[Mild head injury]. / Leichtes Schädel-Hirn-Trauma. Wann zu Hause, wann in der Klinik uberwachen?

Mild injuries to the head are a common everyday occurrence. Only one out of 30,000 patients suffering mild traumatization of the brain subsequently goes on to develop a complication that requires treatment. Such patients can be identified on the basis of the Glasgow Coma Scale and the determination of risk factors, and these data also serve as an aid for deciding whether surveillance at home or hospitalization is indicated.

[Morbidity and mortality in para-articular femoral fractures in advanced age. Results of a prospective study]. / Morbidität und Letalität bei hüftgelenknahen Femurfrakturen im höheren Lebensalter. Ergebnisse einer prospektiven Studie.

UNLABELLED: This study was designed to determine risk factors and individual dispositions associated with morbidity and mortality in the operative treatment of hip fractures in elderly patients. PATIENTS AND METHODS: In a prospective clinical trial, a consecutive series of 278 patients (mean age: 78.7 +/- 6.2 years) with a hip fracture treated by internal fixation or arthroalloplasty was recorded prospectively concerning preexistent diseases and risk factors. Based upon a multivariate analysis the data were related to perioperative complications and mortality. A follow-up during the first postoperative year was performed to determine mortality rate and causes of deaths. Polymorbidity within the meaning of 3 preexistent diseases was present in 117 cases; a solitary disease was found in 25 patients. Only 19 patients were without significant risks representing a comorbidity of 93.2%. In 64.4% diseases of the cardiovascular system were detected followed by diabetes mellitus (21.9%) and diseases of the respiratory tract (20.1%). RESULTS: In the postoperative course systemic complications were observed in 118 patients indicating a general morbidity of 42.4%. According to the preexistent diseases recorded, cardiovascular complications (25.5%), obstructive ventilatory diseases (10.1%) and pneumonias (12.2%) were the most common complications. During hospital stay 21 patients died (mortality: 7.6%). A total of 76 patients died during the first postoperative year corresponding to a mortality rate of 27.3%. Postoperative complications were observed in patients with polymorbidity at 68.4% which differs significantly with the morbidity of low-risk patients at 23.6% (p < 0.001). Multivariate analysis revealed a combination of polymorbidity and age beyond 78 years as significant risk factors towards morbidity and mortality. In detail, a prevalence of cardiovascular insufficiency, pulmonary disease and disturbance of renal function was found to be a significant disposition. CONCLUSIONS: During the preoperative course high risk patients should be identified according to the data presented above in order to take all measures necessary in critical care during the perioperative period. Furthermore, the results underline the importance of an early operative treatment within a posttraumatic period of 12-24 hours. Concerning the method of fracture stabilization procedures allowing a primary full loading should be favoured with regard to early rehabilitation.

[Laser-assisted induction of arthrosis]. / Arthroseinduktion durch Lasereingriffe.

In a controlled experimental trial the induction of gonarthrosis following laser-assisted meniscectomy was assessed. A XeCl excimer laser (lambda = 308 nm, pulsewidth 20 ns, repetition rate 10-70 Hz, radiant exposure 10-40 mJ/mm2) and a continuous wave Nd:YAG laser (lambda = 1064 nm, energy density 21-93 W/mm2) were employed in connection with 600-micrometer and 800-micrometer quartz fibers, respectively. In an animal model, effects on the remaining meniscus and the corresponding cartilage surfaces were studied in vivo within an observation period of 6 months. For evaluation of the pathogenesis in laser induced arthrosis, morphological and biomechanical studies were performed on native human menisci. Compared to conventional meniscectomy, laser energy effectively prevents further fibrillation of the meniscal structure. A remodelling of the meniscus did not occur in any experimental group. The degree of reactive synovitis, assessed by macroscopic and histologic scoring, was significantly greater following Nd:YAG laser surgery than after excimer laser resection and conventional surgery (P < 0.05). On X-ray, more progression of degenerative changes was observed following laser procedures than after conventional meniscectomy. The proteoglycan content in the femoral cartilage corresponding to the zone of meniscus resection was significantly lower in the laser group than after conventional meniscectomy (P < 0.01), which substantiates macroscopic and radiographic findings indicating degenerative derangement of the hyaline cartilage. On light microscopy and scanning electron microscopy of meniscus specimens, excimer laser irradiation led to well-delineated resection borders with a mean transitional zone of 20 micrometers, whereas menisci exposed to Nd:YAG laser irradiation presented extensive vaporization zones with the surface covered by an amorphous structure. Menisci irradiated by excimer or Nd:YAG laser energy showed significantly increased rigidity (P < 0.05 and P < 0.01); the maximum value of radial strain at flexion was lower following Nd:YAG laser irradiation (mean 1.5 +/- 0.3%) and following excimer laser irradiation (mean 2.4 +/- 0.3%) than in non-irradiated menisci (mean 3.0 +/- 0.5%). These observations lead to the conclusion that laser-assisted meniscectomy promotes the early manifestation of gonarthrosis by virtue of a reduced femorotibial contact area and alterations in the biomechanical properties of the meniscus.

