Search

There is an accumulation of blast injuries on New Year's Eve due to fireworks.During an attempt to manufacture a firework the substances being mixed in a mortar exploded. The left hand of the patient was severely injured.During the operative treatment with radical debridement and generous amputation without osteosynthesis, a basic hand function according to Entin could initially be preserved; however, at a later stage the fourth finger could not be preserved, so that a prosthesis became necessary.This case report shows the importance of expertise in hand surgery in the treatment of such severe injuries. A toe-to-hand transplantation represents an additional treatment option.

There is an accumulation of blast injuries on New Year's Eve due to fireworks.During an attempt to manufacture a firework the substances being mixed in a mortar exploded. The left hand of the patient was severely injured.During the operative treatment with radical débridement and generous amputation without osteosynthesis, a basic hand function according to Entin could initially be preserved; however, at a later stage the fourth finger could not be preserved, so that a prosthesis became necessary.This case report shows the importance of expertise in hand surgery in the treatment of such severe injuries. A toe-to-hand transplantation represents an additional treatment option.Zu einem gehäuften Auftreten von Explosionsverletzungen kommt es in der Silvesternacht durch Feuerwerk.Bei dem Versuch Feuerwerk herzustellen, kommt es zur Explosion der in einem Mörser gemischten Substanzen. Die linke Hand des Patienten wird schwer verletzt.Im Rahmen der operativen Versorgung mit radikalem Débridement und großzügiger Amputation ohne osteosynthetische Versorgung konnte zunächst die „basic hand“ nach Entin erhalten werden. Im Verlauf war ein Erhalt des 4. Fingers nicht möglich, sodass eine Prothesenversorgung notwendig wurde.Dieser Fallbericht zeigt die Wichtigkeit von handchirurgischer Expertise in der Versorgung von solchen schweren Verletzungen. Eine „Toe-to-hand“-Transplantation stellt eine weitere Therapiemöglichkeit dar.

The absolute configuration of a chiral molecule is key to its biological activity. Being able to find out what this configuration is, is thus crucial for a wide range of applications. The difficulties associated with such a determination steeply rise as the number of chiral centers in a given compound becomes larger. Concurrently, it becomes increasingly more challenging to determine the levels and identity of potential stereochemical contaminants in a given sample with one and the same technique, leading in practice to extensive and laborious efforts employing multiple analytical techniques. Here, experimental and theoretical studies based on Vibrational Circular Dichroism (VCD) are presented for dydrogesterone, a synthetic drug employed in reproductive medicine that is a prototypical example of such a multi-center chiral compound. We show that our approach allows us to distinguish and assign its absolute configuration without prior knowledge to one of the 64 possible stereoisomers associated with the six chiral centers. Studies on mixtures of dydrogesterone and 6-dehydroprogesterone, one of the diastereomers of dydrogesterone and generally the dominant impurity of dehydrogesterone, show that we can identify the presence of both compounds from one single VCD spectrum. Moreover, we find that we can determine diastereomeric contamination levels as low as 5% from the experimental VCD spectra.

HISTORY AND CLINICAL FINDINGS Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation. INVESTIGATIONS Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding. TREATMENT AND COURSE The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding. CONCLUSION Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

UNLABELLED Differential diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique. AIM The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated. METHOD In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment. RESULTS The sensitivity of this technique was found to be 38.9% for acute appendicitis, 57.1% for diverticulitis and 76.9% for obstructive ileus. The specificity ranged above 90% in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100%. CONCLUSION Low diagnostic sensitivity with high specificity implies the necessity to intensity routine ultrasonic investigation of the gut.

Die Huftkopffraktur ist als „proximalste“ Form der Femurfraktur eine sehr seltene Verletzung, uber deren Prognose relativ wenig bekannt ist. Ziel der vorgestellten retrospektiven Studie war die Evaluation der Spatergebnisse von Huftkopffrakturen. Von 1974 bis 1997 wurden 18 Patienten, 17 davon mannlich, mit einem Durchschnittsalter von 25,6 Jahren (Spanne 15,6–55,9) behandelt. Nach der Klassifikation von Pipkin (1957) handelte es sich um 4 Typ-I-Frakturen, 3 Typ-II-Frakturen und 11 Typ-IV-Frakturen. Die Reposition der luxierten Hufte erfolgte durchschnittlich nach 136 min. Bei 16 Patienten wurde der Huftkopf danach osteosynthetisch rekonstruiert, wobei 13-mal ein dorsaler Zugang zum Huftgelenk gewahlt wurde. Alle Patienten wurden nach durchschnittlich 151 Monaten nachuntersucht (Spanne 59–247). Neben einer Befragung erfolgte eine klinische und radiologische Untersuchung. Die Beurteilung der Spatergebnisse erfolgte nach den folgenden Scores: Thompson und Epstein (1951): sehr gut = 1, gut = 10, masig = 4, schlecht = 3; Merle D’Aubigne (1954): sehr gut = 9, gut = 5, masig = 0, schlecht = 4; Harris (1969): Pipkin Type I = 81 Punkte, Typ II = 97 Punkte, Typ IV = 73 Punkte (im Mittel); Brooker (1973): Grad I = 5, Grad II = 1, Grad IV = 2. Die Spatergebnisse zeigen, dass folgende Masnahmen wesentlich bei Huftkopffrakturen sind: 1. notfallmasige Huftkopfreposition und 2. huftkopferhaltender Eingriff mit Wiederherstellung der Kongruenz und der Stabilitat des Gelenks. Die Lebensqualitat der meisten Patienten war nach standardisierter Nachuntersuchung und Befragung nicht beeintrachtigt, als besonderes problematisch erwiesen sich jedoch die Pipkin-IV-Frakturen mit 3 von 4 schlechten Resultaten.

