Marti / van Heerwaarden Osteotomies for Posttraumatic Deformities

1. Auflage 2008
ISBN: 978-3-13-257890-6
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 720 Seiten, ePub

Reihe: AO-Publishing

Osteotomies in the treatment of degenerative and posttraumatic arthritis seem to be a lost art. Even for young patients joint replacement is in vogue.

An international group of renowned surgeons present an outstanding hands-on approach to perform correction osteotomies in posttraumatic deformities from the clavicle to the foot.

Most of the content is based on case presentations and each case provides step-by-step description of case history, planning, surgical approach, osteotomy, fixation, rehabilitation, and finally pitfalls and pearls. Hundreds of full-color pictures, precise illustrations, and x-rays demonstrate the significant steps in deformity corrections. Long-term follow-ups demonstrate the efficacy of osteotomies in the treatment of malunions.

In the principle part preceding the case presentations relevant theoretical information on posttraumatic deformities and osteotomies, operative techniques, and fixation methods, as well as the formation of a surgical plan is provided. Overall the book features over 110 detailed case presentations.

This book should convince surgeons to use osteotomies in the treatment of posttraumatic deformities and consider joint-preserving techniques in the treatment of posttraumatic osteoarthritis.

Zielgruppe

Ärzte

Autoren/Hrsg.

Marti, René K.

van Heerwaarden, Ronald J.

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Orthopädie- und Unfallchirurgie

Inhaltsverzeichnis

1 Principles part
2 Manual part







Appendix

Leseproben

1.1 Posttraumatic deformities and osteotomies

1 History

The history of osteotomies is really the history of descriptions of deformities starting with Hippocrates. Up to Medieval times the society did not feel responsible for those who suffered from deformities, as diseases and deformity were considered to be punishments for sin. Unfortunately, in some societies in large parts of the world this is still true today. Considering corrections of deformities, only few references are to be found in the older literature. Some texts described how malunited bones should be separated using chisels, however, it took until the 19th century before the word “osteotomy” was first used to describe the cutting of bone. Not until the introduction of antiseptic surgery were osteotomies made popular by a select group of surgeons. At the start of the 20th century it was first acknowledged that malunited fractures impaired joint function and that together with limb shortening a post-traumatic deformity resulted in the decrease of the patient's relative financial economic value.

2 Causes of posttraumatic deformities

A posttraumatic deformity is the result of the treatment of the sequelae of specific traumas to the locomotor system. Know ledge of the initial bone and soft-tissue lesions as well as the specific treatment—whether conservative or operative—and postoperative treatment will help to find the cause of the deformity and is mandatory for decision making, concerning type and technique of secondary reconstructions. Regarding bone deformities the cause of the deformity is often found in the initial choice of fracture treatment. This does not necessarily mean that the wrong treatment had been chosen as sometimes decisions have to be based on factors that may interfere with optimal fracture treatment (Fig 1.1-1).

Fig 1.1-1a–c Severe soft-tissue lesions interfere with optimal fracture treatment.

a Comminuted type C3 fracture of the proximal tibia.

b Lag screw and external fixation, no anatomical reconstruction.

c Vital granulation tissue after debridement of the tibial head, before split skin grafting as performed earlier to repair the skin defect over the distal femur.

Insufficient stability of fixation and wrong postoperative treatment may be a secondary cause of a malunion (Fig 1.1-2). Unfortunately, however, the surgeon specialized in the treatment of posttraumatic deformities is also faced with malunions that are the result of insufficient fracture treatment. In this respect the importance of understanding the principles of fracture treatment, normal anatomy, and biomechanics of the locomotor system cannot be stressed enough. Readers of this book should already be acquainted with such knowledge from textbooks and specific courses.

Fig 1.1-2a–b Internal fixation without anatomical reduction.

a Fracture healing with narrowing of the tibial head, valgus and intraarticular malunion of the lateral condyle.

b The lateral femoral condyle dives into the depressed tibial head, resulting in a bony pivot shift.

3 Characteristics of posttraumatic deformities

Posttraumatic deformities differ significantly from deformities acquired through growth as limb anatomy and function most often were normal before the trauma. In contrast, in deformities resulting from growth the function may be normal whereas abnormal anatomy causes unphysiological loading. Often adaptation to the unphysiologic loading occured through compensatory growth of bone and soft tissues or by compensatory motions of the neighbouring joints. In posttraumatic deformities in children a similar mechanism of compensatory growth may have occurred as a result of malunited fractures. A prerequisite is, that the growth plates still function normally and that growth stimulation and potential suffice, depending on age and the location of the deformity.

