Applying circular posterior-hinged craniotomy to malignant cerebral edemas.

Malignant brain edemas are often fatal, regardless of whether they are treated conservatively with sedation, blood pressure management, mannitol-therapy, hyperventilation and hypothermia, or non-conservatively with routine trepanation. Unfortunately, temporal trepanation may result in significant brain damage through herniation of the cerebrum at the edges of the trepanation openings. In one case of a 26-year-old male with severe head injury, a circular posterior-hinged craniotomy (CPHC) was performed after an ineffective unitemporal trepanation for evacuation of an acute subdural hematoma. This ultimately successful operation prompted experimental and morphologic investigations on a new surgical procedure for lowering intracranial pressure (ICP). In 12 of 15 human cadavers, an experimentally ICP was lowered by a CPHC with between 9-21 mm of frontal elevation of the calvaria. Using computer simulation, the frontal elevations of the calvaria were "virtually" performed on 3D reconstructions from CT scans of skulls, and the intracranial volume gained was measured with a computer software program. The volume increase of the cranial cavity showed a relatively constant relation to the cranial capacity and was increased by 6.0% (+/-0.4%) or 78 cm(3) with a 10 mm elevation and by 12.4% (+/-0.7%) or 160 cm(3) with a 20 mm elevation. There were no significant differences with skulls of different ages or ethnic origin; however, a significant effect of gender (F = 7.074; P < or = 0.013) on the gained volume in percent of the cranial capacity for the 20 mm elevation was observed. This difference can be explained by the inverse relationship between volume increase and cranial capacity (r = -0.507; P < or = 0.004).

[Complications in surgical management of pelvic fractures]. / Komplikationen der operativen Versorgung von Beckenfrakturen.

In the care of pelvic injuries complications arise because of organizational and technical factors, some of which are described here. The following measures are important: autotransfusion, emptying the bladder and catheterization, checking and protection of the colon, correct management of the operation table, and prophylactic measures to avoid thrombosis. From an operational/technical point of view, it is most important that a larger with good exposure route be chosen that takes the anatomical structures into account. Of 123 cases, 20% were not ideally reduced. Twice massive bleeding occurred from the A. glutea superior, once the sacral dura was opened without any adverse effects, infection occurred 8 times and 10 times peroneal paralysis was observed.

[Controlled arched osteotomy for the correction of malposition in healed fractures]. / Geführte bogenförmige Osteotomie zur Korrektur in Fehlstellung geheilter Frakturen.

The guided arched osteotomy and the oscillating saws specially developed for this operation have proven to be a competent technique to correct malposition following fractures. Its essential advantage is that the equipment offers the possibility to perform an exact and protective cylindrical cut, which assures exact parallel, relatively large contact areas and hence a favourable postulate for the healing action. Moreover, the saddle-shaped contact area offers protection against unwanted rotation. Furthermore, the shortening of the bone is limited to the width of the very thin saw cut performed. An additional advantage is offered in the possibility to carry out further correction without the necessity of a repeated osteotomy, should the x-ray control show that the primary correction has not turned out satisfactorily.

[Percutaneous management of intra-articular fractures of the interphalangeal joints of the fingers]. / Perkutane Versorgung von intraartikulären Frakturen der Fingermittelglieder.

Open reduction of intra-articular fractures of the proximal interphalangeal joints of the fingers requires extensive exposure of the bone. This often leads to disturbance of the delicate mechanics of the joint. The results are, therefore, sometimes not as good as expected. The authors describe a new method of treatment, using the image intensifier with magnification. The fragments are reduced by means of a golf-club shaped instrument, which is inserted into the medullary cavity through a small skin incision and a drill hole in the bone. After reduction, the position is held by a framework of percutaneously introduced thin Kirschner-wires.

[Percutaneous management of osseous avulsions of extensor tendons and lateral ligaments of the fingers with the hooked wire]. / Die perkutane Versorgung von knöchernen Ausrissen der Strecksehnen und Seitenbänder an den Fingern mit dem "Hakendraht".

A new method of percutaneous treatment of some fractures of the fingers is being described. With the use of a magnification table, fitted onto the X-ray intensifier, evulsion fractures of extensor tendons or collateral ligaments can be reduced and fixed by means of a K-wire. After insertion, the end of the wire is being bent in the shape of a hook ("wire hook"), into which a pull-out wire is inserted. By anchoring the wire-hook at the opposite side of the finger under tension, the fragment is held in position by the hook. After four weeks the wire-hook is cut below its anchorage and can easily be removed by the pull-out wire. Technique and results of 85 patients are being presented.

[Pseudarthrosis of the scaphoid]. / Die Pseudarthrose des Scaphoids.

For the treatment of scaphoid non-unions, innumerable curative and palliative operations have been recommended. Of the curative operations, the various methods of bone grafting give the best results, whereas screw fixation is not satisfactory. Bone pegs with a cortical graft are no longer used because of technical difficulties. Corticocancellous grafts (Matti-Russe) yield bony union in almost 90% of cases. The combination of corticocancellous grafts with plate stabilization gives the highest rate of bony union (99%). A cure should therefore always be attempted in all non-union cases, with the exception of cases already involving severe, generalized osteoarthritis or extensive necrosis of the scaphoid. Of the different palliative methods, the early results of prosthetic partial or total replacement of the scaphoid are satisfactory. Late results are less satisfactory, with a high rate of complications and carpal collapse. With severe osteoarthrosis, proximal carpectomy, especially the transscaphoideo-lunate resection, gives good results. Intercarpal arthrodeses have been disappointing. Radiocarpal arthrodesis results in a pain-free, strong wrist; however, there is complete loss of motion, whereas denervation gives satisfactory results in 57% and preserved mobility of the wrist.