In the field of local application of antimicrobials, a number of novel drugs and/or new drug delivery systems have been developed in recent years. The present study aimed to investigate hydroxyapatite cement (HAC) as a carrier for vancomycin in the treatment of chronic osteomyelitis due to Staphylococcus aureus strains with various mechanisms of resistance. The release of vancomycin from standard test cylinders was determined in vitro and the efficacy of the delivery system was measured in vivo using a rabbit model of chronic osteomyelitis. First, powdered HAC was mixed with vancomycin at 80, 160 and 240 mg/g. After hardening, formed cylinders were eluted in phosphate buffer and antibiotic release was measured by agar diffusion. High levels of release (1512+/-318 to 1937+/-336 microg/ml) were obtained for 12 to 20 days depending on the dosage of vancomycin. Additionally, bone infection was induced in the tibia of 30 New Zealand white rabbits by injecting either a methicillin-resistant S. aureus strain (MRSA) or a S. aureus strain with a small colony variant (SCV) phenotype. After 3 weeks (chronic infection), all animals were treated by debridement. Moreover, group 1 (challenged with SCVs) and group 2 (challenged with MRSA) were treated by filling the marrow with HAC alone, whereas in groups 3 (SCVs) and 4 (MRSA) the marrow was filled with HAC/vancomycin (160 mg/g). After 6 weeks all animals were sacrificed. At 3 weeks, pathogens were detected in 24 of 30 animals. All swabs of the control groups, positive for S. aureus on day 21, were also positive on day 42 and S. aureus strains recovered were shown to be clonal to the strains used for induction of osteomyelitis. By contrast, no growth was found in the treatment group following 7 days of incubation in BHI bouillon. HAC/vancomycin-treated animals showed no histological evidence of infection on day 42. In the other groups, different stages of chronic osteomyelitis were found histologically. No local or systemic side effects due to HAC or vancomycin were seen. HAC is an effective carrier material for antibiotic compounds even in refractory infections due to MRSA or S. aureus SCVs.

A study was performed to investigate the effectiveness of hydroxyapatite cement (HAC) as a new carrier system in the treatment of chronic, posttraumatic osteomyelitis. In the in vitro study, release of gentamicin from standard cylinders of HAC were measured by agar diffusion test. As a representative for mechanical properties, compression strength was measured in order to detect changes when mixing HAC with gentamicin. In the in vivo study, bone infection was induced according to the model of Norden by injection of 1 ml Na-morrhuat and 3×106 CFU Staphylococcus aureus. After 3 weeks, when chronic stage of infection was obtained, 17 animals were treated by debridement and filling the marrow either with HAC alone or HAC mixed with gentamicin (32 mg/g). Animals of the control groups were left untreated. After 6 weeks, all animals were sacrificed. Hematological, radiological, microbiological and histological examinations were carried out by covered investigation. Best evidence of the efficiency of treatment was observed in histopathological and microbiological findings. In all swabs of the control groups, taken 6 weeks following infection S. aureus were detected which were clonal to the strain used for induction of osteomyelitis. In HAC/gentamicin-treated animals, no growth was detectable after 7 days of culturing in BHI bouillon. In the HAC/gentamicin-treated group, there was no histopathological evidence of infection. In all other groups different stages of chronic osteomyelitis were found. No side effect was observed, neither locally nor systemically by HAC or gentamicin. Therefore, HAC is considered to be a very effective carrier for antibiotics in treatment of chronic, posttraumatic osteomyelitis.

Die Essex-Lopresti-Lasion, eine Kombination aus Radiuskopfchenfraktur und distaler Radioulnargelenkssprengung, stellt aufgrund ihres sehr seltenen Auftretens noch immer eine oftmals primar missinterpretierte Traumafolge des Unterarmes dar. Werden vom Ersttherapeuten, auch zur Rekonstruktion im Handgelenksbereich, nicht bereits die geeigneten chirurgischen Schritte eingeleitet, resultieren gemeinhin gerade in dieser Region jeder weiteren Therapie unzugangliche Schmerzzustande. Gegenwartig existiert demnach keine bisher allgemein bewahrte Therapie der verspatet erkannten radioulnaren Dissoziation. Die ersatzlose Resektion zur Therapie der Speichenkopfchenfraktur ist hier als obsolete Masnahme anzusehen, da bei meist gleichzeitiger Zerreisung der Membrana interossea die komplette Instabilitat des verbliebenen Speichenrestes mit proximalwarts gerichtetem Shift droht. Anhand eines beispielhaften Falles werden die operativen Moglichkeiten in dieser Situation vorgestellt und nach ihrem Nutzen beurteilt.

In dem Zeitraum von 1990–1997 wurde bei 34 Patienten eine Kallusdistraktion am Os metacarpale I nach traumatischer, nicht replantierbarer Daumenamputation vorgenommen. Nach einer Latenz von 7±11 (1–48) Monaten posttraumatisch wurde eine Kortikotomie und anschliesend eine kontinuierliche Kallusdistraktion nach Einbringen eines Fixateur externe durchgefuhrt; 31 (91%) Patienten konnten 41±32 Monate nach Abschluss der Behandlung nachuntersucht werden. Mit diesem Verfahren konnte eine durchschnittliche Verlangerung von 78% der Daumenlange der Gegenseite erzielt werden. An Komplikationen fanden sich in einem Fall ein Kallusabriss, bei 4 Patienten eine Weichteil- und bei 7 Patienten eine Pininfektion ohne Osteitis, die folgenlos ausheilten. Zum Zeitpunkt der Nachuntersuchung wiesen 20 Patienten (64,5%) ein sehr gutes, 9 (29%) ein gutes und 2 Patienten (6,5%) ein unbefriedigendes Ergebnis auf.

Enchondrome sind die haufigsten Knochentumoren der Hand. Im Rahmen einer retrospektiven Studie wurden die Krankenakten und Rontgenbilder von 112 Patienten ausgewertet, die von Januar 1973 bis Juni 1997 operiert worden waren. Nach Tumorexstirpation wurde der Defekt vorzugsweise mit autologem Knochen aufgefullt (102 Patienten). Die histologische Aufarbeitung des Praparats ergab zweimal eine maligne Entartung im Sinne eines Chondrosarkoms. Die Nachuntersuchung von 92 Patienten durchschnittlich 1,6 Jahre postoperativ (7 Monate bis 14 Jahre) zeigte gemas dem Schema nach Wilhelm und Feldmeier bei 76 Patienten (82,6 %) ein sehr gutes oder gutes Behandlungsergebnis. Vier Rezidive waren wahrscheinlich auf eine inkomplette Tumorresektion zuruckzufuhren. Die Autoren folgern, das jedes Enchondrom der Hand zur Diagnosesicherung und Vermeidung eines Stabilitatsverlusts operiert werden sollte.

