Search

BACKGROUND In a retrospective study, we compared the results of different surgical therapies in 30 patients who had an early-onset infection after implantation of a hip hemiarthroplasty. MATERIAL AND METHODS Patients were divided into two groups: In group 1 (n=16, deep infection), we changed the polyethylene inlay as well as the femoral head. In group 2 (n=14, deep infection), an acetabular component was also implanted. RESULTS In group 1, successful treatment was achieved in 37.5% of patients 6 months after the last operation, compared with 71.4% in group 2 (p=0.019). All patients were supported with antibiotics. In group 1, three patients died from septic multiorgan failure. Two patients in group 1 and one patient in group 2 received a Girdlestone operation. CONCLUSIONS These results suggest that aggressive surgical treatment with soft tissue revision, lavage, and implantation of an acetabular component in combination with antibiotics is a useful technique for treating early-onset infection.

Traumatische Bauchwandhernien sind seltene Verletzungen im Vergleich mit der Haufigkeit stumpfer Abdominaltraumen. Der Entstehung dieser besonderen Verletzung liegen meist eine plotzliche Steigerung des intraabdominellen Drucks in Kombination mit grosflachigen Scherkraften zu Grunde. Hierbei gibt die Bauchdecke an anatomischen Schwachpunkten nach. Haufig liegen Begleitverletzungen intraabdominell oder im Becken- und Thoraxbereich vor. Wir berichten uber einen Fall, bei dem ein Quetschtrauma in Bauchhohe zu einer traumatischen Bauchwandhernie links pararektal gefuhrt hat. Hierbei kam es zur Herniation von Darmanteilen durch die rupturierte Bauchdeckenmuskulatur bis in die Subkutis. Nach entsprechender Diagnostik erfolgte der Bruchluckenverschluss mit Einlage eines synthetischen Netzes zur Verstarkung der Bauchwand. Anhand dieses Patientenfalls werden Pathophysiologie und Therapie der traumatischen Bauchwandhernie unter Berucksichtigung der Literatur erlautert.

PURPOSE Description and time analysis of a 16-row MDCT protocol in the evaluation of multiple trauma patients considering transport, time of scanning, patient positioning, image reconstruction, and image interpretation. MATERIALS AND METHODS Between May and December 2004, 60 multiple trauma patients underwent 16-row MDCT (Sensation, Siemens, Erlangen, Germany). The protocol included serial scanning of the head, spiral scanning of the cervical spine and contrast-enhanced spiral scanning of the thorax/abdomen with multiplanar reformations (MPR) of the thoracic/lumbar spine and the pelvis. All time intervals including transport, patient positioning, scanning, duration of MPR, total time in the examination room, and time to first and final image interpretation were prospectively evaluated. Furthermore, patient characteristics, trauma profiles, and mortality rates were recorded. RESULTS 46 male and 14 female patients (mean age 43.6 years) were enrolled in the study. Time analysis of 16-row MDCT revealed the following results (mean time standard deviation): Emergency room treatment and transport 19.2 +/- 6.7 min, patient positioning 16.5 +/- 6.5 min, scan duration 8.0 +/- 3.3 min, total time in examination room 24.5 +/- 7.2 min, image reconstruction including MPR 32.0 +/- 16.4 min, and time of first (16.4 +/- 4.7 min) and final image interpretation (82.5 +/- 30.4 min). Trauma profiles revealed thoracic injuries in 35/60 patients (58.3 %), head injuries in 23/60 patients (38.3 %), abdominal injuries in 15/60 patients (25.0 %), injuries of the cervical (9/60 patients, 15.0 %), thoracic (12/60 patients, 20.0 %), and lumbar spine (19/60 patients, 31.7 %), pelvic injuries in 13/60 patients (21.7 %), and injuries of extremities in 39/60 patients (65.0 %). The mortality rate was 21.7 %. CONCLUSION MDCT provides fast and all-inclusive imaging of multiple trauma patients. With the use of 16-row MDCT technology scanning times of 8 minutes are realistic and first image interpretation can be performed 16 minutes after arrival of the patient in the examination room and 35 minutes after admission in the emergency room, respectively. The duration of all procedures done in the examination room is strongly influenced by positioning maneuvers, whereas final image interpretation depends on image reconstructions including MPR. Beside technical improvements, these circumstances provide the potential to further accelerate the diagnostic process in multiple trauma victims.

Durch die Entwicklung der Marknagelung in den letzten 30 Jahren hat sich die Behandlung von Femurschaftfrakturen geandert. Die antegrade Marknagelung ist operatives Standardverfahren, kann bei entsprechenden Begleitverletzungen aber nicht immer eingesetzt werden. Fur solche Situationen bietet sich die retrograde Marknagelung an. Unter Berucksichtigung der Frakturkonsolidierung konnen mit beiden Verfahren hervorragende Ergebnisse mit Raten uber 90% erzielt werden. Das Aufbohren des Markraums fuhrt sowohl bei ante- als auch retrograder Marknagelung zu keiner erhohten Komplikationsrate. Nachteile der antegraden Marknagelung sind mogliche heterotope Ossifikationen sowie Nervenschadigungen. Dagegen wurde auf vermehrte Knieschmerzen nach retrograder Nagelung verwiesen. Eine Einschrankung der Kniebeugung

