Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Meta Analysis
[The displaced proximal humeral fracture: is there evidence for therapeutic concepts?].
There is no general agreement on the operative treatment of displaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have been favoured during the past decade. The indication for primary shoulder prosthesis is controversial. The purpose of this report was to evaluate the scientific evidence of current treatment recommendations. ⋯ We conclude from our analysis that the scientific evidence for treatment recommendations of displaced proximal humeral fractures is still limited.
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Although proximal humeral fractures are common injuries, there is no generally accepted strategy as to how unstable and displaced two- to four-part fractures should be managed. Surgical therapy is in a conflicting situation between the requirement for anatomical fracture reduction and stable fixation, on the one hand, and the necessity for minimal intraoperative damage to the soft tissue and arterial vascularization of the humeral head in order to avoid avascular necrosis on the other. Whereas minimally invasive procedures using closed or percutaneous reduction and fixation techniques are advantageous for protection of the arterial blood supply of the proximal humerus, plate fixation provides superior fixation stability. ⋯ There is therefore a tendency towards the use of implants with angular stability in order to reduce the risk for secondary loss of reduction during functional after treatment. Innovative new plates and intramedullary nails that provide superior stability of fixation of the humeral head fragment have been actually introduced into clinical practice. Together with the specific patient and fracture characteristics, the final result of operative management, however, remains mainly related to the knowledge and operative skills of the trauma or orthopaedic surgeon who deals with these proximal humeral fractures.
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Randomized Controlled Trial Clinical Trial
[Perioperative local instillation of ropivacaine for postoperative pain relief after surgery on extremities].
The relief of postoperative pain remains one of the most important goals for adequate surgical patient care. ⋯ By the presented method, the surgeon actively contributes to a significant reduction in postoperative pain and analgesic consumption. Furthermore, the patient's benefit is reflected by higher satisfaction with the pain management. Complications due to toxic plasma levels are not seen.
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Fractures of the proximal femur are typical injuries of the elderly. Therefore immediate restoration of weight-bearing capacity and prevention of local complications with the need for of secondary surgical procedures are very important. ⋯ The weight-bearing capacity of the GN (4,230-5,557 N) was about 100% higher than that of the DHS (2,465-3,049 N). The total deformation was 1/3 higher for the DHS (17.3 +/- 2.06 mm) than for the GN (10.73 +/- 4,33 mm). After 100,000 alternating load cycles no instability and a total deformation of 13.3 mm was found for the GN, but for the DHS instability occurred after 15,800 cycles. The migration of the I-beam GN plate at 1,000 N in sowbone femora was 0.7 mm for the gamma screw 1.69 mm and for the PFN 2 mm but one cut-out was observed. At 1,500 N the difference are even higher, all three PFN showed a cut-out and in two of the three gamma screws rotation of the head and neck around the screw was observed. In the cadaver tests similar differences were found with a migration at least double that of the GN I beam plate for the gamma screw and the PFN double-screw fixation. There was no difference between the gamma and PFN fixation in the cadaver pair test.