In this book the surgical correction of malunited fractures is described in adults and in some cases in children after closure of growth plates. Functional deficits in these patients can often be attributed to the malunited bone, as normal muscle and joint function depends on normal anatomy of the bone.

4 Terminology of posttraumatic deformities

A posttraumatic deformity may be the result of a bony deformity considered sufficient to produce a functional deficit including angulation, rotation, translation, and limb shortening, but may also be the result of joint malfunction or contracture.

Angular deformities present themselves either in the frontal plane causing valgus or varus of the affected limbs, or in the sagittal plane causing a recurvatum or procurvatum deformity. A combination of a frontal and a sagittal plane angular deformity has its maximum angulation in an oblique plane. Translation of a segment may produce a deformity without angulation, and can occur in both, the frontal and sagittal planes. Rotation of a segment around its axis causes a rotational deformity, while shortening clinically presents as a limb length discrepancy. These deformities on their own are termed uniplanar deformities. If a deformity in the same bone segment coexists in two planes or in more than two planes, these are termed biplanar and multiplanar deformities, respectively. The site of the deformity may be at the diaphysis, metaphysis, or at the level of the joint, and may either be unifocal or multifocal if the deformity coexists with another, at more than one level, within the same segment of bone. Unifocal or multifocal deformities are also referred to as uniapical or multiapical deformities.

5 Classification of posttraumatic deformities

The general classification of posttraumatic deformities is primarily based on the localization, ie, intraarticular, metaphyseal, and diaphyseal. Furthermore, deformities can be defined as simple (one plane) or complex (several planes and translation).

Classification systems can be of great help to analyze and describe specific bone conditions in a uniform way. For decades the Müller AO Classification of fractures has been helping surgeons to understand fracture types and has also led to standardized advice on how to treat fractures. This allows comparison of treatments for specific fracture types.

Classifications that describe specific types of malunited fractures are rare. For some locations, eg, the proximal humerus and the calcaneus a classification of specific malunion types has been established and based on this differentiated treatments have been advised. In this book these specific classifications, if available, are described in the introductions to the case presentations of the different locations. For the treatment of posttraumatic deformities it is of great help to the surgeon if a classification also includes techniques for deformity correction. Moreover, the aims of treatment should be included as the techniques of deformity corrections increase in complexity as the aims of treatment become more complex: from simple deformity correction, to deformity correction plus lengthening to deformity correction plus lengthening plus correction of contracture (Fig 1.1-3).

To our knowledge only one classification system has been designed, which can serve as the basis for treatment, prognosis, and the comparative evaluation of results of limb deformity corrections. The Sheffield Classification [1] is used to describe the major primary operative intervention and includes a location specific malunion description based on the Müller AO Classification of fractures.

Fig 1.1-3 Posttraumatic deformity: shortening, equinus, and varus deformity of the ankle and hindfoot with inverted midfoot.

6 Effects of posttraumatic deformities

In order to understand the effects of malunions in the upper and lower extremity one should have a thorough knowledge of normal anatomy and biomechanics of limb function. In this book, the cases illustrating the effects and corrective treatments of posttraumatic deformities at specific locations are preceded by an introduction. These introductions offer information on how these posttraumatic deformities affect the specific regions of the locomotor system. In some cases, literature references as well as recommendations for further reading may also be found.

The effects of posttraumatic deformities are often multifactorial. Fractures almost always result in alterations of bone and soft tissues even in cases of optimal fracture treatment. Depending on type and location of malunions these small alterations, whether in angulation, length, rotation or translation, may be well tolerated. Beside the magnitude of the deformity local muscle strength, ligamentous laxity, cartilage integrity and range of motion of the joints of the affected extremity will contribute to the effect of the deformity. Multiple corrections may be necessary to achieve a good result (Fig 1.1-4).

Short-term effects of malunions may cause symptoms immediately after fracture healing. They only arise when the deformity is severe and compensatory limits in adjacent joints are exceeded. The long-term effects of malunions may present with delayed-onset symptoms often related to joint overload and deterioration (Fig 1.1-5). A causal relationship between joint deterioration and altered mechanical loads resulting from malunion is sometimes hard to prove although an...