Kindliche Beckenring- und Azetabulumfrakturen treten mit einer Pravalenz von etwa 3% auf. Ihre—hauptsachlich in den Begleitverletzungen begrundete—Mortalitatsrate liegt zwischen 1,4% und 14%. Fur die Einschatzung und Erkennung der Verletzungen muss die kindliche Anatomie mit Wachstumsfugen und primaren und sekundaren Ossifikationszentren bekannt sein. Apophysenausrisse, isolierte undislozierte und dislozierte Frakturen der Schambeinaste werden konservativ behandelt. Bei isolierten Symphysensprengungen ist eine konservative Behandlung moglich, Verschieblichkeiten >1 cm sollten operativ mit PDS-Kordel oder angepassten Plattenosteosynthesen angegangen werden. Isolierte geschlossene, wenig verschobene Beckenschaufelbruche werden nicht operiert, weit verschobene Bruche oder offene Frakturen erreichen nach Debridement mit Schraubenosteosynthesen bessere Ergebnisse. Instabile Beckenringbruche (Malgaigne-Frakturen) sollten mindestens mit Fixateur externe, besser mit internen Osteosynthesen stabilisiert werden. Azetabulumfrakturen mit Gelenkstufen >1 mm werden operativ versorgt, um einer fruhzeitigen Arthrose sowie Wachstumsstorungen vorzubeugen.

PURPOSE To evaluate whether modification of a standard multislice CT (MSCT) protocol might improve the diagnostic work flow in patients with multiple trauma without relevant loss of image quality. MATERIALS AND METHODS Between September 2002 and September 2003, 80 multiple trauma patients underwent 4-slice CT encompassing head, thorax, abdomen/pelvis and spine. All patients were randomly assigned to either protocol A or B: Protocol A included serial scanning of the head (collimation 1 mm, 350/380 mAs/120 kV) and spiral scans of thorax, abdomen/pelvis and spine (collimation 2.5 mm, 220 mAs/120 kV) with gantry angulation and arm elevation; protocol B included spiral scanning of all body regions (collimation 2.5 mm, 300/150 mAs/120 kV) without gantry angulation or arm elevation. Time intervals, radiation exposure and results of the initial and final analysis were documented. RESULTS In the investigated 64 male and 16 female patients (mean age 41.7 years), 88.7 % of the 407 pathologic findings were correctly identified on the initial images. Protocol B revealed a significant decrease in scan time (6.4 vs. 16.8 min., p < 0.001), time in the CT examination room (22.9 vs. 32.8 min.; p < 0.001), time until initial (25.3 vs. 35.8 min.; p < 0.001) and final image analysis (93.7 vs. 112.9 min; p < 0.005). No significant difference was found for patient transport time and image reconstruction time. Protocol B has a significantly lower effective radiation dose compared to protocol A (10.2 vs. 12.7 mSv, p < 0.001). CONCLUSIONS Applying a modified MSCT protocol without gantry angulation and arm elevation can significantly decrease radiation exposure and examination time in multiple trauma patients without relevant loss of diagnostic image information and, consequently, has the potential of improving the diagnostic process and prognosis in multiple trauma patients.

Wirbelfrakturen am wachsenden Skelett sind selten. Obwohl es sich zum Grosteil um stabile Frakturen handelt, kommt ein neurologisches Defizit ofter vor als bei Erwachsenen. Spatere Wachstumsstorungen sind haufig, jedoch therapeutisch nicht angehbar. Die konservative funktionelle Therapie ist im Kindesalter vorherrschend. Die operative Therapie bleibt Luxationsfrakturen und anderen hohergradig instabilen Frakturen vorbehalten.

The televisite is a form of application of telemedicine, that allows a communication between the patient and the family doctor or specialist in the clinic after discharging of hospital. Pioneers for the use of telematic projects have been up to now wide states like the USA, Canada, Norway or Australia to provide, guarantee and maintain by the means of telemedical solutions medical care in geographic regions hardly reachable and of little medical attention. In central Europe and Germany telemedicine is gaining in significance on the one hand because of increasing importance of the cost factor and resulting pressure on the public health system and on the other hand because of the rising demand of the patients for optimised medical care. It specially represents a new form of treatment in patients care after dischargement of hospital. In the year of 2002 a prospective randomised two-armed study was initiated including patients after operative intervention by arthroplasty in posttraumatic contracture of the elbow. The system of the Televisite is used for 6 weeks after dischargement and patients had been controlled ambulant after 6 months including a physical examination. The functional outcome will be scored, the duration of stay in hospital measured, the arising costs for treatment calculated and the satisfaction of the patients in handling the Televisite surveyed. Over this first results showed a shortened stay in hospital together with lowered costs in medical treatment on the one hand and on the other no difference in functional outcome could be found in comparison to the control group by additionally high grade of satisfaction with the new system.

Major surgery leads to post-traumatic immune dysregulation which is driven by the activation of potent proinflammatory mediators including the leukotrienes (LTs). The LTs of the four-series derive from arachidonic acid (an omega-6 fatty acid). In contrast, LTs of the five-series are metabolic products of eicosapentaenoic acid (an omega-3 fatty acid) and exert less biological activities. Therapeutical strategies to attenuate proinflammatory signals include the provision of omega-3 fatty acids. Thirty patients with major elective abdominal surgery and an indication for total parenteral nutrition (TPN) were compared in a prospective, double blind, randomized study of two parallel groups. Group 1 (n=14) received an omega-3 fatty acid enriched 20% lipid emulsion (MCT:LCT:fish oil = 5:4:1, MLF541; Lipoplus) for 5 days postoperatively. Group 2 (n=16) received a standard 20% fat emulsion (LCT; Intralipid). The LT release from whole blood leukocytes stimulated with Ca-ionophore was analyzed preoperatively and on postoperative days 1, 6 and 8 by HPLC. There was a significant increase in the generation of LTB(5) (P=0.0035) and in the ratio of LTB(5)/LTB(4) (P=0.0017) the omega-3 group, but not in the reference group after 5 days infusion of the lipid emulsions. The omega-6/omega-3 fatty acid ratio 3:1 of the newly developed MLF541 lipid emulsion is appropriate to increase the synthesis of the biologically less active leukotrienes of the five-series. Nutritive enrichment with omega-3 fatty acids in a balanced ratio with omega-6 fatty acids is an important step to avoid hyperinflammatory situations in patients after major surgery.