[Prognostic significance of surgical morbidity in management of coxal femoral fracture in the elderly patient]. / Prognostische Bedeutung der Operationsmorbidität in der Versorgung der koxalen Femurfraktur des betagten Menschen.

The influence of operative morbidity on clinical long-term results is evaluated in a prospective study employing a consecutive series of 120 patients (mean age, 82.5 +/- 4.7 years) with operatively treated fractures of the coxal femur. Perioperative complications which were observed in 37.5%, with a predominance of urinary tract infection (n = 26), bronchopneumonia (n = 16) and cardiac decompensation (n = 4), were significantly associated with a pertrochanteric fracture localization (p < 0.05), prolonged latency from trauma to surgery (p < 0.01), and a prevalence of three and more internal diseases (p < 0.01). At 1-year follow-up patients with a perioperative complication had a significantly worse performance scoring (p < 0.01) than individuals with an unimpaired perioperative course. This leads to the conclusion that perioperative morbidity decisively influences functional outcome in the elderly patient.

[Morphologic, biomechanical and experimental in vivo studies of laser-assisted meniscus resection]. / Morphologische, biomechanische und experimentelle In-vivo-Untersuchungen zur laserassistierten Meniskusresektion.

Arthroscopic meniscectomy is associated with an irregularly shaped resection rim leading to further degeneration and a considerable rate of iatrogenic lesions to the adjacent cartilage. In a controlled experimental trial the clinical value of laser-assisted meniscectomy was assessed with special reference to whether laser application can overcome these common shortcomings of conventional surgery. An XeCl excimer laser (lambda = 308 nm, pulsewidth: 20 ns, repetition rate: 10-70 Hz, radiant exposure: 10-50 mJ/mm2) and a continuous wave Nd:YAG laser (lambda = 1064 nm, energy density: 21-93 W/mm2) were used with 600 microns and 800 microns quartz fibers, respectively. The study comprised an analysis of morphological and biomechanical characteristics of the meniscus exposed to laser treatment and an evaluation of reparative and degenerative changes following laser meniscectomy in an animal model. Light microscopy and scanning electron microscopy showed that excimer laser irradiation leads to well delineated resection borders with a transitional zone measuring 20 microns. Specimens exposed to Nd:YAG laser irradiation present extensive vaporization zones with the surface covered by an amorphous structure. Menisci irradiated by excimer or Nd:YAG laser energy show increased stiffness; the maximum value of radial strain at flexion is reduced, with a mean value of 1.5 +/- 0.3% following Nd:YAG laser irradiation and a mean value of 2.4 +/- 0.3% following excimer laser irradiation, compared with 3.0 +/- 0.5% in nonirradiated menisci. In vivo experiments show that laser energy prevents fibrillation of the menisceal structure, which was common in the control group; menisceal regeneration was not observed in any of the experimental groups. The extent of cellular infiltration in the synovial membrane is significantly increased following laser meniscectomy, indicating reactive synovitis (P < 0.05). Radiographs show enhanced progression of degenerative changes following laser surgery compared with conventional menisectomy; measurements of the subchondral bone density in the tibial plateau reveal significantly increased density following Nd:YAG (P < 0.01) and excimer laser irradiation (P < 0.05), confirming these observations. The proteoglycan content in the femoral cartilage corresponding to the zone of meniscus resection is significantly lower in the laser group than in the group subjected to conventional meniscectomy (P < 0.01). These results have various implications for clinical practice.(ABSTRACT TRUNCATED AT 400 WORDS)

Laser synovectomy of the knee joint. Experimental results on a new approach to joint surgery.

