Der Orthopäde
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Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. ⋯ The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.
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The stabilization of long bone fractures through reaming the medullary cavity and insertion of an intramedullary nail, with or without locking bolts, was a standard procedure in fracture treatment for a long time. With the development of nails, which can be applied without reaming, the procedure lost importance. This publication presents the mechanical principles and impact of reaming on the bone. ⋯ Today nevertheless unreamed nailing is favoured especially in German-speaking countries. This is maybe due to the necessary classic procedure of planning, positioning on the fracture table and reaming in steps, which make the operation slightly more complex, requiring a certain amount of armamentarium and technical understanding. In any case reamed intramedullary nailing offers an alternative procedure for many indications; to treat a hypertrophic non-union of the shaft of the long bones it remains the method of first choice.
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Locked plating is one of the most modern plating techniques, the aim of which is to achieve the smallest possible surgical trauma, small incisions, preserve blood supply to the bone and adjacent soft tissues, and to ensure a minimal bone-implant interface.
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Bone tissue possesses a unique regeneration ability, translating mechanical and metabolic stimuli into a biological response. The perpetual regeneration processes allow continuous self-renewal and adaptation to prevailing mechanical forces. The complex regulation of osteoblastic differentiation during fracture repair has not been completely defined. ⋯ Moreover, correct WNT signalling is also required for BMP2-induced bone formation. There is increasing evidence that patients who develop recalcitrant fracture nonunions exhibit not only reduced numbers and differentiation capacity of osteogenic progenitors but also a significant downregulation of numerous factors in the WNT pathway. Therefore, better understanding of the WNT regulatory mechanisms could reveal new strategies for the treatment of delayed fracture healing and for the tissue engineering of bone.
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Low back pain is still a big medical and social problem. During the last few decades a change of paradigm in treating non-specific low back pain has happened: physical activity and exercise therapy are now recommended as the first-line treatment in all relevant national and international guidelines. In chronic cases only biopsychosocial treatment concepts are successful, which have been introduced in Germany in 1990 in the form of the GRIP (Göttingen intensive low back program) for the first time. Meanwhile, this treatment has now been recommended by all evidence-based guidelines but we are still in the beginning of a full coverage care in Germany.