AIM To establish whether the additional coating of titanium implants with Bone Morphogenetic Protein-3 (BMP-3) might enhance osseous integration. METHOD Each of 15 cylindrical titanium test implants (Ti-6AI-4V) was coated using 230 micrograms porcine BMP-3. A further 15 implants with identical (corundium-blasted) surface served as negative controls. An uncoated and a BMP-3-coated test object were implanted into the femurs of 15 adult giant rabbits. New formation of bone around the implants was examined microscopically and histomorphometrically on postoperative days 14, 35 and 56. RESULTS Coated implants revealed superior osseointegration with statistical evaluation using the t-test for matched samples showing a significantly higher volume of new bone 5 weeks after surgery. Microscopic examination revealed osseointegration with no connective tissue membrane around the surface of the implants. CONCLUSIONS Our results indicate that composite metal implants are suitable carriers for BMP-3 and that improved fixation of the implants can be achieved.

Detection of a bacterial arthritis of the shoulder represents an absolute indication for intervention. Irrespective of the cause of the infection, the most decisive prognostic factors are early diagnosis and therapy. We report on two patients who suffered from generalized sepsis and resulting death after delayed treatment of iatrogenic joint infections of the shoulder caused by intra-articular injection therapy. Both patients suffering from septic shock syndrome had been transferred to our hospital for surgical and intensive care treatment. They died in spite of maximal intensive care and aggressive surgical treatment. On the basis of the cases presented, it can be concluded that an acute infection of the shoulder joint must be excluded early when painfully limited range of motion in combination with clinical and laboratory signs of inflammation become apparent. Successful therapy of joint infection also requires early surgical treatment, including resection of infected tissue. If surgical joint revision is not performed or is performed too late, there is the risk of irreversible damage to the afflicted joint, even septic spread endangering the patient's life.

Purpose. Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap. Methods. 80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically Cortical microcirculation was measured by 2-channel laser doppler flowmetry. Results. Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%). Conclusion. Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

Aim: We performed an investigation of factors for avascular necroses after talus fracture and on the reliability of the Hawkins Sign. Method: From 1984 until 1997 a total of 98 patients with 99 talus fractures were surgically treated. Of these, 79 patients with 80 fractures were examined clinically and radiologically. The average postoperative interval was 6 years and 2 months. Results: With respect to the 65 central fractures, the rate of necrosis amounted to 14%, that of collum fractures to 17%. Necroses arose solely in dislocated central fractures of the talus, type III and IV according to Marti/Weber fracture classification. The rate of necrosis rose with the degree of dislocation of the fractures. In 24 patients the Hawkins Sign could be retrospectively investigated. It proved to be a relatively reliable sign for vitality since only 1 out of 12 patients with positive or partial positive Hawkins Sign developed avascular necrosis. Neither a short interval between accident and operation, the age at the time of the accident, nor the ipsilateral fracture of the medial malleolus showed a necrosis preventive influence. In 5 out of 9 talus necroses the patients were very or mostly satisfied with the result of their treatment. Conclusion: The Hawkins Sign proved to be a relatively reliable sign for vitality of the talus after fracture. Risk for avascular necrosis increases according to the degree of fracture dislocation.

AIM OF THE STUDY Because of the well proven fact of outcome improvement by early, preclinical intubation and ventilation of multiple injured and polytraumatized patients, the guidelines of different medical associations recommend this procedure especially in combination with blunt chest trauma. By the means of a prospective study protocol we analyzed whether these treatment standards were respected and whether the kind of preclinical treatment was influencing treatment outcome. PATIENTS AND METHODS Using a prospective study protocol data were sampled and analyzed. From 1.12.2000 to 25.9.2001 48 consecutive patients were included into the protocol. 12 patients (25 %) had preclinical intubation (group A). 8 patients of group A were intubated by the helicopter emergency team. 36 patients had no tracheal tube (group B). In 34 cases mechanical ventilation has to be started during the emergency room procedures. Two patients were intubated after they were admitted to the intensive care unit (ICU). Insertion of a chest tube was done in 5 patients at the scene by the emergency team, in 15 cases after admission to the hospital and 21 at the ICU. Although the average age of years of patients was higher in group B (37,2 +/- 15,0 y vs. 46,9 +/- 21,1 y), p values calculated by ANOVA test revealed no significant difference. The two groups did not differ regarding to injury severity assessed by the "Injury severity score" (group A: 30,9 +/- 13,3; group B: 29,5 +/- 9,2). The mean duration of mechanical ventilation was 9,4 +/- 9,0d vs. 19,2 +/- 20,4 d in group A vs group B. Patients of group A required intensive care treatment for 12,6 +/- 8,7d vs 21,9 +/- 20,4 d of group B. One patient of group A died because of severe cranio cerebral trauma. 13 Patients of group B died (1 x pulmonal embolism, 12 x multiple organ failure). CONCLUSIONS Assessment of injury severity by the emergency medical teams failed in a very high percentage. Especially the blunt trauma to the chest was not diagnosed and therefore not respected.