Following curettage of enchondromata of the phalanges we filled the resultant bone cavity with hydroxyapatite cement in eight patients to avoid cancellous bone grafting. This material differs significantly from the ceramic hydroxyapatite commonly used in clinical practice. It is produced by the combination of two calcium phosphates which, in the presence of water, form a paste that cures to a solid implant with a microporous structure. Like ceramic hydroxyapatite, this cement is highly biocompatible and does not provoke a foreign body giant cell reaction, a sustained inflammatory response or a toxic reaction. We performed a prospective study with X-rays and clinical assessment up to 1 year after the operation. There were no complications, and all patients regained full function of the hand.

Every 15th case of a bone fracture in patients aged more than 65 years concerns the distal radius in Germany. This means the second rank of all geriatric fractures following fractures of the hip. According to the approved and increased apply of operative stabilisation there are arising more and more reports upon poor results of nonsurgical treatment. Especially in older patients the main reason for the discontented outcome of conservative management is osteoporosis, which is an affirmative circumstance for the genesis of fracture but also for secondary mal-aligment of comminuted thin cortical walls and crushed porotic cancellous bone. The rational of this perception is either filling artificial bonelike tissue--avoiding the need of harvest cancellous bone graft from a second surgical site--into the resultant cavity following reduction, or supplementary trans-styloidal or intrafocal K-wiring until remodeling is obtained within an average of 10 weeks. Both arrangements should be secured in addition with a trans-articular external fixation. According to a literature review and our own experiences of 92 follow up cases of distal radius fractures in patients who were older than 65 years this procedure seems to be superior at present for A-2, A-3 and most cases of type-C fractures of the distal radius, despite the disadvantage of joint immobilisation for about 5 weeks. Type B-fractures, however, should be provided better with an internal fixation. Sudeck's algodystrophia is the mostly serious complication of the distal radius fracture and its treatment in older patients. Recognising punctually neurovegetative stimulated patients, treat them cautiously and coming in on their special situation is usually the best way to reduce this risk. To pay attention to the topography of the nerves during the application of the pins and to act at the first signs of complications immediately is also very important. We examined 92 patients who were older than 65 years with a fracture of the distal end of the radius in a follow up study. In this group we treated 62 distal radius fractures of the type A and C of the AO classification with an trans-articular external fixateur and with supplementary measures if necessary. Additionally we filled the bone cavity with an artificial bone graft (Endobon) following closed reduction in 32 cases, 12 times a complementary K-wiring was added and in 8 cases the external fixateur was combined with both. Sudeck's disease appeared in 1.1% of all cases. In 5 cases we recorded complications with an obligation to treatment as well. Lesion of the superficial branch of the radial nerve were noted in 2 cases (2.1%), as far as we extended the surgical approach for the pin application. Technical problems from the site of the external fixateur appeared in 3 cases, two of them could be attributed to an infirmity of the fixateurs ball joints which is now eliminated by the producer. 4 patients with a type-B fracture was provided by plating, additionally 4 patients with a type-C fracture because of non-compliance. The external fixateur is an essential part of a differentiated treatment with reference to the several types of distal radius fractures in older patients.

In Deutschland ist jeder 15. Knochenbruch eine distale Radiusfraktur bei einem uber 65-jahrigen. Damit liegt diese Fraktur hinter der Schenkelhalsfraktur an 2. Stelle der ,,geriatrischen“ Frakturen. Parallel zu den verbesserten und immer mehr eingesetzten operativen Stabilisierungsverfahren mehren sich Berichte uber schlechte Ergebnisse der konservativen Behandlung. Hauptursache bei den alteren Patienten ist die Osteoporose, die nicht nur die Entstehung der Fraktur begunstigt, sondern auch fur die Sinterung bei konservativer Behandlung verantwortlich ist. Die logische Konsequenz ist entweder die Auffullung des Defekts nach Entstauchung der Fraktur – zur Vermeidung zusatzlicher Morbiditat nicht durch autologe Spongiosa, sondern – mit Knochenersatzstoffen (Endobon®) oder die transstyloidale oder intrafokale Kirschner (K)-Draht-Fixation, zusatzlich gesichert durch transartikulare externe Fixation, die in einem Literaturquerschnitt und nach eigener Erfahrung bei 92 Fallen von uber 65-jahrigen Patienten trotz des Nachteils der 5-wochigen Gelenkimmobilisierung fur A2-, A3- und fast alle C-Frakturen das derzeit effizienteste Verfahren zu sein scheint, wahrend die B-Frakturen besser mit der Platte zu versorgen sind. Die schwerstwiegende Komplikation der Radiusfraktur alter Menschen ist auch bei der operativen Behandlung immer noch die Sudeck-Dystrophie, der immer noch am besten vorgebeugt wird durch rechtzeitige Erkennung neurovegetativ stimulierter Patienten und entsprechend fursorglicher Behandlung und Nachbehandlung und durch die strenge Beachtung der Nerventopographie bei der Pinplatzierung. Wir haben 62 A- und C-Frakturen mit dem Fixateur und, wo notig, mit Komplementarmasnahmen versorgt, 32-mal mit Endobon, 12-mal mit komplementaren K-Drahten, und 8-mal mit beiden zusammen. Die gravierendste Komplikation war ein ,,Sudeck“ (1,1 %). Behandlungspflichtige Komplikationen sahen wir in 5 Fallen, Irritationen von Radiushautasten 2-mal (2,1 %) in der Anfangsphase, bis wir zur Pinapplikation anatomiegerechtere grosere Zugange wahlten. Technische Probleme mit dem Fixateur halten wir in 3 Fallen, davon gingen 2 zu Lasten einer mittlerweile vom Hersteller behobenen Schwache des Gerats. 4 Patienten mit B-Frakturen wurden mit einer Platte versorgt, auserdem 4 aus der Gruppe der C-Frakturen aus Grunden der Compliance des Patienten. Der Handgelenkfixateur ist ein wesentlicher Bestandteil im Konzept einer differenzierten und typenorientierten Behandlung der Radiusfraktur beim alten Menschen.

