Arthroscopic partial meniscectomy: a 12-year follow-up and two-step evaluation of the long-term course.

The long-term results after arthroscopic partial meniscectomy of 119 patients with a mean follow-up of 12 years are presented in this study. The same series of patients had an earlier follow-up 4 years postoperatively. Thus, an evaluation of the actual long-term course and not only a single result after partial meniscectomy is presented. Arthroscopic partial meniscectomy is shown to be the definitive means of therapy for meniscal lesion of the knee joint; 91.7% of patients had an excellent or good result 4 years after surgery, and 78.1% rated excellent or good 12 years after surgery. Full recovery regarding ability to work and sports activity level was achieved in a very high percentage of patients. Early results were mostly representative and did not change significantly during the long-term course for the isolated meniscal lesion. The factor with the highest impact on long-term results was damage to the articular cartilage, which did not influence knee function for several years after surgery but became increasingly symptomatic over time after 5 years and more. Only 62% of patients with additional cartilage damage rated excellent and good 12 years after surgery, in contrast with 94.8% good and excellent results in patients with isolated meniscal tears. Similar observations were made for the untreated rupture of the anterior cruciate ligament.

[Arthroscopic intra-articular drainage as the therapy of choice in meniscus ganglia of the knee joint]. / Die arthroskopische intraartikuläre Drainage als Therapie der Wahl bei Meniskusganglien des Kniegelenks.

The meniscusganglion of the knee is rare but it's an indication for the operation, because it is painful and in the most cases it is connected with an injury of the meniscus. Between 1987 and 1992, 23 patients with meniscusganglion were operated only with the method of the inner drainage. There was no recurrence. We have seen that the concept of the arthroscopy of the knee with the inner drainage of the meniscusganglion is an easy and effective treatment with all the advantages of the arthroscopy.

Dissociation of frontal and parietal components of somatosensory evoked potentials in severe head injury.

Reports on the topography of SEPs in non-comatose patients have drawn attention to a second thalamo-cortical loop connecting the thalamus with the frontal cortex, which has a close anatomical relation to the fronto-limbic structures frequently damaged in severe head injury (SHI). We studied whether the frontal component (P20/22) of the somatosensory evoked response (SEP), known to be due to a generator different from that of the traditionally analysed parietal SEP component (N20), would be differently affected by SHI. Moreover, we examined whether its analysis would improve the prognostic evaluation in the Glasgow outcome scale (GOS) after 3-6 months. In 50 patients examined within 72 h after the injury we found a dissociated impairment of frontal and parietal components in 24% of the recorded SEPs. When both frontal and parietal components were used as predictors, discriminant analysis correctly classified 94% of the patients into good (GOS good recovery and moderate disability) or poor (GOS severe disability, persistent vegetative state or death) outcome groups. Classification was less accurate and misclassifications grosser when considering parietal or frontal parameters alone. Our results show that (i) the evaluation of frontal components provides information different from that of the parietal SEPs, confirming the presence of different generators, and (ii) a combined analysis of the two components improves the prognostic evaluation with regard to the global outcome.

[Arthroscopy of the shoulder joint. Technique, indications, surgery and complications]. / Arthroskopie des Schultergelenks. Technik, Indikationen, Operationen und Komplikationen.

Diagnostic and operative arthroscopy of the shoulder joint has gained considerable importance in traumatology and orthopedic surgery over the last years. Injuries of the limbus glenoidalis, in particular traumatic shoulder luxation, injuries of the rotator cuff, infection of the glenohumeral joint and unclear posttraumatic pain are indications for diagnostic and operative arthroscopy. Arthroscopy of the shoulder is a procedure, which offers exact diagnosis and the possibility of immediate surgery at the same time. The technique of the shoulder joint arthroscopy has to be carried out carefully and according to a standard protocol. The complication rate of around 5% of shoulder arthroscopy has not to be neglected.

Intestinal infarction after nonabdominal trauma; association with cerebral trauma.

Nonocclusive bowel infarction in nonabdominal trauma has been ascribed to periods of hypotension. However, to our knowledge only 17 cases have been reported, and hypotension was not always found. We studied the frequency and possible causes of intestinal infarction in all patients treated at our traumatologic intensive care unit from 1977 through 1986 (n = 2350). Intestinal infarction was diagnosed at the time of surgery or autopsy; patients with pre-existing vascular disease were excluded. We found 12 patients (incidence: 0.5%) of age 45 +/- 20 years (mean +/- SD). All had severe cerebral trauma [Head and Neck Abbreviated Injury Scale (AIS) score: 4-5, admission Glasgow Coma Scale (GCS) score: 6.5 +/- 3.8]. Eight patients suffered from additional injuries. The Injury Severity Score (ISS) was 27 +/- 7. All patients received ventilator assistance continuously before the diagnosis of intestinal infarction or death. The leading symptom of intestinal infarction was sepsis and multiple organ failure with abdominal distention. Five patients with favorable cerebral prognosis underwent surgery: one survived with good cerebral and gastrointestinal recovery. Four patients did not have surgery because of a poor cerebral prognosis. Three patients died of their cerebral trauma before intestinal infarction was clinically manifested. The data show that early diagnosis in ventilated patients with head injuries is extremely difficult because of the heterogenicity of this group of patients, the low frequency of the complication, and the complexity of the clinical picture. Although patients inevitably were exposed to several agents or situations associated with intestinal infarction, the ubiquitous causes were dehydration and diuretic therapy.