Wir untersuchten 53 Patienten mit 57 Radiuskopfchenfrakturen (4 Patienten mit einer beidseitigen Fraktur) aus den Jahren 1993–1998 nach und befassten uns mit den Radiuskopfchenfrakturen unter folgenden Fragestellungen: 1. Zusammenhang zwischen dem Fraktur-Typ und der jeweiligen Therapie? 2. Zusammenhang zwischen dem gewahlten Behandlungsverfahren und dem Ergebnis? Folgende Frakturen traten auf: Mason I: 3 Falle, Mason II: 26 Falle, Mason III: 11 Falle, Mason IV: 15 Falle. 30 Patienten mit 31 Frakturen hatten postoperativ ein gutes, 8 Patienten mit 9 Frakturen ein zufriedenstellendes und 13 Patienten mit 14 Frakturen ein schlechtes Ergebnis. Die Patienten mit einer Mason-I-Fraktur hatten unter funktioneller Therapie ein gutes Ergebnis. Von den 26 Mason-II-Frakturen wurden 14 Patienten mit Hilfe einer Kleinfragmentschraube oder Ethipins behandelt, von denen subjektiv 14% ein dauerhaft schlechtes Ergebnis hatten. 6 Patienten wurden mittels K-Draht, Titan- oder Prevot-Nagel behandelt, keiner dieser Patienten hatte ein schlechtes Ergebnis. 10 Patienten mit einer Mason-III-Frakturen wurden bei uns mit einer Resektion des Radiuskopfchens behandelt. Bei dem 11. Patient haben wir aufgrund einer intraoperativ festgestellten Ellbogengelenkinstabilitat nach erfolgter Resektion eine Prothese mit einem guten postoperativen Ergebnis implantiert. Letztendlich bestand bei nur einem Patienten (9%) ein subjektiv schlechtes Ergebnis. Patienten mit einer Mason-IV-Fraktur wurden in 11 von 15 Fallen mit einer Resektion des Radiuskopfchens behandelt. Hierunter zeigte sich bei 5 Patienten (33%) ein objektiv schlechtes Ergebnis, wobei nur 3 Patienten (20%) dies subjektiv so empfanden.

We analyzed the influence of heparins (unfractionated heparin, UFH and low molecular weight heparin certoparin) on the generation of IL-1ra, IL-6, IL-10, and IL-12p40 and from leukocyte fractions in vitro. Polymorphonuclear neutrophil leukocytes (PMN) and peripheral blood mononuclear cells (PBMC) from 16 different healthy donors were isolated and adjusted to 1 × 106 cells/ml supplemented RPMI 1640. Leukocyte fractions were differentially stimulated (PMN with 1 μg and 5 μg LPS, PBMC with 10 ng TSST-1 or 2 μg ConA) in the presence or absence of heparins (1 U/ml, 2 U/ml, and 4 U/ml) for 24 h at 37°C. Cytokine release was analyzed by ELISA. Certoparin but not UFH led to a dose-dependent increase in IL-6 from non-stimulated PBMC. In contrast, the release of IL-1ra, IL-10, and IL-12p40 was not modulated by heparins in a dose-dependent fashion. Increases in these cytokines occurred only as single incidents at intermediate heparin levels. An influence of the heparins on the apoptosis of PMN (measured as DNA-fragmentation in non-stimulated or LPS-stimulated cell-fractions) was not observed.

Polymorphonuclear granulocytes (PMN) play a key role in host defense against microbial infections. After severe trauma PMN show cellular dysfunctions including chemotactic migration, phagocytosis, and bacterial killing. In these settings the contribution of the cellular matruation stage compared to functional activities has not been investigated. Polymorphonuclear granulocytes are potent producers of lipid mediators via the 5-lipoxygenase (5-LO) pathway (leukotrienes, LTs) which exert important proinflammatory and immunoregulatory activities. We analyzed leukotriene generation from PMN-fractions (N = 23) of 15 polytrauma patients in comparison to 17 healthy donor cell fractions and correlated this lipid mediator release to the hematopoietic maturation stage of respective PMN. Polymorphonuclear granulocytes were isolated from EDTA-anticoagulated peripheral blood employing a one step procedure based on a discontinuous double Ficoll-gradient. Cells (5 × 106/500 μl phosphate-buffered saline) were stimulated for 20 min at 37°C with 1 μM Ca-ionophor A23187 in the presence of 1 mM Ca++ and 0.5 mM Mg++. Leukotrienes were analyzed by reversed-phase HPLC. Expression of 5-lipoxygenase (5-LO) was additionally determined by Western blot. Maturation stage of PMN was quantitated by Pappenheim-staining of cell smears. After polytrauma the generation of leukotrienes from PMN was individually diminished. Synthesis of enzymatically formed metabolites (LTB4, OH-LTB4 and COOH-LTB4) was concomitantly reduced. The decresaed leukotriene synthesis strongly correlated (r2 = 0.907, P < 0.0001) to the occurrence of immature PMN (mostly band cells). The expression of 5-lipoxygenase in PMN fractions consisting mainly of band cells was decreased. Our results provide evidence that posttraumatic granulocyte dysfunction is partly due to immature functional cell capacities.