The clinical impact of laser-assisted synovectomy was investigated in a two-part study consisting of a morphological part with morphometric measurements and an in vivo part using an animal model. A continuous wave Nd:YAG laser (lambda = 1064 nm; power density 18-106 W/mm2; exposure 0.5-5 s) and a XeCl excimer laser (lambda = 308 nm; pulsewidth 20 ns; repetition rate 10-70 Hz; energy density 20-45 mJ/mm2; exposure 10-60 s) were employed in combination with a fused silica fiber with diameters of 600 microns and 800 microns, respectively. In vitro study. Under light microscopy, synovium exposed to Nd:YAG laser energy presents a transitional band (with a mean diameter of 2 mm) with three zones: a carbonized area, a vesicular zone, and a coagulated part. In contrast, pulsed UV-laser irradiation leads only to a narrow transitional zone extending 10-70 microns. Scanning electron microscopy reveals a clear-cut surface following excimer synovectomy, whereas Nd:YAG laser irradiation forms an irregular surface with numerous bursts due to vaporizing activity. In vivo study. Partial synovectomy of the knee joint was performed in two groups of 14 New Zealand white rabbits with a 1064-nm Nd:YAG laser and a 308-nm XeCl excimer laser. Another 14 animals synovectomized in a conventional technique served as a control. Morphological examination and histopathological scoring of the synovial membrane were performed 4 days to 6 months after the operation. The progress of synovial regeneration following excimer laser synovectomy did not differ from observations in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Biomechanical aspects of the over-the-top reconstruction of the anterior cruciate ligament]. / Biomechanische Aspekte der "Over-the-Top"-Rekonstruktion am vorderen Kreuzband.

Strain characteristics of anterior cruciate ligament grafts inserted in the over-the-top technique were studied in an in-vitro model. A cruciate ligament attached at the center of the anatomical insertion sites provides a constant preload and accomplishes the principle of isometry during the whole range of motion. In contrast, the over-the-top reconstructed ligament shows an increasing laxity proportional to the degree of joint flexion due to an approach of the attachment areas. These observations indicate that a sufficient ligament function is not provided so that the over-the-top reconstruction cannot be recommended as method of choice.

[Clinical results of Palmer's primary cruciate ligament insertion without augmentation]. / Klinische Ergebnisse der primären Kreuzbandreinsertion nach Palmer ohne Augmentation.

The clinical importance of primary cruciate ligament reconstruction without augmentation-plasty is discussed on the background of long term results following 51 operations. Based on standardized methods of evaluation 38 patients had a very good and good result, in eleven cases the operation lead to a fair and in two cases to a poor result. A significant instability with a pivot shift grade III was recorded in two cases: twelve patients showed a low degree of instability whereas 37 patients had regained full stability. The coincidence of a cruciate ligament lesion and a rupture of a collateral ligament had a negative influence on the postoperative long term result (p less than 0.01). Our results suggest that a primary repair without augmentation-plasty is a qualified procedure for stabilizing the knee joint in cases with an acute femoral rupture without accompanying collateral lesions. In patients with old ruptures or a complex joint lesion primary repair with augmentation is recommended.

[Ender nailing for stabilization of pertrochanteric fractures in advanced age. A safe procedure?]. / Die Endernagelung zur Stabilisierung pertrochantärer Frakturen im hohen Lebensalter. Ein risikoarmes Verfahren?

The postoperative course of 138 patients with a pertrochanteric fracture treated by nailing according to Ender is analysed with regard to the operative morbidity and lethality. As secondary factors associated with morbidity the specific and unspecific rate of complications, the lethality, the perioperative loss of blood and the duration of postoperative hospitalisation are evaluated. Specific complications occurred in 27%, unspecific complications in 50%, and the rate of hospital mortality was 15.2%, 60.9% of patients required a postoperative transfusion to compensate the perioperative blood loss. In contrast to other authors we cannot regard Ender nail osteosynthesis as a lowrisk procedure with a low operative morbidity. When choosing the treatment procedure alternative methods of stabilisation should be taken into account. An intensive postoperative care is of utmost importance in elderly patients.

[Management of femoral neck fracture with an intermediate (dual head) prosthesis in geriatric surgery]. / Die Versorgung der Schenkelhalsfraktur mit einer Intermediär- (Duo-Kopf-) Prothese in der Alterschirurgie.

Between 1980 and 1989 in 195 elderly patients with fractures of the femoral neck a duo-cup endoprosthesis was inserted. The average age was 78 years, most of them were high risk patients with sometimes more than 2 preexisting diseases. The hospital mortality after hip replacement was 9.7%, specific complications like protrusio acetabuli and shaft fractures were not observed. In 2 cases immediate postoperative luxation required reintervention. The incidence of infection was significantly reduced to 2.4% after antibiotic therapy. When discharged from hospital, 86% had a good functional result. We regard hemiarthroplasty with duo-cup endoprosthesis as an acceptable alternative to total hip replacement in elderly patients with fractures of the femoral neck.