Introduction The aim of our study was to evaluate external fixation in the treatment of unstable distal radius fractures in a long-term follow-up. Methods Within 8 years 174 patients with severely displaced distal radius fractures were included in a prospective study and treated with an external wrist fixator (Orthofix Srl, Italy). A total of 148 patients were reviewed with an average follow-up time of 28 months. Results Using the functional outcome score according to Gartland and Werley, we obtained 29.3 % excellent, 42.5 % good, 10.3 % fair and 2.9 % poor results; 14.9 % of the patients were not available for follow-up. Additional procedures were carried out in 54.1 % to obtain dorsal stabilization. The list of complications included two major pin-tract infections requiring surgical intervention, one pin cut out of the second metacarpal bone, one fixator dislocation, and one patient had algodystrophy. The length of the radius and joint congruity did not significantly from the situation when the fixator has been removed at the end of the treatment. Conclusion The results show the importance of anatomical reduction, and especially restoration of radial length, in order to obtain good functional outcome.

Object. The authors conducted a metaanalysis of reports of anterior interosseous nerve syndrome, a rare nerve compression neuropathy that affects only the motor branch of the median nerve. This syndrome is characterized by paralysis of the flexor pollicis longus, the flexor digitorum profundus to the index finger, and the pronator quadratus, with weakness on flexion of the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger without sensory loss.Methods. The authors reviewed reports of 34 cases of anterior interosseous nerve syndrome combined with supracondylar fractures of the humerus in children. They have added a new case identified in a 7-year-old boy in whom a diagnosis was made from the clinical findings and whose treatment and outcome are analyzed. The ages of patients reported in the literature ranged from 4 to 10 years. Ten patients (29%) were treated with closed reduction and application of a cast, whereas 25 patients (71%) were treated with open reduction and fixation of the fracture.Conclusions. All patients regained full flexion and strength after 4 to 17 weeks. The fractures that were surgically treated showed no entrapment of the anterior interosseous nerve.

HISTORY A 51-year-old woman was accidentally given an intra-arterial injection of 10 mg diazepam to control an acute claustrophobic anxiety attack. She complained of severe knocking pain in the entire left arm during the injection. On the second day the hand and lower arm were red an swollen and she complained of increasingly feeling cold and having paraesthesias. On the fifth day the radial half of the palm as well as the first to third digits showed livid discoloration. In the further course necrotic areas developed in the palmar aspect of the distal phalanx of the thumb and of the index finger proximal to the middle phalanx. INVESTIGATION Angiography on the tenth day after the injection revealed very poor perfusion of the radial artery as far as the wrist, occlusion of the superficial palmar arterial arch and occlusions of the digital arteries of the five fingers. TREATMENT AND COURSE Infusion of 25,000 IU heparin over 24 h brought no improvement. On the 24th day after the diazepam injection the palmar aspect of the distal phalanx of the thumb and the index finger became necrotic, requiring amputation of the latter and, after removal of necrotic tissue, flap-plasty using subcutaneous soft tissue of the extensor surface of the index finger to cover the defect on the thumb. The patient was without symptoms on discharge and the wounds were healing well. CONCLUSION Every doctor should be aware of the dangers of accidental intra-arterial injection. The slightest suspicion and symptoms require immediate and adequate treatment to save the limb.

Das N.-interosseus-anterior-Syndrom ist ein seltenes, den rein motorischen Nervenast des N. medianus betreffendes Nervenkompressionssyndrom. Klinisch imponiert der Ausfall des M. flexor pollicis longus und des M. flexor digitorum profundus II, was zu dem charakteristischen Bild des „Kneifgriffs“ fuhrt ohne Sensibilitatsverlust. Aus chirurgischer Sicht hat diese Symptomatik besondere Bedeutung im Zusammenhang mit kindlichen Frakturen des distalen Humerus. Anhand eines Fallbeispiels eines 7 jahrigen Jungen mit posttraumatischem Ausfall des N. interosseus anterior nach supracondylarer Humerusfraktur wird diese Nervenlasion, die Differentialdiagnosen, Therapie und Prognose dargestellt und diskutiert.

Es war Ziel der Untersuchung, den Einflus der Dekontamination im Vergleich zu einer Placebomedikation auf die postoperativen Behandlungskosten nach Gastrektomie zu ermitteln. Die Ergebnisse einer prospektiv doppelblind angelegten und placebokontrollierten Multicenterstudie zeigen, das eine perioperative i. v.-Prophylaxe mit Cefotaxim und eine topische Dekontamination mit Polymyxin B, Tobramycin, Vancomycin und Amphotericin B in der Pravention oesophagojejunaler Anastomoseninsuffizienzen hochst wirksam ist. Beim Kostenvergleich der beiden Gruppen wurden nur dem Studienprotokoll entsprechend dekontaminierte Patienten (n = 90) den mit Placebo behandelten (n = 103) gegenuber gestellt, weil der Einflus der Dekontamination auf die Behandlungskosten ermittelt werden sollte. Die oesophagojejunale Nahtinsuffizienzrate betrug 10,6 % bei Placebopatienten (n = 103) und konnte unter Dekontamination (n = 90) hochsignifikant auf 1,1 % reduziert werden (p = 0,0061; Fisher-exact-Test, 2-tailed). Es konnte nur eine asymptomatische Anastomoseninsuffizienz im Gastrografinschluck nachgewiesen werden. Auch die Lungeninfektions- (p = 0,0173) und Gesamtkomplikationsrate (p = 0,0238) waren in der Gruppe der Dekontaminierten signifikant reduziert. Im Beobachtungszeitraum verstarben 9 (8,7 %) der Placebopatienten und 3 (3,3 %) der Dekontaminierten. Die Kostenermittlung umfaste die orale Prophylaxe, Pflegekosten der Normal- und Intensivstation, Nachsorgeklinik, Antibiotica sowie Reoperationen und Interventionen. Sie beschrankte sich ausschlieslich auf die ersten 42 postoperativen Tage. Die Gesamtkosten der Placebogruppe beliefen sich pro Patient auf 20 000,– DM. Die durchschnittlichen Gesamtkosten pro Patient betrugen in der Prophylaxengruppe dagegen nur 16 200,– DM, weil signifikant weniger Patienten fur kurzere Zeitraume intensivmedizinisch behandelt werden musten (p = 0,0082), signifikant weniger Patienten antibiotisch therapiert (p = 0,0232) wurden und die Anzahl der Patienten mit Reoperationen und Reinterventionen geringer war als in der Placebogruppe (p = 0,0909). Die Durchfuhrung einer Prophylaxe zum Preis von 400,– DM senkte die postoperativen Behandlungskosten um 3800,– DM oder 19 %. Die Prophylaxe kann empfohlen werden, weil sie die Morbiditat, die Letalitat und die Kosten der Gastrektomie senkt.