This study will present trends and recommendations to increase active and passive safety in paragliding on the basis of current state-of-the-art equipment and typical patterns of injury. This German-Swiss teamwork presents data of 55 male and 9 female patients treated after paragliding accidents between 1994 to 1998 respectively 1996 to 1998. 43.7% of the pilots presented with multiple injuries, 62.5% suffered spinal fractures and 18.8% pelvic fractures. 28.4% of the injured pilots were admitted with injuries of the lower extremities mainly affecting the tarsus or the ankle joint. Only three patients with single injuries could be treated in an ambulatory setting. 54.0% of the injuries left the patients with lasting functional residues and complaints. Main causes of accidents were either pilot error in handling the paraglider or general lack of awareness about potential risk factors. 46.0% of injuries occurred during landing, 42.9% of injuries during the flight and another 11.1% of injuries during starting procedures. With noticeable enhanced performance sails of the beginners and intermediate level are increasingly popular. Protective helmets and sturdy footwear reaching above the ankle joint are indispensable pieces of equipment. The use of protective gloves is highly recommended. Back protection devices of the new generation provide the best passive prophylaxis for the pilot against pelvic and spinal cord injuries. This area hold the most promise for increasing safety and reducing risk of injury in future, apart from using beginners and intermediate wings. After acquisition of the pilot license performance and security training provide the best preparing to master unforeseeable situations.

Praventiv-chirurgische Therapie am Skelett- und Bewegungsapparat betrifft verschiedene Indikationsgebiete, die von praarthrotischen Achsenfehlern uber Knochentumoren bis hin zu Gelenkinstabilitaten traumatischer oder habitueller Art oder posttraumatischen Gelenkinkongruenzen reichen. Entscheidend ist die fruhzeitige Erkennung von Zustanden, die prospektiv Krankheitswert besitzen, um durch die praventiv-operative Intervention entweder eine praarthrotische Konstellation zu beseitigen oder bei einer bereits vorliegenden Schadigung die Progredienz der Erkrankung zu verzogern, im Idealfall sogar aufzuhalten.

Fragestellung: Die komplizierte Heparin-induzierte Thrombozytopenie (HIT) kann als eine seltene Ursache fur arterielle Thrombosen und Embolien auftreten. In der Literatur sind acht Falle der Lysetherapie von arteriellen Verschlussen bei HIT beschrieben: in 5 Fallen erfolgreich, in 2 Fallen mit anschliesendem Extremitatenverschlus, in 1 Fall mit Exitus letalis. Anhand der Literaturubersicht, eines eigenen Falls und immunhistochemischer Untersuchungen von HIT-verursachten Thromben soll eine Erklarung fur die frustranen Lysen vorgestellt werden. Patientengut: Ein Heparin-induzierter, infrarenaler Aortenverschlus bei einem 59jahrigen Patienten wurde transaxillar direkt am Thrombus mit Urokinase hochdosiert lysiert. Es resultierte umgehend eine komplette Ischamie beider Beine. Durch eine beidseitige, inguinale Thrombektomie nach zentral und peripher konnte unter perioperativer Protektion mit dem Heparinoid Org 10 172 die arterielle Durchblutung komplett wiederhergestellt werden. Thromboembolische Komplikationen im venosen System wurden in diesem Fall nicht beobachtet. Ergebnis: Als Erklarung fur die frustranen Lysen bei HIT-verursachten Gefasverschlussen werden immunhistologische Befunde von „white clots“ angefuhrt, die den strukturellen Unterschied zum Aufbau von regularen Abscheidungsthromben zeigen: die sog. „white-clots“ entstehen durch eine immunvermittelte Plattchenaggregation und zeigen einen sehr niedrigen Fibringehalt. Somit fehlt der enzymatischen Fibrinolyse das entscheidende Substrat. Die vorwiegend IgG-vermittelte Plattchenaggregation weist auf einen moglichen immunologischen Therapieansatz hin. Schlusfolgerung: Die medikamentose Thrombolyse zur Behandlung von heparininduzierten, arteriellen Gefasverschlussen empfiehlt sich nur dann, wenn fur den Fall einer frustranen Lyse mit arterieller Komplikation eine rasche gefaschirurgische Interventionsmoglichkeit besteht. Die Indikation zur Lyse sollte damit in diesen Fallen kritisch gestellt werden.

The scapulothoracic dissociation (SD) is a complex injury of the shoulder girdle, mostly associated with polytraumatized critically ill patients. This case report of 3 patients shows the variety of possible injuries combined with SD. Diagnosis and therapy in such a rare trauma, which is most likely seen in specialized trauma centres are being described. The 3 patients are presented from trauma to management, with remarks to various possibilities in treatment. Reports of other groups include multicenter studies with small numbers of patients, making it different to look for homogenity or defining standards, whereas current guidelines are being mentioned, including remarks on the management of these mostly polytraumatized and vitally endangered patients.

The standard treatment in forearm fractures in children is usually conservative. Unstable fractures of the proximal parts of the forearm often show poor results after nonoperative management so that these fractures usually require surgical intervention. We report 30 children (ages, 4-14 years) who were treated by elastic intramedullary nailing. Sixteen patients were treated by intramedullary splinting immediately after their accident; 14 children required intramedullary nailing after failure of conservative treatment and fracture redisplacement. At the time of follow-up 6 months later, functional results were excellent in 24 children, good in five children, and fair in one child. There were no serious complications other than one delayed union. According to these results intramedullary nailing can be recommended for the treatment of unstable fractures of the proximal and middle thirds of the forearm in children.

