Der Unfallchirurg
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Fracture dislocations of the cunei-navicular joints are a very rare type of intertarsal dislocation and most people are probably unfamiliar with this entity. Clinical, radiological and pathological aspects allow discrimination of such injuries from the dislocations in Lisfranc's and Chopart's articulation. We have seen one patient who was found to have a crush fracture of the cuneiforme mediale on one side and a fracture disruption with dorsal dislocation of the first and second metatarsals and of the medial and intermediate cuneiform bones on the other. According to the principles of treatment for other tarsal injuries, we carried out open reduction with joint debridement, reconstruction of ligaments and internal stabilization with transfixation screws.
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Patellofemoral loads are calculated by means of a mathematical model based upon an elliptical approximation of the articulating profile. Differences in the sagittal curvature of morphological and arthroplastic gliding surfaces can be approximated by a differing eccentricity of the ellipse. The joint is balanced in a static situation by two tension forces. ⋯ The model also takes into account the patellar ligament turning around the proximal tibia at wide flexion angles. Besides the design of the prosthesis, patellofemoral loads depend on the height of implantation of the femoral component. It must be borne in mind that forces will vary in magnitude at different flexion angles; the patient's activities after the operation must also be considered.
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This collective study was conducted by the German section of AO International to work out the indications for fixation of the tibial shaft by means of dorsal plating. Primary dorsal plating was done in 70 cases. Most of the patients had second- or third-degree open fractures with severe ventral soft tissue injuries or closed fractures that could not be reduced and fixed conservatively. ⋯ Most of these patients had such severe damage following fractures that dorsal plating was the last chance of avoiding amputation. The high rate of complications (12 infections and 7 non-unions and breakages of implants after primary dorsal plating; 20 infections and 11 non-unions and breakages of implants after secondary dorsal plating) has to be considered in the light of the extraordinary indications for the dorsal plating of the tibial shaft in especially severe fractures or disastrous sequelae. In cases with extremely severe conditions before fixation, dorsal plating of the tibial shaft for secondary operative treatment yields adequate results.