OBJECTIVE Since minitracheotomy has been established in 1984 for prophylaxis and therapy of postoperative sputum retention, numerous publications represent technical descriptions, case reports or empirical results, but only few specific facts related to this method have been investigated. In this study we review the efficiency, complications and late follow-up results of minitracheotomy in a department of general surgery. DESIGN Between 1987 and 1991 we prospectively included 152 intensive-care patients who received minitracheotomy. The average follow-up was 24.2 +/- 6.1 (4-50) months. RESULTS Endotracheal secretion could be sucked off significantly more often after mini-tracheotomy. The rate of endotracheal suction increased from 5.9 +/- 4.5/d to 18.4 +/- 6.1/d (p < or = 0.01). The pulmonary gas exchange improved at the same time. PaO2 level of 78.9 +/- 9.9 mmHg that decreased to critical values of 60.7 +/- 8.9 mmHg, rose after minitracheotomy above the original levels. Although the PaCO2 level remained constant, a compensatory hyperventilation with a rate of 27.3 +/- 6.9/min was normalised by minitracheotomy. Furthermore, the various methods of minitracheotomy were opposed in this study. In the group of minitracheotomy by cricothyroideal stab incision (n = 55) we recorded 5.4% serious complications. In contrast minitracheotomy by the Seldinger technique (n = 87) could be accomplished without any disturbance. CONCLUSION Minitracheotomy seems to be an effective and safe treatment for therapy and prophylaxis of postoperative complications due to tracheobronchial sputum retention in critically ill patients. Manipulation was simplified and rendered more safe by the technique of transcutaneous bouginage.

Die Differentialdiagnose einer Ruptur des M. flexor pollicis longus und M. flexor digitorum profundus II zum N.-interosseus-anterior-Syndrom kann schwierig sein und zu Fehlinterpretationen des klinischen Bild fuhren. Anhand von 2 Fallberichten soll dies aufgezeigt werden. Im ersten Fall fand sich bei klinischem Verdacht auf ein N.-interosseus-anterior-Syndrom eine Spontanruptur des Flexor pollicis longus rechts. In einem zweiten Fall wurde eine operative Exploration der langen Daumen- und tiefen Zeigefingerbeugesehne unter der Annahme einer Ruptur vorgenommen. Hier fanden sich intakte Sehnen. In einer zweiten Operation wurde die Neurolyse des N. interosseus anterior vorgenommen, die zu einer vollstandigen Wiedererlangung der Beugefunktion in den Endgliedern des Daumen und Zeigefingers fuhrte.

Traumatic hip dislocation combined with fracture of the femoral head is a rare condition for which little known in terms of long-term prognosis. The aim of the retrospective study presented here was to evaluate the clinical and radiological outcome of this specific injury.In a 23 year period, 18 patients (17 male) with an average age of 25.6 (range 15-55 years) were treated. There were four type-I, three type-II, no type-III, and 11 type-IV fractures according to the Pipkin classification (1957).The average time to sufficient reduction was 136 min (60-420 min), two by open means. A total of 16 patients were operated for open reduction and internal fragment fixation, 13 through a dorsal approach. All patients filled out a standardized questionnaire, and clinical and radiological examinations were also carried out on average 12.6 years (range 59-247 months) after injury. Four scoring systems were used to classify the outcome: Thompson and Epstein (1951): very good = 1, good = 10, fair = 4, poor = 3; Merle D'Aubigne (1954): very good = 9, good = 5, fair = 0, poor = 4; Harris (1969): Pipkin I = 81 points, Pipkin II = 97 points, Pipkin IV = 73 points (mean); Brooker (1973): grade I = 5, grade II = 1, grade IV = 2.Quality of life was not reduced in most patients in the long term, however three of four patients suffering Pipkin type-IV fractures developed functional restrictions with poor results. We conclude that acute reduction of the dislocated joint and anatomical reconstruction of the femoral head instead of primary hip replacement may end in good to excellent results in type-I and type-II fractures. Due to the young age of these patients, joint reconstruction should always be the first choice even in type-IV fractures with a higher probability of poor prognosis.

Handgelenksfrakturen betreffen am haufigsten den distalen Radius. Seltener sind Frakturen des Os scaphoideum sowie Frakturen und Luxationen der ubrigen Handwurzelknochen, die an dieser Stelle keine Berucksichtigung finden sollen.

We retrospectively reviewed 197 patients who underwent reconstruction with a megaprosthesis of the lower extremity. A cobalt-chrome alloy system was used in 77 patients and a titanium alloy system in 120 patients. The overall infection rate was 20.8% (n = 41). Separated into the 2 prosthesis systems used, an infection rate of 31.2% was found in the patients with a cobalt-chrome-alloy prosthesis and 14.2% in the titanium alloy group of patients (P < .01). Early infection occurred in 5.1% (n = 10) and late infection in 15.7% (n = 31). Selecting 2 identical subgroups for further analysis, the cobalt-chrome alloy prostheses were associated with a significantly higher infection rate, with 5 infections of 26 megaprostheses vs 1 infection of 36 titanium megaprostheses (P < .05).