In this article, the problems of sample preparation of annealed cold-work and plastic mold steels were gone into in more depth. Due to the characteristic microstructure, namely a relatively soft matrix with hard carbide inclusions, great problems arise with respect to quantitative analysis (e.g. purity analysis) of the section as the necessary quality can hardly be achieved with normal automatic preparation methods. The aim of this work is to optimise the preparation parameters for the two material groups on two chosen examples, in order to guarantee section surfaces as fault free as possible.

We analyzed DNA-fragmentation in human polymorphonuclear neutrophil granulocytes (PMNs) from healthy donors after addition of exogenous arachidonic acid (AA) and eicosapentaenoic acid (EPA) by flow cytometry (propidium iodide staining of DNA and DNA strand break detection). The PMNs were incubated from 30 min up to 48 hours in RPMI 1640 which was supplemented with different concentrations of AA or EPA (5-40 microM). In contrast to EPA the addition of AA led to a significant increase in apoptosis up to 67.8% compared to the RPMI-control whereas the addition of EPA led to an inhibition of DNA-fragmentation. When the cells were incubated with MK 886 (1 microM, inhibitor of leukotriene biosynthesis) an increase in DNA-fragmentation (up to 63.3%) was observed. Conversely, in the presence of indomethacin (1 microM, inhibitor of prostanoid synthesis) an inhibition in DNA-fragmentation (up to 60.9%) occurred. Furthermore, preincubation of PMNs with pentoxifylline (1mM, phosphodiesterase inhibitor) reduced AA-stimulated DNA-fragmentation up to 43.4%. These data provide evidence for the involvement of AA and distinct AA metabolites in the regulation of apoptosis in human PMNs.

Die Behandlung der Pseudarthrosen hat durch die Arbeiten von Ilizarov mit den Prinzipien Kompression und Distraktion unter Anwendung des Ringfixateurs eine wichtige Weiterentwicklung erfahren. Wahrend bei hypertrophen Pseudarthrosen die lokale Kompression ausreicht, kommen bei atrophen Infekt-Defektpseudarthrosen die Kortikotomie in Verbindung mit dem Segmenttransport zur Anwendung, insbesondere dann, wenn Defekte von mehr als 3 cm vorliegen. Dabei stellt die primare Verkurzung eine verbesserte Ausgangssituation fur die Weichteilrekonstruktion als auch fur ein fruhzeitiges Docking dar. Fixations- und Transportsysteme sind Ringfixateur, unilateraler Fixateur sowie Hybridsysteme. Der Ringfixateur weist eine geringere Konsolidierungszeit (25,8 gegenuber 35,8 Tagen pro cm) gegenuber dem unilateralen Fixateur auf. Eine Sanierung der Weichteile vor Beginn des Transportes verkurzt ebenfalls die Konsolidierungszeit im Vergleich zu einer Weichteildeckung nach Transportbeginn. Die Dockingregion wird im metaphysaren Bereich durch eine Minimalosteosynthese in Verbindung mit einer Spongiosaplastik unterstutzt. Kompliziert wird der Segmenttransport durch lokale Infektionen, Regeneratversagen (4,3 %) sowie Regeneratfraktur (2,9 %).

The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures.From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis.The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required.Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Allergies against bone cement or bone cement components have been well-described. We report on a 63-year-old patient who presented with progressive vitiligo all over the body after implantation of a cemented total knee replacement. A dermatological examination was performed and an allergy to benzoyl peroxide was found. A low-grade infection was diagnosed 5 months after implantation of the total knee replacement and the prosthesis was replaced with a cement spacer. After treating the infection of the knee replacement non-cemented arthrodesis of the knee was performed. In cases of new, unknown skin efflorescence, urticaria and periprosthetic loosening of cemented joint replacement, the differential diagnosis should include not only infections but also possible allergies against bone-cement and components such as benzoyl peroxide or metal components.

Heterotopic ossification (HO) is a common and serious complication after spinal cord injury, with an incidence of 5-50 %. Single-dose radiation therapy with 7 Gy is an established procedure for HO prophylaxis after total hip replacement. The aim of our study was to determine the clinical outcome after single-dose radiation therapy in the prophylaxis of HO in paraplegic patients.Between January 2006 and July 2009, 75 paraplegic patients with heterotopic ossification were treated in our hospital. On the basis of the defined inclusion and exclusion criteria, 62 patients were included in our study, whereas 55 patients participated in our follow-up examination. All patients received a bi-weekly ultrasound of the hip for an attempt at early diagnosis of the condition. In case of an ultrasound suspicion of HO, a computed tomography (CT) or magnetic resonance imaging (MRI) of the hip was performed. After confirmation of HO, a single-dose radiation therapy with 7 Gy was performed. In group A, the patients were irradiated with an electrode voltage of 15 MeV (36 patients) and in group B with 6 MeV (26 patients). All patients were assessed with a standardised questionnaire with a mean follow-up of 30.6 months (range 6-78 months).The mean interval time between the initial spinal injury and HO development was 58,2 days (range 14-125). 69,4 % of all patients revealed a Brooker grade I, 27.4 % grade II and 3.2 % a grade III. No cases of Brooker grade IV (ankylosis) occurred. No patient showed side-effects after radiation therapy. However, in group A one patient (3,2 %) and in group B three patients (12.5 %) developed HO relapse. Those patients were treated again with a single-dose radiation therapy with 7 Gy and 15 MeV and, afterwards, they were free of complaints. Deep vein thrombosis was confirmed in 11 patients (32.3 %) in group A and in 8 patients (33.3 %) in group B.Single-dose radiation therapy with 7 Gy in the treatment of heterotopic ossification is an effective option. A higher electrode voltage improves the effectiveness of the irradiation and the clinical outcome. Essential for the outcome is the early detection and treatment of HO with single-dose radiation therapy. Randomised, prospective studies should be undertaken in order to confirm these findings.

Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia.In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention.A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group.A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

Destructive changes of the elbow joint represent a challenge for both patient and surgeon. Resection arthroplasty is associated with postoperative instability and loss of power and is a rarely performed procedure. Interpositional arthroplasty remains a useful option for healthy active patients with severe post-traumatic elbow arthrosis and is one of the oldest methods used to reconstruct the elbow. The principle of interpositional arthroplasty is based on a sparing resection of the destroyed joint surface and on creating a congruent elbow joint with human tissue. Nowadays, autogenous dermis, fascia lata or Achilles allograft are used. A preoperatively stable elbow is required to prevent instability following interpositional arthroplasty. The use of total elbow arthroplasty is limited due to the contraindications and in such cases the only remaining options are salvage procedures of the elbow. In general, arthrodesis should be performed in patients with painful osteoarthritis of the elbow with high demands on the upper extremities. Historically, tuberculosis was the most common indication for elbow arthrodesis and various methods of elbow arthrodesis have been described. However, most attention has been given to the position in which the elbow joint should be fixed and should be decided depending on the individual characteristics of the patient. Sufficient bone stock is crucial for a successful elbow arthrodesis and in cases with massive bone loss reconstruction of the elbow using an allograft can be performed to restore bone quality. However, the high complication rate of this procedure limits the scope of its use. Nevertheless, allograft procedures can restore pain-free joint function for several years.

The treatment of severe bacterial infections of the ankle joint is difficult and complex. In the case of a chronic infection with destruction of the ankle joint, a tibiotalar arthrodesis with external fixation is the treatment of choice. In this study the results of ankle arthrodesis due to bacterial infection using the Ilizarov external fixator are presented.Between 2001 and 2004 37 patients (10 female, 27 male, mean age 58 years) were treated with a tibiotalar arthrodesis using the Ilizarov fixator. All patients had a confirmed infection in the course of their disease. Active infection was present in 20 patients at the time of the operation. Most secondary ankle arthritides (81 %) were caused post-traumatically after various internal fixation procedures. Previous ankle arthrodeses were tried in 14 cases (12 cases with internal fixation, two cases with external monolateral fixation). Patients were treated with a four-ring Ilizarov frame (in two cases with a five-ring frame) and stainless steel wires. All patients could be included at a mean follow-up of 46 (12-49) months. A modified AOFAS score was used for the functional outcome.The operation took 141 minutes at an average ranging from 90 to 252 minutes. The inpatient treatment lasted between 10 and 63 days (mean 26 days). The time spent in the fixator was 116.7 (69-245) days. All patients were mobilised under full weight bearing with the external fixator. Surgical revision was necessary in 13 patients: four patients needed wound revisions due to ongoing infection, six patients needed wire exchange due to deep infection in three cases and wire breakage in three cases, one patient needed additional wires because of an initially instable frame configuration and two patients needed secondary skin grafting. Bony consolidation was achieved in 32 patients (86.5 %). With a re-arthrodesis performed in four patients using the Ilizarov fixator, the overall fusion rate was 94.6 %. Infection was persistent in two cases with one solid ankle fusion and one ankle pseudarthrosis. At the time of follow-up 35 patients were able to walk under full weight loading with orthopaedic shoe modifications, four patients needed support of a cane and three patients wore an ankle-foot orthesis. The two patients with persistent pseudarthrosis were mobilised in a lower-leg orthesis after declining another surgical revision. The positioning of the hindfoot showed in seven cases an equinus of 10°, in one case a varus of 10° and in two cases a valgus positioning of 10°. A plantigrade foot positioning or with minimal degrees of deviation could be achieved in all other cases. The modified AOFAS score at the time of the follow-up examination ranged from 19 to 86 with an average score of 67.9 points. All patients except three were satisfied or rather satisfied with the treatment procedure and its results.The Ilizarov external fixator is a safe method for ankle fusion in cases of infection. The advances are a possible application at acute infection and immediate mobilisation at full weight bearing. However, it remains a time-consuming and stressful procedure for the patient.

Complex vertebral fractures can lead to injury of the spinal cord with resulting paraplegia. High-speed accidents are common causes, especially in younger patients. Malignant or inflammatory processes play an important role in the elderly. Less common reasons for a spinal cord injury are congenital malformations. We here report about a 17-year-old patient who suffered from paraplegia after an isolated rupture of the spinal cord without an injury of the vertebral bodies, intervertebral disc or ligamentous structures. This type of injury has not been reported in the literature before.We report about a 17-year-old patient, referred to our hospital, presenting with lumbal paraplegia after a high-speed accident 8 days prior to admission. After initial stabilisation of the polytraumatised patient, he was referred to our hospital for further treatment.The radiological examination showed a bilateral acetabular fracture, a right anterior pelvic ring fracture and shaft fractures of the left humerus and right femur. Furthermore, the spinal cord at thoracic level 10/11 was ruptured. Interestingly, there was no injury of the vertebral bodies, intervertebral disc or ligamentous structures. A tethered cord as a possible anatomic variation could be excluded in this case by MRI. However, anatomic variations could be the reason for this injury and should be kept in mind.

