Tibiapseudarthrosen

Zusammenfassung

Pseudarthrosen gehören zu den häufigsten Komplikationen nach Tibiaschaftfrakturen. Hypertrophe Pseudarthrosen erfordern eine Verbesserung der biomechanischen Stabilitätseigenschaften der Osteosynthese. Der Verfahrenswechsel mit Umnagelung und die augmentierende Plattenosteosynthese bieten verlässlich gute Ausheilungsergebnisse. Bei der atrophen Pseudarthrose sind zusätzliche Maßnahmen zur Verbesserung der Biologie erforderlich. Infektpseudarthrosen sind besonders anspruchsvoll und erfordern die Therapie sowohl des Infektes als auch der Frakturheilungsstörung. Die sorgfältige Analyse der Ausgangssituation und der Ursachen der Frakturheilungsstörung sowie die konsequente Therapie führen zu hohen Ausheilungsraten.

Abstract

Nonunion is a common complication after tibia shaft fractures. Hypertrophic nonunion requires an improvement of biomechanical stability. Exchange nailing and augmenting plate fixation leads to reliably good fracture healing results. Atrophic nonunion requires additional measures in order to improve local biology. Infection nonunion represents a challenging situation that requires the treatment of both the infection and the fracture healing problem. Careful analysis of the ethiology of the fracture healing disturbance and a consequent treatment regimen leads to reliably high healing rates.

Schlüsselwörter

Fraktur - Tibia - Pseudarthrose - Nagelung - Verfahrenswechsel - RIA - Osteomyelitis