The therapeutic efficacy of an antimicrobial peptide, human lactoferrin 1-11 (hLF1-11), was investigated in a model of chronic methicillin-resistant Staphylococcus aureus (MRSA) (gentamicin susceptible) osteomyelitis in rabbits. We incorporated 50 mg hLF1-11/g or 50 mg gentamicin/g cement powder into a calcium phosphate bone cement (Ca-P) and injected it into the debrided tibial cavity, creating a local drug delivery system. The efficacy of hLF1-11 and gentamicin was compared to that of a sham-treated control (plain bone cement) ( n = 6) and no treatment (infected only) ( n = 5). The results were evaluated by microbiology, radiology, and histology. MRSA was recovered from all tibias in both control groups ( n = 11). On the other hand, hLF1-11 and gentamicin significantly reduced the bacterial load. Furthermore, no growth of bacteria was detected in five out of eight and six out of eight specimens of the hLF1-11- and gentamicin-treated groups, respectively. These results were confirmed by a significant reduction of the histological disease severity score by hLF1-11 and gentamicin compared to both control groups. The hLF1-11-treated group also had a significantly lower radiological score compared to the gentamicin-treated group. This study demonstrates the efficacy of hLF1-11 incorporated into Ca-P bone cement as a possible therapeutic strategy for the treatment of osteomyelitis, showing efficacy comparable to that of gentamicin. Therefore, the results of this study warrant further preclinical investigations into the possibilities of using hLF1-11 for the treatment of osteomyelitis.

Intramedullary nailing is the treatment of choice for the stabilization of fractures of long tubular bones. An important disadvantage of this method is the increase in intramedullary pressure and the resulting release of fat into the venous blood system during reaming of the medullary canal. We have developed a new type of rinsing-suction-reamer (SSB) in order to minimize these disadvantages. Trials were initiated to investigate whether it is possible to ream the medullary canal with the SSB without pressure increase in comparison with the standard AO-reamer (AOB).Reamed intramedullary nailing was performed in 20 isolated pig femora. The intramedullary pressure was recorded continuously.While stepwise reaming was performed, the pressure only rose above the physiological level in AOB. During insertion of the guide wire and the nail, comparable values were measured for AOB and SSB.Our experiments show that reaming of the medullary canal is possible without a pressure increase using the SSB in comparison with AOB.

Use of intramedullary reamers (IR) is typically associated with pressure generation during the reaming process, which may result in the introduction of fat and marrow particles into the venous system. Thus, a new System was designed in order to avoid pressure generation and thus to reduce the risk of embolic events. In vitro testing was carried out using pig femura. Intramedullary pressure was recorded during drilling with either the new pressure-free intramedullary reamer (PF-IR; n = 10) or a Standard AO-IR (n = 10). For in vivo testing, nailing of the femur was performed in sheep using either the PF-IR (n = 7) or the Standard AO-IR (n = 7). Fat intravasation was measured using echocardiography and the Gurd test. Hemodynamic and pulmonary parameters as well as intramedullary pressure were continuously recorded during the experiments. The animals were then sacrificed and tissue samples were taken from all regions of the lungs. The incidence of lung fat emboli in histological sections was scored in a blinded manner. A finite element analysis was carried out to assess Performance of the PF-IR under load. The in vitro tests showed that the new PF-IR resulted in significantly less intramedullary pressure (15 ± 12 mm Hg) than the Standard AO-IR (813 ±247 mm Hg; p< 0.001, Mann-Whitney-U test). These results were confirmed in vivo. Moreover, the PF-IR group had significantly less fat intravasation (Gurd test) and better hemodynamic and pulmonary values than the AO-IR group. The incidence of fat microemboli in the lungs was reduced by 90% in the PF-IR group. Finite element analysis showed that the new drilling System performed well under load. The newly developed pressure-free IR clearly outperformed a Standard AO-IR. Use of the new PF-IR was associated with low intramedullary pressures, significantly less fat intravasation, and a markedly lower incidence of fat emboli in the lung. This, in turn, may have been the reason for the better hemodynamic and pulmonary values in the PF-IR group.

A .375 Holland & Holland Magnum Winchester Fail Safe bullet was fired against a steel plate. The big-game hunting bullet (17.4 g, approx. 810 m/s) has a solid copper-alloy hollow point design including a lead core limited to the rear portion. The range of firing was 20 m and the angle of impact was 90 degrees. A large fragment (10.9 g) consisting of the main part of the copper portion was deformed in a peculiar manner similar to a tube or ring and wounded the left hand of the person shooting. The unique fragment trajectory strictly against the line of fire and the velocity sufficient to shatter bone after a distance of 20 m can be explained by an extraordinary deformation mechanism. Unlike in tissue, the high resistance of the steel plate caused the lead core in the rear of the bullet to move forward perforating the central copper barrier behind the hollow point cavity. Thus, the peculiar fragment was created. The subsequent backwards acceleration of the ring-like fragment was probably caused by the partly elastic impact of the copper-alloy portion against the hard steel plate. Due to the perpendicular impact resulting in a centric and symmetrical deformation, the fragment moved in a direction exactly backwards along the original line of fire.

From 1990 to 1997, callus distraction of the first metacarpal bone was performed on 34 patients with a traumatic amputation of the thumb, if replantation was not possible. After a period of 7 +/- 11 months (range, 1-48), a corticotomy and continuous distraction with an external fixator was carried out. Of the patients, 31 (91%) were reviewed after treatment. The follow-up period range was 41 +/- 32 months. With this method, the average lengthening of the thumb was 78% in comparison to the uninjured side. Complications were rupture of the callus in one case, four patients suffered a superficial wound infection, and seven patients showed pin tract infection without osteitis. At follow-up examination, 20 patients (64.5%) showed excellent, 9 (29%) good and 2 patients (6.5%) unsatisfying results.

The Essex-Lopresti lesion, a combination of radial head fracture and distal radioulnar dislocation, rarely occurs but nevertheless represents a frequently unknown result after forearm fracture. The responsible physician soon has to initiate surgical treatment to prevent his patient from permanent pain of the wrist. Previously unrecognised distal radioulnar dislocation remains to be an unsolved problem. A generally accepted management concept does not exist. Since rupture of the membrana interossea nearly ever occurs, resection of the radial head is followed by radial shifting and seems to be obsolete under these circumstances. An exemplary case is presented and surgical management in this situation is discussed.

