Der Orthopäde
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In a retrospective study, 1.173 fractures of the proximal femur, which had been treated surgically, were analysed in two periods from 1975 to 1991 and from 1992 to 2000. The influence on mortality of preoperative risk factors and primary treatment with total hip replacement (THR), even in cases of pertrochanteric fractures, was analysed by stepwise logistic regression. In the later period, mortality within 90 days was 13.1%, and within 1 year 22.2%. ⋯ Although the influence of some risk factors could be reduced, age, sex and morbidity influenced the outcome more than surgical treatment. THP, even after pertrochanteric fractures, is reasonable if it guarantees a quick and enduring mobilisation of the patient. Bicentric bipolar prostheses are recommended for high risk patients.
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The talonavicular joint as part of the coxa pedis plays a pivotal role in the overall motion of the foot. The necessity for talonavicular fusion arises from isolated arthritis of posttraumatic, rheumatoid, degenerative, or idiopathic etiology. Posttraumatic arthritis is seen after malunited mid-tarsal (Chopart) fracture-dislocations and is frequently accompanied by malalignment due to an imbalance between the medial and lateral columns of the foot. ⋯ Fusion with mini-plates is biomechanically superior to fusion with screws and especially staples, the latter being associated with non-union rates of up to 37%. Talonavicular fusion allows reproducible pain reduction in isolated arthritis with subjective patient satisfaction of between 86% and 100% in a literature review. The substantial reduction of movement in the triple joint complex leads to overload of the adjacent joints with development of arthritis in about 30% in the medium term.
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The amount of postraumatic deformities of the calcaneus after fracture is classified in 5 types (Type I-V). The bony situation includes in the simple group A malunions, in group B the more demanding nonunions and in Group C the worst cases with additional aseptic or septic necrosis of parts of the calcaneus. For type I with posttraumatic arthritis of the subtalar joint and without malalignement, an in situ-arthrodesis is suitable. ⋯ Therefore, in addition to the bilateral approach and calcaneal osteotomy, an anteromedian approach to the ankle joint is necessary. The surgical procedure in group A (malunion) is more or less the same like in group B (nonunion). Group C (aseptic / septic osteonecrosis) needs a preliminary radical necrectomy in a two stage reconstructive procedure.
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The Bone marrow edema (BME) is a common finding when evaluating patients with knee pain by magnetic resonance imaging (MRI). The typical signal patterns of BME are unspecific and can be found with different diseases of the knee. Since different therapeutic approaches are mandatory, differential diagnosis of the several forms of BME is important. ⋯ Group 3 reactive BME: inflammatory gonarthritis, degenerative gonarthrosis, postoperative and tumours. The typical MRI morphologies and differential diagnosis of these BME manifestations will be described. The different therapeutic consequences will also be briefly mentioned.
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Malunited fracture dislocations at the tarsometatarsal (Lisfranc's) joint regularly lead to painful deformities with severe functional impairment for the affected patients. Malunions result from initially overlooked injuries as well as from misjudged and inadequately treated injuries. Depending on the nature of the primary dislocation, either abduction or adduction of the forefoot will result, accompanied by a planus or cavus deformity. ⋯ Fusion should be limited to the medial metatarsocuneiform joints if full realignment of all five metatarsals can be achieved with this procedure. A review of the literature revealed that corrective tarsometatarsal arthrodesis reproducibly leads to considerable pain reduction and functional improvement with patient satisfaction between 69% and 100%. Favourable prognostic factors are anatomic realignment and limited fusion of the first to third metatarsocuneiform joints.