multidisciplinary approach involving neurosurgeons, oncologists, and other specialists to determine the best course of treatment for each individual case. Regular follow-ups are essential to monitor the tumor’s growth and manage any recurrent symptoms.

Indications for surgical treatment should be considered on a case by case basis.  There is no good literature on the proportion of cases that require surgical treatment.  However, in all cases the option of surgery should be considered and normally surveillance imaging is required if conservative management is pursued.

Apart from malignant transformation the indications for surgical treatment are in the main the development of a progressive radiculopathy, spinal cord extension and  rapid growth of the tumour.

Nerve sheath tumours in the cervical spine are most often approached from posteriorly as this allows easy visualisation of the critical neural structures and less risk to the vertebral artery.

There are several variations on the posterior approach, including formal laminectomies or laminoplasty, when the bone is replaced. The advantages of laminoplasty are thought to be restoration of spinal stability and lower risk of late progressive kyphosis. This is the approach described here.

There are a variety of laminoplasty implant options available on the market.  In this case simple  titanium mini plates are used to fashion a laminoplasty.

Bioplate fixation is with self-drilling screws and two hole straight plates, the screws and plates are made from titanium.  The screws are available in 1.9mm and 1.5mm lengths.

If there are concerns regarding spinal stability there is also the option to perform a posterior instrumented fusion. This was not deemed necessary in this case.

OrthOracle readers will also find the following associated instructional techniques of interest:

Cervical laminectomy and resection of spinal cord tumour

Cervical Laminoplasty for treatment of Cervical spondylotic myelopathy

Posterior Cervical Decompression and Fusion using DePuy Mountaineer Instrumentation

Cervical spine decompression: Posterior approach (Degenerative cervical myelopathy).

(With thanks to Navin Furtado FRCS whose case is demonstrated)

Author: Mark Nowell FRCS

Institution: Southmead Hospital, Bristol, UK.

Übersetzt aus dem Englischen:

Lernen Sie die chirurgische Technik zur Revision der totalen Knieendoprothese: Zweite Stufe unter Verwendung des Adler Pantheon-Ersatzes mit Rekonstruktion des Gastrocnemius-Lappens mit schrittweisen Anweisungen auf OrthOracle. Unsere E-Learning-Plattform enthält hochauflösende Bilder und eine zertifizierte Fortbildung (CME) des chirurgischen Verfahrens zur Revision der totalen Knieendoprothese: Zweite Stufe unter Verwendung des Adler Pantheon-Ersatzes mit Rekonstruktion des Gastrocnemius-Lappens.

Die Anzahl der primären und revidierten Knieendoprothesen steigt stetig, was zwangsläufig zu mehr Protheseninfektionen führt, die von spezialisierten multidisziplinären Teams für Protheseninfektionen behandelt werden. Infektionen sind eine verheerende Komplikation der totalen Gelenkendoprothetik und nicht nur die häufigste Ursache für frühzeitiges Versagen von Gelenkersatzoperationen, sondern auch die häufigste Ursache für das Versagen von revisionsbedürftigen Knieendoprothesen zu jedem Zeitpunkt.

Dass Protheseninfektionen mit einer höheren Sterblichkeitsrate verbunden sind als einige häufige Krebserkrankungen, wurde weit verbreitet berichtet. Die Fünfjahresüberlebensrate nach einer Protheseninfektion beträgt 78% im Vergleich zu 90% bei Patienten, die sich einer aseptischen Revisionsendoprothetik unterziehen (Matar H, et al. Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients). Journal of Arthroplasty 2021).

Original Intro:

Revision total knee replacement: Second stage using Adler Pantheon replacement with gastrocnemius flap reconstruction

Learn the Revision total knee replacement: Second stage using Adler Pantheon replacement with gastrocnemius flap reconstruction surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Revision total knee replacement: Second stage using Adler Pantheon replacement with gastrocnemius flap reconstruction surgical procedure.

Increasing numbers of primary and revision knee replacements are being performed which inevitably lead to more prosthetic joint infections (PJI) presenting to specialist PJI multi-disciplinary teams. Infection is a devastating complication of total joint arthroplasty and not only the most common cause for early failure of joint replacements but also the most common cause for failure of revision knee replacements at any time.

That PJI is associated with higher mortality than some common malignancies has been widely reported. The five year survival after PJI is 78% compared to 90% in patients undergoing aseptic revision arthroplasty (Matar H, et al. Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients). Journal of Arthroplasty 2021).

The treatment of prosthetic joint infection typically requires surgery involving explant of the infected prosthesis, radical debridement and then either immediate reimplantation or use of an antibiotic loaded cement spacer and delayed reimplantation  (a two-stage revision, as in this case). Alternative strategies include debridement and implant retention with modular exchange (indicated in acute PJI) and single-stage revision (considered in infected primary arthroplasty implants, sensitive organisms and without soft-tissue defects requiring plastic surgery). There is endless debate about selecting the correct option for each case, the decision is multi-factorial and probably best decided in specialist PJI multi-disciplinary meetings.

Infected revision knee replacements are increasing in prevalence due to the increasing numbers of revision joint replacements being performed for septic and aseptic indications such that a 7.5-fold increase in re-revision knee replacements due to infection that has been experienced in the UK since 2005 (Lenguerrand et al. Description of the rates, trends and surgical burden associated with revision for prosthetic joint infection following primary and revision knee replacements in England and Wales: an analysis of the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. BMJ Open 2017)

The outcomes however of repeat two-stage revision are not widely described; our own hospital data suggests that failure due to recurrent infection after 2 years can be as high as 50%, compared to 10% in primary two-stage revisions of infected primary knee replacements, so proceeding must be a carefully considered and consented intervention. Failure to control PJI may lead to further surgery, antibiotic suppression or amputation.

Here I present a challenging case of reconstruction of an infected revision knee replacement, which underwent a two-stage revision using a porous tibial cone for severe bone loss and a silver-coated endoprosthetic replacement to manage segmental bone loss.

Readers will also find the following related OrthOracle surgical techniques of interest:

First Stage Revision Total Knee Replacement for Acute Prosthetic Joint Infection (Zimmer Biomet articulating spacer)

Second Stage Revision Total Knee Replacement. PFC / MBT TKA with metaphyseal sleeve and stem (Depuy)

Revision total Knee Replacement: Legion CCK (Smith and Nephew)

Revision total Knee Replacement- Legion Rotating Hinge Knee ( Smith and Nephew)

Revision Total Knee replacement (Tibia only): Smith and Nephew Legion revision knee system and Implantcast Epore tibial cone

First stage re-revision total knee replacement of Implantcast MUTARS MK EPR using reinforced static antibiotic cement spacer

Revision total Knee replacement: Second-stage with distal femoral EPR (Implantcast MUTARS MK) and EPORE collar and tibial cone

Revision Total Knee Replacement: Second stage using PFC / MBT with metaphyseal sleeve and stem (Depuy)

Total knee replacement: First stage revision with a hinged spacer and tibial tubercle osteotomy

Author: Jonathan Stevenson FRCS (Tr & Orth)

Institution: The Royal Orthopaedic Hospital, Birmingham, UK

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.