In einem 5-Jahres-Zeitraum (1993-1997) wurden 76Patienten mit einer Achillessehnenruptur operativ in der Technik nach Bunnel versorgt. Ab dem 5. postoperativen Tag wurde mit einer dynamischen Nachbehandlung in einer speziell konzipierten Schiene unter Vollbelastung begonnen. Die gesamte Behandlungsdauer dauerte 6 Wochen. Nach 1 und 2 Jahren erfolgte die Nachuntersuchung von 73 Patienten („drop out“ 3,9%, n=3).

Insgesamt wurden 284 Patienten in die prospektive Studie aufgenommen und nach einem Jahr klinisch nachuntersucht. Die Versorgung der Frakturen richtete sich ausschlieslich nach dem Frakturtyp und unabhangig vom Alter. Die bis zu 65 Jahre alten Patienten und die uber 65jahrigen wurden vergleichend hinsichtlich des funktionellen Langzeitergebnisses ausgewertet. Die Spatergebnisse nach mindestens einem Jahr unterschieden sich weder nach funktionellen, noch nach radiologischen Kriterien signifikant zwischen beiden Gruppen. In beiden Gruppen ergaben sich uber 70% sehr gute und gute Resultate nach der Klassifikation von Gartland und Werley (73,9% bei den uber 65jahrigen und 71,8% bei den jungeren Patienten). Die radiologische Sinterung des Radius war ebenfalls statistisch nicht signifikant. Bei alteren Patienten sind demnach bei vergleichbaren Frakturen ebenso gute funktionelle Ergebnisse erzielbar.

The aim of the present study was to investigate hydroxyapatite cement (HAC) as an in vivo setting composite of tricalcium phosphates to be used as a carrier for the local application of antibiotics in a three-step research program: Elution of gentamicin and vancomycin from HAC in vitro, changes in the mechanical properties of HAC mixed with these antibiotics and in vivo investigation of the efficacy of the delivery system in an experimental model of chronic osteomyelitis. Our data suggest that HAC is a highly biocompatible in vivo setting bone cement for bone void filling. By replacing water with antibiotic solution HAC can be a convincing carrier. Neither the active substance nor the mechanical properties were disturbed by mixing in the used range of concentrations. Because of its prolonged release of high levels of antimicrobial agents this delivery system obtains long-term antibacterial effectiveness locally. Side effects of the antibiotic were not observed. Our in vivo study shows a positive effect on the course of experimental osteomyelitis.

Enchondromas are the most common bone tumors of the hand. In a retrospective study, medical records and radiographs of 112 patients were reviewed. These patients were operated on between January 1973 and June 1997. After extirpation of the tumor, the defect was preferably treated with bone grafting in 102 patients. A malignant transformation (chondrosarcoma) was diagnosed in 2 patients. Follow-up examination of 92 patients with a mean follow-up of 1.6 years (range: 7 months to 14 years) yielded excellent or good results in 76 patients (82.6%), according to the evaluation scheme of Wilhelm and Feldmeier. Four recurrences were probably related to an incomplete resection of the tumor. The authors conclude that enchondromas of the hand should be treated surgically to prove the diagnosis and to prevent a pathologic fracture.

From January 1989 until October 1993, 102 patients with 103 distal radius fractures were included in a prospective study with the Pennig wrist fixator (Orthofix, Srl, Italy). 90.5% of these patients were reviewed with a minimum follow-up of 12 months. Using the functional outcome score according to Gartland and Werley, we obtained 41% excellent, 46% good, 10% fair and 3% poor results. Additional procedures such as K-wires, bone grafting or radio-ulnar stabilizations were carried out in 61% of cases. The complications included five fixator displacements, four of which happened with the prototype used until the first half of 1990. Two major pin-track-infections required surgical intervention, three patients in the beginning of the series encountered irritations of the superficial radial nerve, one pin cut out of the second metacarpal bone and one patient sustained algodystrophy. The results show the significance of an anatomical reduction, the restoration of the radial length seems to be of special importance to obtain good functional outcome. This can not always be achieved with the fixator alone; often additional procedures are required in order to obtain an anatomical joint reconstruction. The advantage of this fixator lies in its lightweight and small-size design as well as in its easy application technique and the possibility to carry out the reduction after mounting the fixator with the double ball joint centered on the fracture level and the carpus.

A quantitative analysis of the injury severity of 40 patients with open pelvic fractures was performed. Data were analyzed using the Statistical-Analysis-System (SAS Institute Inc., Cary, NC) with regard to patients' age, gender, trauma mechanism, classification and nature of the pelvic injury, associated lesions, and mortality. Trauma-scoring included the Hannover-Polytrauma-Score [11], the Pelvis-Fracture-Scale [2] and the Pelvis-Score [19]. Five patients died. The survivors had a mean Polytrauma-Score of 34.1, the nonsurvivors had a mean Polytrauma-Score of 44.6 (p = 0.7; Mann-Whitney-test). The nonsurvivors required highly significant more units of blood transfusions than the survivors (49.4 vs. 14.1; p = 0.003; Mann-Whitney-test). The loss of blood was related to the severity of the injury according to the Polytrauma-Score. There was no significant difference in the Pelvis-Fracture-Scale of survivors and nonsurvivors. Neither there was a significant correlation between the fracture type and the Polytrauma-Score nor between the fracture type and the mortality. The Pelvis-Score--with the variable "bleeding" defined as "major vessel lesion"--was significantly higher in the nonsurvivors than in the survivors (12.0 vs. 4.9; (p = 0.04; Mann-Whitney-test). In conclusion, in this retrospective study the Polytrauma-Score and the Pelvis-Score proved effective regarding some important aspects of the prognostic estimation of the general injury and the pelvic trauma, respectively. The Hannover-Pelvis-Fracture-Scale allows an exact documentation of the pelvic trauma as it pays proper attention not only to the fracture classification but especially to the soft tissue damage.