Arm wrestling may cause severe injuries. Various injuries after arm wrestling have been reported in the literature, whereas the most common injury is the humeral shaft fracture. In this context we report on eleven cases with different injuries during arm wrestling.All patients were analyzed using a standardized questionnaire. The effect of drugs, pre-existing conditions and injuries as well as sport activities were examined. Furthermore we report about a 24 year old patient who sustained a radial shaft fracture which has not been reported in the literature yet.8 patients suffered from a fracture. The humerus was the most affected bone in 7 cases. 3 patients had a muscle strain, whereas in all 3 cases the patients were regularly sportive active and warmed-up be for the injury. Ten patients were reintegrated into the previous job after an average time period of 6 weeks. One patient was out of work.Regular sport activity and the muscle strength are important factors for the injury intensity. Further studies are necessary to confirm this theory.

Blunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies.A 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography.Histologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively.The diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.

Repeated luxations, periprosthetic fractures, infections, and nerve palsies are the most frequent complications of hip alloarthroplasty. Paresis acquired during elective implantation entails considerable restrictions in the quality of life. The risk of sustaining a nerve injury depends upon the initial clinical situation, cases of planned leg lengthening in patients with hip dysplasia and high luxations being particularly at risk.A Medline search was conducted using the query "nerve palsies during hip prosthesis implantation", yielding 126 publications, of which 18 were used to predict the risk of nerve palsies in cases with simultaneous leg lengthening during total hip arthroplasties according to different preconditions.The risk for an acquired nerve lesion during hip alloarthroplasty in arthritis was 0.5 %. In cases of hip dysplasia (with no or moderate leg lengthening during the procedure), the risk was increased to 2.3 %. An even higher risk of 3.5 % was found in cases of revision surgery. According to the literature, the risk of nerve palsies in cases of continuous leg lengthening before THA is raised to 5.9 % with a linear correlation between the amount of leg lengthening and rate of nerve palsies.Neural lesions during single-stage leg lengthening of less than 3 cm in hip alloarthroplasty are uncommon. More extensive lengthening can be achieved with continuous procedures, which should be conducted under clinical monitoring of the peripheral nerves to avert possible nerve injury.

The operative management of open fractures of the lower limb requires a consistent treatment to avoid soft tissue complications. Acute angular shortening of the fracture enabling primary soft tissue closure is still an uncommon operative technique because of difficulties in correcting the secondary deformity. The case of a pediatric open fracture of the lower limb (Gustilo type IIIa) is described, which was treated with acute angular shortening followed by gradual correction using the Taylor spatial frame (TSF).

Grundlagen: Akute oder chronische Weichteildefekte nach operativer Therapie von Schienbeinkopfbruchen stellen eine schwerwiegende Komplikation dar. Um eine chronische Infektion des Knochens zu verhindern oder bei manifester Osteomyelitis die Infektbeherrschung zu ermoglichen, ist eine suffiziente Weichteildeckung eine conditio sine qua non.

Bipolar hemiarthroplasty is frequently used in femoral neck fractures. There is only little evidence regarding differences in complication rates if the procedure is performed by either a junior or senior surgeon.360 bipolar hemiarthroplasties were retrospectively investigated. Complication rates for junior and senior surgeons were evaluated as well as differences between daytime and nightshift surgery. We also assessed the duration of surgery for the two groups and its impact on the complication rate.The average duration of the procedure was 67 minutes (23-194) with statistically significant differences between junior and senior surgeons (77 vs. 61 minutes, p0.001). Complications occurred in 27 (7.5%) of all cases. Postoperative infections were most frequently found (3.1% of all complications), followed by haematomas and dislocations of the implant (1.7% and 1.1 %, respectively). 25 patients required revision operations. More complications were found in cases performed by junior surgeons (9.56% vs. 6.25%). This difference was not significant (p = 0.248). During on-call duty we also observed more complications compared to daytime surgery (11% vs. 7%). There was no coherence between the duration of surgery and the incidence of complications.Bipolar hemiarthroplasty is a reliable treatment option for femoral neck fractures even when performed by a junior surgeon. The higher incidence of complications during nighttime surgery should be a reason to perform those cases that are not urgent during the daytime shift.

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

Post-traumatic supramalleolar deformities and malunions of ankle fusion require mostly a multiplanar correction. In cases of severe soft tissue damage, external fixation and gradual correction is a definite treatment alternative.Between 2003 and 2007 a correction of supramalleolar deformities was performed in 9 patients with the Taylor spatial frame external fixator. The mean age was 30 years (min. 12, max. 68). There were 6 patients with deformities after malunion of supramalleolar fractures and 3 patients with malunion after ankle fusion. The mean angular deformity was 30 degrees and 5 patients had a rotational malposition of 13.6 degrees (min. 5 degrees, max. 25 degrees). 5 patients needed also lengthening (min. 10 mm, max. 40 mm) of the post-traumatic deformed tibia. The mean time of the follow-up examination was 23 months (min. 12, max. 41).Anatomic correction could be achieved in all patients. The average correction time was 36 days (min. 10, max. 82) with an average time period of 163 days (min. 130, max. 218) until the fixator was removed. The healing index of the leg lengthening cases was 77 d/cm. There were 2 pin-tract infections, 1 prolongated callus formation and 1 insufficient callus formation.In cases of post-traumatic supramalleolar deformities with poor soft tissue and bone quality the Taylor spatial frame is a useful tool. Angular, axial, translational and rotatory deformities are corrected simultaneously without complex and time-consuming fixator reconstructions.