[Pathogenesis of Achilles tendon rupture]. / Zur Pathogenese der Achillessehnenruptur.

The etiology underlying ruptures of the Achilles tendon is analyzed in 65 patients in a retrospective clinical study. A typical mechanism leading to a rupture of the tendon consists in an extraordinary tension force applied on a tendon in a state of active preload. A spontaneous rupture was observed in merely 3 cases. In 21 out of 65 patients risk factors such as hypercholesterolemia, hyperuricemia and arteriosclerosis were present. A systematic application of corticosteroids proved to be a decisive factor in the etiology of a tendon rupture. There was no correlation between the presence of associated risk factors and the degree of histological degeneration. During follow-up 3 re-ruptures and 6 ruptures of the contralateral tendon were registered. Our results lead to the conclusion that the etiology of the rupture of the Achilles tendon is based on a multifactorial disposition which includes the mechanism of injury, preexistent risk-factors as well as degenerative changes in the tendon structure.

[Additional intra-abdominal injuries in multiple-traumatized patients with pelvic fractures. Difficulties in diagnosis and therapy]. / Intraabdominelle Zusatzverletzungen bei Polytraumatisierten mit Beckenfrakturen. Schwierigkeiten in Diagnostik und Therapie.

Between 1.1. 1987 to 31.12. 1988 178 polytraumatized patients were treated with 62 patients demonstrating pelvic fractures. In 58% of patients injured by rapid falls pelvic fractures were diagnosed compared to only 25% of all patients with traffic accidents. 22% of all polytraumatized patients suffered from intraabdominal injuries, with raise to 47% in patients with pelvic fractures. To avoid unnecessary laparotomies caused by questionable positive lavage ultrasonography is recommended because of its high accuracy and lack of any diagnostic morbidity. 27 of 29 patients with intraabdominal injuries underwent laparotomy. One patient with an isolated kidney rupture was treated conservatively and one patient died before operation. The most common intraabdominal lesion was rupture of liver in 52% and splenic injury in 10 patients. Lesions of the intestine were diagnosed in 11 patients mostly in combination with parenchymal injuries. Concerning the therapeutical approach a conservative treatment is recommended in order to shorten time of operation in concern of the progressively increasing retroperitoneal hematoma. The overall mortality rate was 36%. Most common cause was direct injury of CNS in 14 patients of whom 6 patients suffocated during the first 24 hours. Unstable dislocated pelvic fractures were primary stabilized by external fixator which may help to avoid further progressive retroperitoneal hematoma.

[Clostridium perfringens infection following intramedullary nailing of an open femur shaft fracture]. / Clostridium perfringens-Infektion nach Marknagelung einer offenen Femurschaftfraktur.

In a 47-year old patient, clostridial bacteraemia and local gas gangrene developed following osteosynthesis of a penetrating femoral fracture by a medullary nail. The operation had been performed in a post-injury interval of 14 days. The first clinical symptoms did not appear until 6 days after surgery. Operative treatment by large local incisions, debridement and drainage with the medullary nail left in situ accompanied by administration of penicillin G resulted in recovery. In the case presented here, local haematoma and debris due to the osteosynthesis procedure had probably induced a proliferation of clostridia leading to gas gangrene. The delay in development of signs and symptoms and the benign appearance of the wound resulted in delay in early diagnosis and appropriate treatment of this potentially life-threatening entity. Ultrasound proved to be a valuable tool in the evaluation of local changes. Even in performed in an appropriate postinjury interval, medullary nailing bears a potential risk of inducing a clostridial infection, so that the indication must be very strict.

[Experimental results of biomechanical strength of the meniscus suture in the area of zone II]. / Experimentelle Ergebnisse zur biomechanischen Belastbarkeit der Meniskusnaht im Bereich der Zone II.

The biomechanics of the sutured meniscus were studied in an experimental in vitro assembly. The characteristics of load transmission and changes in radial tensile strength were analyzed under static load conditions. With the knee joint in extension the longitudinally ruptured meniscus presents only slight changes with regard to load transmission and radial stretch. Increased gaping of the anterior horn accompanied by a compensatory radial compression in the posterior segment occurs with flexion and contralateral tibial rotation. Repair of the meniscus results in partial compensation of these phenomena, although both changes are still reproducible to a lesser extent. A vertically applied suture provides more mechanical stability than horizontal fixation. Static weight bearing is of lesser significance in producing separation of the reconstructed meniscus. Postoperative care following meniscus reconstruction must include immobilization, although early weight bearing can be permitted.