Key words

fracture - tibia - nonunion - nailing - exchange nailing - RIA - osteomyelitis

• Literatur

• 1 Fong K, Truong V, Foote CJ. et al. Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study. BMC Musculoskelet Disord 2013; 14: 103
• 2 Burrus MT, Werner BC, Yarboro SR. Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures. Injury 2015; 47: 465-470
• 3 Litrenta J, Tornetta 3rd P, Vallier H. et al. Dynamizations and exchanges: success rates and indications. J Orthop Trauma 2015; 29: 569-573
• 4 Sanders DW, Bhandari M, Guyatt G. et al. Critical-sized defect in the tibia: is it critical? Results from the SPRINT trial. J Orthop Trauma 2014; 28: 632-635
• 5 Xia L, Zhou J, Zhang Y. et al. A meta-analysis of reamed versus unreamed intramedullary nailing for the treatment of closed tibial fractures. Orthopedics 2014; 37: e332-e338
• 6 Schemitsch EH, Bhandari M, Guyatt G. et al. Prognostic factors for predicting outcomes after intramedullary nailing of the tibia. J Bone Joint Surg Am 2012; 94: 1786-1793
• 7 Finkemeier CG, Schmidt AH, Kyle RF. et al. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 2000; 14: 187-193
• 8 Reed AA, Joyner CJ, Brownlow HC. et al. Human atrophic fracture non-unions are not avascular. J Orthop Res 2002; 20: 593-599
• 9 Brownlow HC, Reed A, Simpson AH. The vascularity of atrophic non-unions. Injury 2002; 33: 145-150
• 10 Calori GM, Phillips M, Jeetle S. et al. Classification of non-union: need for a new scoring system?. Injury 2008; 39 (Suppl. 02) S59-S63
• 11 Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007; 38 (Suppl. 04) S3-S6
• 12 Giannoudis PV, Gudipati S, Harwood P. et al. Long bone non-unions treated with the diamond concept: a case series of 64 patients. Injury 2015; 46 (Suppl. 08) S48-S54
• 13 Vaughn J, Gotha H, Cohen E. et al. Nail dynamization for delayed union and nonunion in femur and tibia fractures. Orthopedics 2016; 39: e1117-e1123
• 14 Rupp M, Biehl C, Budak M. et al. Diaphyseal long bone nonunions – types, aetiology, economics, and treatment recommendations. Int Orthop 2018; 42: 247-258
• 15 Yang JS, Otero J, McAndrew CM. et al. Can tibial nonunion be predicted at 3 months after intramedullary nailing?. J Orthop Trauma 2013; 27: 599-603
• 16 Ateschrang A, Albrecht D, Stöckle U. et al. High success rate for augmentation compression plating leaving the nail in situ for aseptic diaphyseal tibial nonunions. J Orthop Trauma 2013; 27: 145-149
• 17 Menon DK, Dougall TW, Pool RD. et al. Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing. J Orthop Trauma 2002; 16: 491-497
• 18 Hierholzer C, Friederichs J, Glowalla C. et al. Reamed intramedullary exchange nailing in the operative treatment of aseptic tibial shaft nonunion. Int Orthop 2017; 41: 1647-1653
• 19 Penzkofer R, Maier M, Nolte A. et al. Influence of intramedullary nail diameter and locking mode on the stability of tibial shaft fracture fixation. Arch Orthop Trauma Surg 2009; 129: 525-531
• 20 Griffin LV, Harris RM, Zubak JJ. Fatigue strength of common tibial intramedullary nail distal locking screws. J Orthop Surg Res 2009; 4: 11
• 21 Högel F, Gerber C, Bühren V. et al. Reamed intramedullary nailing of diaphyseal tibial fractures: comparison of compression and non-compression nailing. Eur J Trauma Emerg Surg 2013; 39: 73-77
• 22 Zelle BA, Gruen GS, Klatt B. et al. Exchange reamed nailing for aseptic nonunion of the tibia. J Trauma 2004; 57: 1053-1059
• 23 Garnavos C. Treatment of aseptic non-union after intramedullary nailing without removal of the nail. Injury 2017; 48 (Suppl. 01) S76-S81
• 24 Metsemakers WJ, Claes G, Terryn PJ. et al. Reamer-Irrigator-Aspirator bone graft harvesting for treatment of segmental bone loss: analysis of defect volume as independent risk factor for failure. Eur J Trauma Emerg Surg 2019; 45: 21-29
• 25 Kanakaris N, Gudipati S, Tosounidis T. et al. The treatment of intramedullary osteomyelitis of the femur and tibia using the Reamer-Irrigator-Aspirator system and antibiotic cement rods. Bone Joint J 2014; 96-B: 783-788
• 26 Zalavras CG, Sirkin M. Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: indications, method and clinical results. Injury 2010; 41 (Suppl. 02) S43-S47
• 27 Tosounidis TH, Calori GM, Giannoudis PV. The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update. Eur J Trauma Emerg Surg 2016; 42: 417-423
• 28 Simpson AH, Tsang JST. Current treatment of infected non-union after intramedullary nailing. Injury 2017; 48 (Suppl. 01) S82-S90
• 29 Schmidmaier G, Kerstan M, Schwabe P. et al. Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures. Injury 2017; 48: 2235-2241
• 30 Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma 2007; 21: 258-268
• 31 Ferguson J, Diefenbeck M, McNally M. Ceramic biocomposites as biodegradable antibiotic carriers in the treatment of bone infections. J Bone Jt Infect 2017; 2: 38-51
• 32 Mühlhäusser J, Winkler J, Babst R. et al. Infected tibia defect fractures treated with the Masquelet technique. Medicine (Baltimore) 2017; 96: e6948
• 33 Moghaddam A, Ermisch C, Fischer C. et al. [Tibial defects and infected non-unions: treatment results after Masquelet technique]. Orthopade 2017; 46: 263-274
• 34 Hessmann M, Rommens PM, Hainson K. [Callus distraction of femur and tibia. Experiences with the mono-fixateur–indications for procedural changes]. Unfallchirurg 1998; 101: 370-376
• 35 Morris R, Hossain M, Evans A. et al. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J 2017; 99-B: 680-685
• 36 Tong K, Zhong Z, Peng Y. et al. Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis. Injury 2017; 48: 1616-1622
• 37 Haffner N, Antonic V, Smolen D. et al. Extracorporeal shockwave therapy (ESWT) ameliorates healing of tibial fracture non-union unresponsive to conventional therapy. Injury 2016; 47: 1506-1513
• 38 Leighton R, Watson JT, Giannoudis P. et al. Healing of fracture nonunions treated with low-intensity pulsed ultrasound (LIPUS): a systematic review and meta-analysis. Injury 2017; 48: 1339-1347