[Injuries of the large brain-feeding arteries]. / Verletzungen der grossen hirnversorgenden Arterien.

Among 2923 severely injured patients in the period 1980-1988, 17 had injuries or large supraaortic arteries. The incidence was 0.58%, with an overall mortality of 53%. In 75% of survivors there was a persistent neurological deficit. We treated 5 penetrating (A. carotis 4, A. vertebralis 1) and 12 nonpenetrating (A. carotis 11, A. vertebralis 1) injuries. In all penetrating carotid injuries (4) repair was performed on admission and mortality was 50%; 1 of 2 survivors has postoperative hemiparesis. Localization of nonpenetrating carotid injuries (11) was intrathoracic (2), in the neck (7) and intracranial (2). Main complication of nonpenetrating extracranial carotid injuries is neurological deficit (7/9) due to thrombosis (3) or stenosis (4) with embolism (2). Surgery was performed in 3 cases comprising pseudoaneurysm in 2 and concomitant aortic rupture in 1. Mortality was 44%, and 80% of survivors had persistent neurological deficits. Extracranial carotid injuries (n = 13) carried a mortality rate of 83% in occluded and 29% in nonoccluded vessels (p less than 0.05). Location of carotid injury in the neck (n = 11) carried a mortality of 55%, and intracranial (n = 2) of 100% respectively. Duplex-Doppler scanning of carotid arteries is a safe, noninvasive method which is essential in blunt carotid artery trauma. Prognosis is dependent upon the size of cerebral infarction. Once neurologic deficit has been established for more than 24 hours, reconstruction of the artery should be postponed and performed only for complications (pseudoaneurysm or embolization). Clamping of arteries without hypothermic circulatory arrest or shunt should be avoided. The danger of rupture in dissection and pseudoaneurysm is slight.(ABSTRACT TRUNCATED AT 250 WORDS)

[Simple references of the differential blood picture in assessing the immune status of immunologically compromised severely injured patients]. / Einfache Hinweise des Differentialblutbildes auf die Abwehrlage des immunologische belasteten Schwerverletzten.

Infectious complications threaten the survival of severe traumatized patients in the intensive care unit. Major cause is a secondary immunodeficiency syndrome as a consequence of overloading the immune system by tissue debris and microbial antigens. Antigen presenting cells of the monocyte-macrophage line become activated unspecifically and produce immunosuppressive monokines, which modulate the T- and B-cell systems and weaken the specific immune response to antigens. In 150 severe injured patients (mean ISS 31; 15 patients died due to infections) we found that a decrease of lymphocytes below 1000/microliters and an increase of monocytes up to more than 1000/microliters within the first 24 hours correlate with developing infection in such a manner, that the lymphocyte/monocyte-quotient on day 1 was 2.0 in survivors and 0.9 in subjects, who died due to infections.

[Immunosuppression caused by surgery and severe trauma]. / Immunsuppression durch Operationen und schwere Traumen.

The present prospective study was performed to describe physiological immunosuppressive effects dependent on minor surgical interventions and an immunodeficiency syndrome after major surgery and severe trauma. Parameters of cellular and humoral immunity were monitored in 64 patients of the Department of Surgery of the University Hospital Zurich preoperatively and on days 1, 2, 3 and 4 after selective surgery or polytrauma. 22 patients were multiply traumatized (mean ISS 34.7 +/- 13), 14 patients underwent Y-grafting of the abdominal aorta, 11 resection of colorectal carcinoma, 8 cholecystectomy and 9 inguinal herniotomy. There could be seen a decrease of parameters of cellular immunity (absolute lymphocyte count, CD-4-/CD-8-cell-ratio and release of IL2-receptors), a decrease of humoral defense (immunoglobulins and complement factors) and an increase of macrophage activation (serum levels of neopterin).

[Surgery of traumatic aortic rupture]. / Die Chirurgie der traumatischen Aortenruptur.

This report describes the clinical presentation, diagnosis, surgery and results of patients with acute traumatic rupture of the aorta in a series of 21 consecutive patients. Direct cross-clamping without additional methods of spinal cord protection was used in 18/21 patients (86%). Direct suture was possible in 12/21 patients (60%). In the remaining patients, the repair was carried out by interposition of a Dacron graft. Overall mortality was 7/21 patients (33%). However, in 3 patients with severe polytrauma irreversible brain damage was the cause of death whereas 2 patients died from septicemia and myocardial infarction, respectively. No paraplegia nor paraparesis occurred in the surviving patients which were operated by direct cross-clamping of the aorta and rapid reanastomosis without additional methods of spinal cord protection.

