[Promoting Young Talents in Trauma Surgery through Students-On-Call]. / Nachwuchsförderung in der Unfallchirurgie durch studentischen Rufdienst.

BACKGROUND: Due to restrictions on admission to medical school, changing claims to an optimized work-life balance and occupational perspectives, surgical professions in particular are struggling with strategies to motivate young academics. Surgical disziplines aim towards a profound transfer of knowledge and pique student's interest by ensuring a sustainable education at university. OBJECTIVES: The goal of this study was to evaluate a Students-On-Call System (SOCS) and to identify a financial benefit. MATERIALS AND METHODS: In this study the SOCS was compared pre-/postevaluation using questionnaires and the supporting X­rays within a curricular teaching module of orthopedic trauma surgery, with students in the fourth semester of specialism and those in the practical semester at medical school. RESULTS: The students of SOCS showed significantly better results prior to the course and afterwards than the two other groups. By establishing SOCS medical students get involved into the treatment of emergency patients in the trauma resuscitation unit (TRU) and operating room (OR). Students get the chance to enhance their comprehension of diagnostics, therapy and decision making in surgical context. This highly valuable traineeship combines a minimized teaching effort with an effective motivation of young academcis for the surgical profession. A SOCS has reduced the workload of medical colleagues. Establishing SOCS spare the residents being on call and results in reduced costs of 23,659.86 Euro per year. CONCLUSION: The results presented show that the SOCS leads to an excellent cost-benefit balance, which has been established in multiple surgical departments at the medical school of the University of Göttingen. Apart from practice-oriented surgical teaching, the SOCS is a way of promoting successful young talent saving resources in the medical on-call services.

[Conservative therapy for metatarsal 5 basis fractures - retrospective and prospective analysis]. / Konservatives Therapiekonzept bei Metatarsale-V-Basisfrakturen - Retrospektive und prospektive Analyse.

BACKGROUND: Approximately 30 % of all bone injuries are foot metatarsal fractures. Metatarsal V basis fractures occur most frequently. The classification is done into the tuberosity avulsion fractures, Jones fractures and stress fractures of the proximal diaphysis. The treatments of non-displaced fractures are generally conservative. The indication for surgical treatment depends on the load and the associated refracture rate. There are different types of treatment of these fractures. We present a possible approach to conservative treatments and show how different therapies affect healing of metatarsal V basis fractures and social reintegration of patients. METHODS: A retrospective study consisted of 68 patients analysed during a 9-year period, whereas for a prospective analysis 18 patients were included for a period of 3 years. The treatment was performed using either a splint, closed bandage of the ankle or special Göttinger Anklesplint bandage, with immediate pain-oriented full load in all groups. The subjective and objective treatment results were analysed accoding the Göttinger Phillips score. RESULTS: In retrospect, the fracture consolidation was observed after 8.1 weeks full load-bearing was achieved after 6.3 weeks on average. In the prospective analysis, the osseous consolidation occurred after 6.2 weeks, and the full load was applied after 1.7 weeks. After 10 weeks the treatment with the Anklesplint bandage was assessed with 105 points of a maximum 110 points of the Phillips score. The Anklesplint bandage was also the cheapest option in the cost comparison. CONCLUSION: Using the immobilisation of the metatarsal supination with the Anklesplint bandage the metatarsal V basis fractures can heal in a regular way. The functional outcome is better in comparison to the that with other treatments and it is a cost-effective treatment.

[Soft tissue protective and minimally invasive osteosynthesis for metacarpal fractures II-V]. / Weichteilschonende minimal-invasive osteosynthesen bei mittelhandfrakturen II-V.

