Der Unfallchirurg
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Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. ⋯ Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.
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Nonunions represent a very heterogeneous, rare and sometimes very complex disease picture. The causes, localization and degree of expression show a very high variability, which makes it difficult to establish uniform treatment standards. Nevertheless, the process of bone healing is subject to some essential factors, which should be ensured for a successful treatment. ⋯ The diamond concept is nowadays widely used and many studies have already demonstrated a successful application. It must be understood as a framework, in which the various treatment options available (bone substitute materials, mesenchymal stem cells, osteosynthesis procedures etc.) are incorporated into the individual factors and therefore provides the physician with a certain freedom of choice in the selection of tools. Additionally, it is not a rigid corset and subject to medical scientific progress in its factors, so that it is exciting to see which new developments will be incorporated in the future.
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Non-unions occur in 5-10% of all fractures, whereby there is a large variability in the rate with respect to the anatomical location. All non-unions have in common that without any further medical treatment no healing can be expected, independent of the time. There is a wide range of surgical approaches for treatment of these extremely complex pathological situations, which are successful in 75-85% of the cases. Besides surgical approaches there are various conservative treatment options, which should be considered in every treatment planning. Vital non-unions sometimes shows a very good response to noninvasive procedures, particularly in the early stages. ⋯ In every individual case an experience physician should determine whether a conservative treatment option is possible for this complex condition.
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Non-union is defined as an insufficiently consolidated fracture in which healing without a surgical intervention is no longer foreseeable. Several underlying predispositions and factors have to be taken into account in order to optimize the diagnostics, classification and surgical treatment of this complex and challenging pathology. ⋯ A practicable and precise classification of the different types of non-union can only be successful based on a focussed diagnostic procedure using radiologic and functional diagnostic tools, which guide the surgeon in establishing the optimal treatment. This also includes modern functional imaging examinations, such as CEUS and DCE-MRI.
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Spondylodiscitis is a rare disease with an increasing incidence. ⋯ Old age, abscess formation, positive detection of pathogens and renal failure can be used as prognostic criteria. Risk factors for formation of abscesses include a lumbar localization of spondylodiscitis, nephropathy as well as detection of a pathogen and obesity.