Unfallchirurgie最新文献

Heparin-induced thrombocytopenia type II (HIT II) is the most severe complication during prophylactic treatment with low doses of heparin. Five cases demonstrate the life-threatening consequences of this immune-mediated thromboembolic disease. In order to improve prognosis it is most important to start therapy just before diagnosis is assured by laboratory tests. First choice treatment is the low-molecular-weight heparinoid Orgaran. In patients with an episode of HIT II both low-molecular-weight heparin and unfractionated heparin will be contraindicated for a life time.

Cultivation and transplantation of autologous keratinocytes has been used in the last 15 years to treat complicated wounds of different origin. In spite of excellent technical advancements and clinical experiences cultured keratinocyte grafting still is associated with practical limitations. Application of hyaluronic acid ester membranes as carrier substrate for the transfer of keratinocytes allows improved graft handling: reduces total time required for tissue cultivation and furthermore enhances vitality of the keratinocytes because of possible grafting at semiconfluence.

For trauma surgeons the compliance with and keeping to well organized and planned courses of action is obligatory. This is valid as well for the highly sensitive areas of preclinical emergency treatment, the primary treatment in the hospital and the exceptional management in polytrauma, as for treatment of solitary injuries of the musculo-skeletal system. Despite considerable activities--so far voluntarily--(optimization of courses of action, classification systems for injury grades, algorithms and close-meshed further education) control mechanisms are demanded by politicians and insurance companies. Therefore, comprehensive quality control is strived for in all different types of insurance coverage systems. In spite of justifiable restraints against control mechanisms, which oppose increasingly medical freedom in diagnostics and treatment, only cooperation with and proficient guidance of the often self-appointed quality assurance personnel is useful.

During 41 procedures of intramedullary nailing of femoral and tibial fractures the primary surgeon and the first assistant wore ring dosimeters on their dominant index fingers. While the average fluoroscopy time per procedure was 4.6 min the average dose of radiation to the dominant hand of the primary surgeon was 1.27 mSv and 1.19 mSv to the first assistant. The dose limit for the extremities is 500 mSv per year recommended by the International Commission on Radiological Protection. Extrapolation of the average dose of the primary surgeon and first assistant per procedure of 1.23 mSv leads to the result, that the recommended dose limit of 500 mSv would only be exceeded if more than 407 intramedullary nailing procedures are carried out per year. The duration of fluoroscopy-time correlated with the radiation dose of the hands of the surgeons, though it was determined by phantom measurements that the majority of radiation exposure occurred during brief exposures of the hands in the direct X-ray beam on the X-ray tube near side of the patient.

Thirty-one revisions for aseptic or septic loosening of knee arthroplasty have been performed between 1983 and 1995. In 18 cases we had loosening of uni- or bicondylar prosthesis and in 13 cases a tricompartmental revision arthroplasty. With an average of 53 months (1.5 to 13 years) after the last operation 21 patients could be examined. Main reasons for failure of uni- and bicondylar prosthesis were as well a proceeding of the arthritis in other compartments, instability, incorrect alignment and other reasons depending on the surgical technique. We found similar reasons in aseptic loosening of total knee arthroplasties including wrong choice of non-constrained condylar prosthesis. Seven cases of late infection affected semi-constrained prosthesis. Two of the reimplantations in a 2-stage procedure failed. Using the Insall-Score in the follow-up the patients reached 71.9 points in the knee score and 58.9 points in the functional score. Patients with former aseptic loosening reached better results than these with septic loosening. 38% were absolutely painfree, 14% complained about permanent pain. Unlimited walking was found 5 times, none of the examined persons was unable to walk. Main problems in revision surgery concern reconstruction of a good alignment and the management of bone loss.

Forty-four patients undergoing elective hip joint operation were analyzed to assess whether a new slit-suction drainage is less painful than the regular Redon-suction drainage. Main endpoint of the study was the effectiveness to draw off secretion and the pain at the time of removal of the drainage. Other endpoint was the rate of postoperative complications. At the time of removal patients with slit drain rarely complained about pain (p < 0.01). On contrary, patients with Redon drain always complained about pain. Clotting were seldom shown in slit drains and were frequently shown in Redon drains. Both slit drains and Redon drains were effective to drain secretion. As the new slit drain was more comfortable for patients following hip joint repair slit drain should always be used as suction drainage.

The sensory innervation of the rabbit anterior cruciate ligament was studied by retrograde tracing technique using wheat-germ-agglutinin-horseradish-peroxidase (WGA-HRP) and Fast Blue as neuronal tracers. Injection of the tracer into the ligament was followed by histo- and immunohistochemical investigation of labelled nerve cell bodies located in the dorsal root ganglia. In 4 animals we injected the tracer into the joint cavity to label general joint afferents. The segmental distribution of retrogradely labelled neurons following injection into the anterior cruciate ligament (L6, L7, S1) is significantly different from the distribution pattern after injection into the knee joint (L4-S2). Retrogradely labelled nerve cells innervating the anterior cruciate ligament were further investigated using immunohistochemical and morphometric analysis. The sensory innervation of the anterior cruciate ligament is therefore comprised of at least 2 different qualities of sensory afferent nerves: 1. Small neurones immunoreactive to the inflammatory peptide substance P most likely transmitting nociceptive information centrally (44%). 2. Large, presumably fast conducting A-fibre-afferents characterized by neurofilament proteins transmitting proprioceptive information from corpuscular mechanoreceptors (43%). The results of this study put further weight to the importance of the sensory role of the anterior cruciate ligament using neuroanatomical and immunohistochemical techniques.

Hundred and twenty-eight supracondylar fractures of the humerus were studied retrospectively after an follow-up time of 4.3 years (1 to 17.8 years). In 87 cases (68%) the operative procedure was the closed reduction and percutaneous crossed-pin fixation for 19 fractures type III (56%). 22 fractures type II (76%) and 46 fractures type I (85%), whereas 41 fractures were treated by open reduction and crossed-pin fixation. The findings were evaluated according to "Flynn's criteria" leading to the following results: "excellent" 77 times (60.2%), "good" 44 times (34.4%) "fair" 3 times (2.3%) and "poor" 4 times (3.1%). Our results show that with approximately 50% of all fractures type III the treatment by closed reduction and percutaneous crossed-pin fixation leads to a very good long-term result. On the other hand, rotated or interponated fractures type I and II require an open reduction and crossed-pin fixation. Independent of the type of fracture, the closed reduction and percutaneous crossed-pin fixation should always be taken into consideration. Exceptions are open fractures and those with multiple fragments.