OBJECTIVES: Soft tissue protection, closed reduction or short open reconstruction of length, rotation and articulation of metacarpals. Aftercare: early active exercises protected by additive orthesis. INDICATIONS: Closed or grade 1 open fractures with significant dislocation, deviation of rotation or loss of length. Fractures of the metacarpal, metaphyseal and extensive oblique or spiral fractures. Intra-articular fractures of the distal metacarpal that can be reduced without a step in articular surface. Proximal partial articular fractures that can be reduced without a step in articular surface in the mini-open technique. CONTRAINDICATIONS: Grade 2 and 3 open fractures, extensive bending fractures in the middle third and absence of the palmar bony restraint. Multifragmentary proximal and distal metaphyseal fractures that cannot be reduced by closed methods. Intra-articular fractures that cannot be reduced without a step in articular surface. SURGICAL TECHNIQUE: Intramedullary antegrade or percutaneous K-wires or mini-open repair screw/K-wire osteosynthesis. POSTOPERATIVE MANAGEMENT: Two or three finger forearm cast for about 3-4 days, subsequent metacarpal orthesis, an integrated hard cast Longuette (Combicast) SoftCast™ is preferred beginning with active and passive exercises of the fingers. RESULTS: In this retrospective study we analyzed metacarpal (MC) fractures that were treated with minimally invasive osteosynthesis during the period 2009-2010 and 65 patients (mean age 34.8 years, female/male 13/52) with 75 metacarpal fractures were enrolled. Fractures affected MC-2 (n=9), MC-3 (n=5), MC-4 (n=15) and MC-5 (n=46). Removal of implant was performed after 6-12 weeks in 44 patients. All fractures except one showed bony healing in x-ray. At 2-months follow-up 61 patients could be evaluated and at 27-months (15-37) follow-up 34 patients could be evaluated according to the DASH score. Median DASH score results were 16 points (SD 49, n = 61) after 2 months and median DASH score results were 5 points (SD 23, n = 34) after 27 months (15-37). Range of motion was limited in 6 patients after 8 weeks (range 6-12 weeks) with a deficit in flexion of finger to distal palmar crease of 1.0 cm (range 0.5-1.5 cm), 2 patients showed a deficit in finger extension of 10° in the metacarpophalangeal joint. One patient showed restricted finger extension of 15° in the proximal phalangeal joint after tendon rupture and tendon reconstruction. Complications were observed, such as circumscribed redness in two patients at the entry point of k-wires which was managed by early removal of the implant. Perforation of the k-wire occurred in one patient with subcapital and diaphyseal fracture and was managed by plate osteosynthesis. One diaphyseal transverse refracture healed after plate osteosynthesis, three circumscribed cases of paresthesia occurred, one at the entry point of the K-wires and two at the level of fracture.

[What are the clinical results of operated fractures of the talus?]. / Wie sind die klinischen Ergebnisse operativ behandelter Talusfrakturen?

UNLABELLED: Our study focuses to determine the medium range results of function and radiological findings of operatively treated fractures of the talus. Furthermore we had the intention to investigate risk-factors for posttraumatic arthrosis and necrosis of the talus. MATERIAL AND METHODS: We included all 41 patients (w/m: 13/28) operated between 1995-2000 with talus neck, corpus or dislocated fracture of the talus edge (open/closed: 11/30). Fractures were classified according to Hawkins: type 1: 6 x, type II: 17 x, type III: 7 x, type IV: 3 x, 8 x dislocated peripheral fractures. 39 x screw osteosynthesis, 2 x K-wire fixation were done and 12 additive transfixation with fixateur externe. Score: AOFAS Ankle-Hindfoot-Scale, radiological assessment according to the Bargon score. 34 patients, mean age 35 years (12-60), were followed up clinically with an average of 4 years (24-72 months). RESULTS: AOFAS Score: pain (40 points): diameter 31 [10-40]; function (50 points): diameter 39 [14-50]; alignement (10 points):diameter 7 [0-10]; degree of arthritis due to the Bargon scale: 0 degree: 5x,1 degree: 8x, 2 degrees: 7 x, 3 degrees: 7 x. COMPLICATIONS: 4 x necrosis of margin of the wound, 1 deep infection, 5 necrosis of the talus bone. The severity of the fracture was 1 x type II according to Hawkins 3 x type III and 1 x type IV. 3 of the 5 patients who developed a talus necrosis had 28 or 38 soft tissue damage. One patient had an imminent compartment syndrome. One patient who suffered a polytrauma was operated six days post injury. Second operation: 1 Syme amputation due to necrosis of the talus subsequent to an infection. 4 x arthrodesis of the upper ankle joint and 5 x arthrodesis of the subtalar joint due to posttraumatic arthritis. CONCLUSION: Primary screw osteosynthesis is the treatment of choice depending on the lesions of the soft-tissue and accompanied injuries in combination with a fixateur externe. Nevertheless the primary osteosynthesis is not able to prevent necrosis of the talus completely, that occurs in a frequency of 15%. Risk factors for a posttraumatic arthritis in addition to the type of fracture and the result of reconstruction are an accompanied soft tissue defect and local capsule-band complex with necessary temporary transfixation. Early plastic reconstruction of defects can reduce the time of immobilisation and allows motion therapy. The functional results are positive compared with the radiological results that showed arthritis in 70%.