The aim of our study was to evaluate external fixation in the treatment of unstable distal radius fractures in a long-term follow-up.Within 8 years 174 patients with severely displaced distal radius fractures were included in a prospective study and treated with an external wrist fixator (Orthofix Srl, Italy). A total of 148 patients were reviewed with an average follow-up time of 28 months.Using the functional outcome score according to Gartland and Werley, we obtained 29.3 % excellent, 42.5 % good, 10.3 % fair and 2.9 % poor results; 14.9 % of the patients were not available for follow-up. Additional procedures were carried out in 54.1 % to obtain dorsal stabilization. The list of complications included two major pin-tract infections requiring surgical intervention, one pin cut out of the second metacarpal bone, one fixator dislocation, and one patient had algodystrophy. The length of the radius and joint congruity did not significantly from the situation when the fixator has been removed at the end of the treatment.The results show the importance of anatomical reduction, and especially restoration of radial length, in order to obtain good functional outcome.

A 51-year-old woman was accidentally given an intra-arterial injection of 10 mg diazepam to control an acute claustrophobic anxiety attack. She complained of severe knocking pain in the entire left arm during the injection. On the second day the hand and lower arm were red an swollen and she complained of increasingly feeling cold and having paraesthesias. On the fifth day the radial half of the palm as well as the first to third digits showed livid discoloration. In the further course necrotic areas developed in the palmar aspect of the distal phalanx of the thumb and of the index finger proximal to the middle phalanx.Angiography on the tenth day after the injection revealed very poor perfusion of the radial artery as far as the wrist, occlusion of the superficial palmar arterial arch and occlusions of the digital arteries of the five fingers.Infusion of 25,000 IU heparin over 24 h brought no improvement. On the 24th day after the diazepam injection the palmar aspect of the distal phalanx of the thumb and the index finger became necrotic, requiring amputation of the latter and, after removal of necrotic tissue, flap-plasty using subcutaneous soft tissue of the extensor surface of the index finger to cover the defect on the thumb. The patient was without symptoms on discharge and the wounds were healing well.Every doctor should be aware of the dangers of accidental intra-arterial injection. The slightest suspicion and symptoms require immediate and adequate treatment to save the limb.

The differential diagnosis of the rupture of flexor pollicis longus tendon and profundus tendon to index finger to the interosseus anterior nerve syndrome can be difficult and can lead to misinterpretation of the clinical impression. Two cases are reported to demonstrate this problem. In the first case a spontaneous rupture of flexor pollicis longus was found, when first an interosseus anterior nerve syndrome was suspected. In a second case surgical exploration of flexor pollicis longus tendon and profundus tendon to index finger was done on the assumption of a rupture, that revealed intact tendons. In a second operation neurolysis of the interosseus anterior nerve was carried out with full recovery of flexion of the thumb and index finger.

The interosseus anterior syndrome is a rare nerve compression syndrome that concerns only the motor branch of the median nerve. It is evidenced by paralysis of the M. flexor pollicis longus and M. flexor digitorum profundus II with weakness of flexion of the terminal joint of the thumb and index finger but without sensory loss. From the surgical point of view this complication has special importance because of pediatric fractures of the distal humerus. In this paper we discuss the differential diagnosis, therapy and prognosis of this nerve injury by presenting an illustrative case of a 7-year-old boy suffering a supracondylar fracture of the humerus with a post-traumatic anterior interosseus nerve syndrome.

Recurrences and persistent symptoms of carpal tunnel syndrome after its surgical treatment is most commonly due to inadequacies of the first procedure, recurrent tenosynovialitis and in particular adhesion formation between the median nerve and its surrounding tissue and scars. Because of the encouraging experiences with oxidized regenerated cellulose (INTERCEED) as an absorbable adhesion-barrier in abdominal surgery, we began using INTERCEED in carpal tunnel surgery. In nine patients who underwent division of the flexor retinaculum combined with epineurotomy or synovialectomy, we covered the median nerve with a monolayer of INTERCEED. According to our good experiences concerning handling, compatibility and recovery, the application of INTERCEED might potentially reduce the recurrence rate in carpal tunnel surgery.

The aim of this study was to examine the effect of decontamination as compared to placebo medication on post-gastrectomy treatment costs. The results of a prospective double-blind placebo-controlled multicenter trial indicate that perioperative i.v. prophylaxis with cefotaxim and topical decontamination with polymyxin B, tobramycin, vancomycin and amphotericin B from the day before surgery until the 7th postoperative day is most effective in the prevention of esophagojejunal anastomotic leakage following total gastrectomy. For the cost analysis, only patients who had been decontaminated according to the study protocol (n = 90) were compared to the non-decontaminated patients (n = 103). The esophagojejunal leakage rate was 10.6% in placebo patients (n = 103) and could be reduced significantly to 1.1% in decontaminated patients (n = 90, P = 0.0061; two-tailed Fisher's exact test). There was only one asymptomatic leakage detected on Gastrografin swallow. The pulmonary infection (P = 0.0173) and overall complication rates (p = 0.0238) were significantly reduced in the decontamination group as well. During the observation period, 9 (8.7%) patients in the placebo group and 3 (3.3%) in the decontaminated group died (P = n.s.). Patients were followed up for the initial 42 postoperative days and treatment costs were calculated for this time period only. The parameters compiled in the study pertaining to use of medical resources formed the basis for the determination of the postoperative treatment costs. These were the costs for decontaminating drugs, intravenous antibiotics, reoperations and non-surgical reinterventions as well as daily treatment costs of the general ward, the intensive care unit (ICU) and rehabilitation. The average costs per patient in the placebo group amounted to DM 20,000 while the costs for decontaminated patients were only DM 16,200, which was due to a significantly lower number of patients requiring treatment in the ICU (P = 0.0082), significantly fewer patients requiring i.v. antibiotics (P = 0.0232) and fewer patients with reoperations (P = 0.0909). The prophylaxis employing decontaminating drugs in the amount of DM 400 lowered post-gastrectomy treatment costs by DM 3800 or 19%. The prophylaxis can be recommended, because it lowers morbidity, mortality and the costs of total gastrectomy.