[Incidence of complications and early mortality in surgical management of coxal femoral fractures]. / Zur Komplikationsinzidenz und Frühletalität bei der operativen Versorgung coxaler Femurfrakturen.

In a retrospective study the clinical course of 393 patients treated for proximal femur fractures is evaluated. Intraoperative complications occurred in 2% whereas early complications related to the operative procedure were seen in 19.8% and unspecific complications in 36.8%. Factor analysis proved the following items to be associated with a high risk of complication: age (p less than 0.01), preexistent diseases, kind of operative procedure (p less than 0.05) and the lapse of time between trauma and operation. The extraordinary high incidence of unspecific complications is explained by the prevailing proportion of elderly patients with a corresponding multimorbidity. A decrease in complications and lethality can be achieved by early operative treatment. With regard to the necessity of early mobilization we prefer a hemiarthroplasty in fractures of the femoral neck for elderly patients. Stable pertrochanteric fractures are treated by a dynamic hip screw whereas instable pertrochanteric fractures are an indication for Ender nailing.

[New aspects in the treatment of pneumonitis (author's transl)]. / 45. Die Schocklunge - ein neues Behandlungsprinzip

Two groups of patients suffering from pneumonitis received different treatments and were compared retrospectively. The first group (38 patients) was treated with heparin and aprotinin. The overall mortality was 50 percent; of the patients who were artifically ventilated 64 percent died. The second group (60 patients) was treated with heparin, fresh-frozen plasma, nicotinic acid, methylprednisolone, and alpha-receptor blocking agents. In this group the overall mortality was 26.5 percent and the mortality among the patients who were artificially ventilated was 33 percent. These results lead the authors to feel that the treatment of pneumonitis with aprotinin is no longer indicated.

[Problems of the one- or two-stage operations of carcinoma on the left part of the colon (author's transl)]. / Probleme der ein- oder mehrzeitigen Operationsverfahren am linken Colonabschnitt beim Dickdarmacarcinom

260 radically operations of carcinoma of the colon were carried out from 1963-1972; 163 of these operations have been done on the left part of the colon. The results of the one- and two-stage procedures were compared with the related literature. 46.5 per cent of the resected lymphnodes were affected by carcinoma. An expanded resection was done in 24 cases complicated with tumour perforation in adjacent organs. Among 147 one-stage left-side resections 20 insufficiencies of the anastomoses (13.5 per cent) were observed. To protect the anastomoses in 8 cases a coecal fistula and in 4 cases a fistula of the transverse colon were performed. There was no insufficiency of the anastomose. In 4 cases of two-stage precedures insufficiencies of the anastomose were found at the extraperitoneal replaced anus. The mortality was found to be 11.6 per cent. Peritonitis occurred in 18 cases: after 6 right sited and 12 left sited resections.

[On-line monitoring of cardiac output with a new pulse contour computer (author's transl)]. / Kontinuierliche Uberwachung des Herzminutenvolumens nach herzchirurgischen Eingriffen mit einem Computer

A new pulse contour cardiac output computer, operating from the aortic pressure wave form was tested in cardiac surgical patients. Reference cardiac output was measured by thermal dilution technique. Satisfactory agreements were obtained between the thermal dilution and the COC-pulse-contour cardiac outputs when rapid variations of cardiac output occurred as well as slowly developing changes. The results show that the computation of the stroke volume from the aortic pressure wave form offers a simple, clinically useful method for on-line monitoring of cardiac output in critically ill patients. Possible error sources are discussed.

Ischemic tolerance of the human heart during extracorporeal circulation: clinical experience.

Our clinical experiences with ischemic tolerance of the human heart under the condition of ECC during the last 15 years allow us to state the following points: 1. The healthy human myocardium can be exposed to ischemia without danger on the basis of 15 min and a myocardial temperature of 35 degrees C. This time can be prolonged following the described value of Q10=2. 2. The previous damaged human myocardium is usually not able to cover this range. Frequently ischemic load within these limits causes functional deterioration. So, in such cases ischemic tolerance has to be applied on a distinct lower base. 3. Occasional transgressions of the described ischemic tolerance time without a fatal result do not allow us in our clinic to leave the effective principles in daily routine.