[Free scapular or parascapular flaps for soft tissue damage accompanying talus or calcaneus fractures]. / Freier Paraskapular-/Skapularlappen bei frakturbegleitendem Weichteildefekt an Talus oder Kalkaneus.

BASIS: Fractures of the talus or calcaneus with accompanying soft tissue damage require precisely planned treatment to prevent infection of the wound over time, especially in severely injured patients. MATERIAL AND METHODS: Seven patients with fractures of the talus or calcaneus and accompanying 2nd and 3rd degree open or 3rd degree closed soft tissue injuries were followed up retrospectively. These patients were operated on between January 1999 and January 2006 with free fasciocutaneous scapular or parascapular flaps. The average age was 34 (range 16-54). Follow-up was at 6-36 months. RESULTS: Osteosynthesis was primarily in six cases, post-primarily in one, and in four cases exterior fixation was used additively. Temporary vacuum therapy was performed for a mean of 28 days (6-42). Parascapular, scapular, and Latissimus dorsi flap coverage was performed six, one, and one times, respectively. Six flaps healed without complication. One necrosis of a parascapular flap occurred and made a Latissimus dorsi flap necessary. In one case of donor-site wound dehiscense, a local rotation flap became necessary. There was no joint infection or osteomyelitis. Bony consolidation was achieved within all fractures. CONCLUSION: Traumatic soft tissue damage must be taken into account when primary or secondary internal fixation is performed and should influence the choice of implant. Free fasciocutaneous parascapular or scapular flaps are a powerful tool for preventing infection if local flaps are not sufficient to achieve stable soft tissue coverage.

[Epithelioma cuniculatum plantare in the region of a skin scar due to mechanical trauma. Insurance law aspects of scar carcinomas]. / Carcinoma cuniculatum plantare im Bereich einer mechanisch-traumatisch verursachten Hautnarbe. Versicherungsrechtliche Aspekte des Narbenkarzinoms.

We herein report a case of a highly differentiated verrucous squamous cell carcinoma of the sole of the left forefoot ("epithelioma" or "carcinoma cuniculatum plantare") that had--as a specific feature--developed within a preexisting long-standing skin scar due to an earlier occupational crush injury. Because of expansive tumor growth extending to the metatarsal bones and penetrating the tissue between the tendons, an ultrashort amputation of the hindfoot was performed according to the method of Chopart. The pathogenetic mechanisms possibly underlying the formation of scar carcinomas are discussed. For judgement of legal liability insurance questions, the criteria indicating a causal relationship between traumatic scars and cancer development are presented.

[Minimally invasive removal of a broken femoral nail]. / Minimal-invasive Entfernung eines gebrochenen Oberschenkelmarknagels.

The removal of a broken femoral nail due to refracture or nonunion is always a surgeon's challenge. Especially the distal fragment is often difficult to remove. We describe here another minimally invasive and safe method using the antegrade and retrograde approach to the femur.

[Resection of the calcaneus as a treatment option in osteitis following an open calcaneus fracture]. / Die Resektion des Fersenbeins als Therapieoption bei Osteitis nach offener Fersenbeinfraktur.

Surgical treatment of calcaneal fractures is demanding due to the poor musculocutaneous coverage. Infection with osteitis is a severe complication with open fractures. The appearance of osteitis requires aggressive surgical treatment including amputation in case of persistence, leading to considerable invalidism. We report the case of an 37-year-old mason with an grade III open calcaneal fracture caused by a fall. Osteitis appeared after primary osteosynthesis with open reduction and eventually--after several revisions--required a calcanectomy. By preservation of the forefoot and midfoot and thanks to sufficient orthosis treatment the patient was able to return to his profession after eight months.

[Initial experiences with interposition of a silicon sheet in reconstruction of the wrist joint]. / Die ersten Erfahrungen mit der Interposition einer Silikonfolie bei der Wiederherstellung des Handgelenkes.