[Intestinal necroses in severely injured patients without abdominal trauma]. / Darmnekrosen beim Schwerverletzten ohne abdominales Trauma.

Bowel necrosis in the critical trauma patient without abdominal involvement or preexisting vascular disease is a known but rare complication. During 1977-1986 we observed 31 cases in 2530 patients. Symptoms were unspecific, and since most of the patients were artificially ventilated, pain and tenderness were of little diagnostic value. Twenty-three patients presented with paralytic ileus, fifteen with diarrhea, and four with melena. In eleven patients diagnosis was made clinically, and in twenty patients at autopsy. Twenty-three patients died from septic shock, six from cerebral complications, and one from myocardial infarction. Risk factors for bowel necrosis were fluid restriction, hypotension, hypoxemia, venous congestion, vasoconstrictive drugs, paralytic ileus, and constipation.

[Arthroscopic surgery--current status and perspectives]. / Arthroskopische Chirurgie--heutiger Stellenwert und Perspektiven.

The morbidity after arthroscopic surgery is low; a hospitalization is not necessary in most patients. The possible operations of the knee joint include removal of loose bodies, resections on meniscus, plicae and synovium as well as more complicated procedures as suturing of a meniscus, total synovectomy and operations in patients with osteoarthritis. The advantage of the arthroscopic operation compared with arthrotomy is well documented in meniscal resection (shorter treatment, stay in the hospital and sick leave, reduced costs, and nevertheless excellent results) whereas the indication and clinical value of other arthroscopic procedures (i.e. suturing of a meniscal tear, lateral release, abrasion-arthroplasty) still are discussed. Diagnostic and operative arthroscopy of the shoulder joint has found its place and will certainly improve our knowledge on significance and treatment of disorders and injuries of this joint. In selected cases, an arthroscopy of the elbow, the hip, the ankle, the wrist or the temporomandibular joint offers important diagnostic information and may allow operative treatment. Arthroscopic surgery is technically difficult and not without problems. However, the rate of complications is extremely low (0.56%). Infections occur in significantly less than 1% of the cases. In veterinary medicine, therapeutic arthroscopy is used mainly in horses, but arthroscopies have been performed in the ox, the cow, the pig, the dog, the cat, and the rabbit. Modern joint surgery includes arthroscopic techniques; the training of trauma surgeons and orthopedic surgeons in arthroscopy is therefore mandatory.

[Immunologic changes and infection in severely injured patients]. / Immunologische Veränderungen und Infektion beim Schwerverletzten.

The severity of major surgery determines the extent of immunodeficiency which follows. The most pronounced immunodepression is found after severe blunt trauma; in polytraumatized patients the alterations of many measured parameters correlate with the injury severity score (ISS) i.e. with the severity of the injuries. Infection is also followed by many changes in the immune response. A score including serum concentrations of IgA, beta 2-microglobulin and percentage of monocytes was found to be predictive for the first 3 days after trauma with regard to subsequent occurrence of infection. In the first post-trauma day the lymphocyte-monocyte ratio correlates with the probability of survival or death by infection. Pneumonia occurred in 47% and septicemia in 22% of 150 polytraumatized patients ventilated artificially for more than 24 hours. The first signs of these infections were already present during the first 5 days, i.e. in the period of the most severe immunodeficiency. The preliminary results of a pilot study with immunomodulation by thymopentin are encouraging and show a significant decrease in the frequency of infections.

[Open knee joint injuries (including vascular and nerve lesions)]. / Offene Kniegelenksverletzungen (einschliesslich Gefäss- und Nervenläsionen).

Immediate definitive reconstruction of all damaged structures leads to better results than delayed operations. If direct closure of the joint is not possible, local rotational flaps, muscle flaps or free skin-fat tissue flaps (i.e. a scapular flap) may be used. In injuries of the popliteal artery, the interposition of a saphenic vein graft is preferable to local reconstruction of the artery. Nerve injuries are the only exception to comprehensive primary repair. Reconstruction in these lesions is usually done later when all wounds are healed. The postoperative treatment includes the use of continuous passive motion whenever possible.

[Knee arthroscopy today]. / Die Kniearthroskopie heute.

Arthroscopy is not only the most reliable diagnostic tool in disorders of the knee joint but it also allows a one-step procedure of diagnosis and therapy in many cases. Most arthroscopic operations can be performed without hospitalisation. Post-operative morbidity is usually low. An excellent or good result was achieved in 91% of arthroscopic partial meniscectomies. Costs were reduced by sFr 6000 to 7000 for arthroscopic operations compared with arthrotomy. The advantage of most arthroscopic procedures performed today has been proven; however, the clinical value of others (i.e. arthroscopic suture of meniscal tears, repair of cruciate ligaments and abrasion-arthroplasty) is still not clear. The frequency of complications is low (0.56%), and infections occur in less than 1%.