We report about the possibility to improve the condition of incongruent joint surfaces by temporary interposition of silicon sheet in the radiocarpal joint. The implant was used in 18 patients with damaged joint surfaces, either for the primary operation or for revision. It was removed four to six weeks after having started physiotherapy. Our results show that this procedure can improve the condition of joint surfaces. Silicon-induced granulation tissue can even uprough parts of the joint surface and thus reduce chondral friction. We did not see any complications.

[Preoperative MR-mammography in diagnosed breast carcinoma. Useful information or useless extravagance?]. / Präoperative MR-Mammographie bei bekanntem Mammakarzinom. Sinnvolle Mehrinformation oder sinnloser Mehraufwand?

In a retrospective study the value of MR mammography in cases of radiological well-known carcinoma of the breast was evaluated preoperatively in 76 cases of histopathologically verified carcinoma one lesion was missed by MR imaging. Compared to the results of conventional X-ray mammography additional malignant lesions were detected in 5 patients ipsilaterally and in another 8 patients contralaterally by MR mammography only. In additional 4 cases MR mammography demonstrated suspicious lesions contralaterally, but histopathology revealed benign lesions. The therapeutic procedure was changed in 15 cases (18.5%) due to the findings of MR imaging: Ipsilateral mastectomy instead of tumorectomy (n = 5) or primary chemotherapy instead of operation (n = 1); contralateral additional tumorectomy (n = 3) or mastectomy (n = 2) by carcinoma and open biopsy (n = 4) by benign finding.

[Experience with the Ender hooked plate in the management of 42 scaphoid pseudarthroses]. / Erfahrungen mit der Ender-Hakenplatte bei der Versorgung von 42 Skaphoid-Pseudarthrosen.

To treat the pseudarthrosis of scaphoid, there exist many operative procedures. We describe the method of H. G. Ender: A hook plate fixes the main bone fragments and exerts a pressure on the in-between lying bone transplant. We report on 42 patients operated on using the Ender-plate. In 39 cases a follow-up was possible. 95% of the patients had a consolidation of the bone, in two cases a further operation was required. 36 patients complained preoperatively of pain during exercise and only seven patients had the same complaints after the operation. In some cases, a minor reduction of the motion had to be taken into account to achieve painfree movement.

[Corrective interventions for malunited fractures of the distal end of the forearm. Indications, choice of procedure, results]. / Korrektureingriffe nach in Fehlstellung verheilten Brüchen am distalen Unterarmende. Indikation, Verfahrenswahl, Ergebnisse.

Malunion, non-union, as well as painful ligamentous joint instability following fractures to the distal forearm may seriously compromise the function of a hand. Forty-seven surgically treated cases, thirty-nine of which were followed up, are presented in order to point out the problems of such lesions. Retrospective evaluation of the lesion is absolutely mandatory, as it often dates back to childhood. Management should take clinical findings as well as the patient's functional demands on his hands into consideration, but without overestimating therapeutic potentials.

[Rupture of the Achilles tendon. Causes and late results after surgical management]. / Achillessehnenrupturen. Ursachen und Spätergebnisse nach operativer Versorgung.

In a retrospective study 143 cases of surgically treated Achilles tendon ruptures were evaluated. The patients most commonly were male and between 31 and 40 years old. The majority of ruptures were sport injuries, mostly caused by indirect violence. The histological examination of the tendon very frequently revealed degenerative changes. 55 patients with unilateral Achilles tendon rupture were postoperatively evaluated by clinical examination and sonography. Because of the excellent functional and cosmetical results surgery remains the appropriate treatment of Achilles tendon rupture.

[Sonographic assessment of gliding characteristics and gliding bed of the Achilles tendon following surgery]. / Die sonographische Beurteilung von Gleitverhalten und Gleitlager operierter Achillessehnen.

A bilateral comparative ultrasound evaluation of 55 patients 1-10 years after unilateral Achilles tendon rupture showed that glide was reduced by varying degrees in the tendon in a dynamic evaluation. Disturbed tendon glide was often the cause of persistent disability. In the evaluation of the glide characteristics it was helpful to allocate patients to three categories, structural changes in the tendon bed also being taken into consideration. According to this classification, 56% of the Patients had either good or only slightly reduced glide characteristics, whilst 42% demonstrated severe reductions. It was striking that it was not so much alterations in the tendon itself, but rather changes in the tendon bed that had the more deleterious effects on glide characteristics.