[Innovative 3D imaging]. / Innovative 3D-Bildgebung.

Intraoperative 2D fluoroscopy is often performed for repositioning and implant control. However, this does not always provide the details needed to reliably detect joint steps or incorrect repositioning. Over the last few years, intraoperative 3D imaging has been established and further developed. Multiple studies demonstrate an advantage and better intraoperative control through 3D imaging. Examples are the upper ankle, the proximal tibia and the distal radius; the rates of intraoperative revisions with digital volume tomography (DVT) are between 20-30%. Technical advancements, such as metal artifact reductions, automated plane setting, automated screw detection, and robotic DVT devices, facilitate intraoperative operation, shorten surgical time, and provide improved image quality. By processing the data sets in the form of an immersive, computer-simulated image in terms of "augmented reality" (AR), increased precision can be achieved intraoperatively while reducing radiation exposure. The implementation of these systems is associated with costs, which are offset by cost savings from avoided revisions. Adequate counter-financing is still lacking at the present time. Intraoperative 3D imaging represents an important tool for intraoperative control. The current data situation makes it necessary to address the routine use of 3D procedures, especially in the joint area. The indications are becoming increasingly broader. Technical innovations such as robotics and AR have significantly improved 3D devices in recent years and offer high potential for integration into the OR.

[Distortion of the cervical spine : Pathophysiology, diagnostics, treatment and assessment]. / Distorsion der Halswirbelsäule : Pathophysiologie, Diagnostik, Therapie und Begutachtung.

Distortion or whiplash trauma of the cervical spine is an injury pattern associated with motor vehicle collisions and typically occurs after rear impact collisions, but is not limited to this type of collision and accident. The vast majority of these injuries are low-grade injuries according to the Quebec Task Force (QTF) classification, whereby no objective morphological correlates can be determined in clinical and radiological examinations. The prognosis is predominantly favorable and the condition is self-limiting; however, care must be taken with respect to complex courses with chronic pain and the manifestation of neuropsychiatric complaints. Due to the mechanism of the accident this injury pattern is particularly frequent in accidents associated with third party liability insurance claims. The discrepancy between subjective complaints and the presence of objective findings is a particular challenge for the assessment by the medical expert.

S100ß as a novel and accessible indicator for the presence of monocyte-driven encephalitis in AIDS.

AIMS: The pathogenesis of human/simian immunodeficiency virus encephalitis (HIVE/SIVE) remains incompletely understood, but is associated with alterations in the blood-brain barrier. At present, it is not possible to easily determine if an individual has HIVE/SIVE before post mortem examination. METHODS: We have examined serum levels of the astroglial protein S100ß in SIV-infected macaques and show that it can be used to determine which animals have SIVE. We also checked for correlations with inflammatory markers such as CCL2/MCP-1, IL-6 and C-reactive protein. RESULTS: We found that increased S100ß protein in serum correlated with decreased expression of the tight junction protein zonula occludens-1 on brain microvessels. Furthermore, the decrease in zonula occludens-1 expression was spatially related to SIVE lesions and perivascular deposition of plasma fibrinogen. There was no correlation between encephalitis and plasma levels of IL-6, MCP-1/CCL2 or C-reactive protein. CONCLUSIONS: Together, these data indicate that SIVE lesions are associated with vascular leakage that can be determined by S100ß protein in the periphery. The ability to simply monitor the presence of SIVE will greatly facilitate studies of the neuropathogenesis of AIDS.

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients.

BACKGROUND: Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear. OBJECTIVE: To compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients. METHODS: A multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher's exact tests, Mann-Whitney U-tests and adjusted analysis of variance (ANOVA). RESULTS: Forty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17-86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up. CONCLUSIONS: Our findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

Prevalence of dental fluorosis in German schoolchildren in areas with different preventive programmes.

In a retrospective study in two different regions of Germany, 1,041 fifteen-year-old pupils were examined for dental fluorosis. The adolescents had taken part in different caries prevention programmes. There were 746 subjects in the study group and 295 subjects in the control group. For each participant, specific aspects of early development, diet and fluoride exposure in group prevention programmes and at home were determined by means of questionnaires. The Thylstrup-Fejerskov index was used to classify the fluorosis scores on the buccal surfaces of teeth 11, 12, 13, 14, 15 and 16 after compressed air drying of the teeth. Binary logistic stepwise regression analyses were conducted to identify associations between fluorosis and potential influence factors. A distinction was made between early and late developing tooth parts. The significance level was set at alpha = 0.05. Fluorosis prevalence in the regions studied was 7.1 and 11.3%, respectively. The difference was not statistically significant (p = 0.052; chi square). Binary logistic stepwise regression analysis revealed that 'early start of toothbrushing' was a statistically significant predictor of dental fluorosis in the early-mineralizing enamel (OR = 1.99, p = 0.027). For the late-mineralizing enamel no single independent variable was identified as a significant predictor of dental fluorosis.

[Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation]. / Versorgung von bikondylären Tibiakopf-Frakturen mit einem unilateral platzierten winkelstabilen Plattensystem.

BACKGROUND: This study was initiated to evaluate early results of a locked screw plate for unilateral fixation of bicondylar fractures of the tibial plateau. Emphasis was laid on malreduction, secondary loss of reduction, union rate, and infection. MATERIAL AND METHODS: A case series of patients with AO/ASIF 41-C type fractures treated with the less invasive stabilization system for the proximal lateral tibia (LISS PLT) were prospectively followed up until 11-13 months after surgery. Malreduction and malalignment were defined as an intra-articular step-off of 2 mm or more or as a malalignment in the frontal or sagittal plane of more than 5 degrees. RESULTS: Sixty-eight patients with 69 fractures were involved. Fourteen fractures were open. Primary bone grafting was performed in 13 patients. Significant malreduction was seen in 16 patients. Sixty-two (91%) patients returned for follow-up. All but one fracture healed eventually. The number of infections was low (4 superficial, 1 deep). Nine patients had a significant loss of reduction. Of 54 patients outcome scores were good to excellent in 47 patients on the Lysholm score (average 87.2) and in 44 patients on the Rasmussen score (average 26.7). CONCLUSION: We concluded that unilateral locked screw plating is a good alternative in the treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

[Inferior epigastric artery. An atypical source of bleeding in pelvic fracture]. / A. epigastrica inferior. Atypische Blutungsquelle bei Beckenfraktur.

The most common mechanism of pelvic fractures after blunt trauma is lateral compression of the pelvis. Most of these fractures are of slight severity but it is possible, that a life-threatening hemorrhage can appear. The inferior epigastric artery is an atypical bleeding site but it has to be considered in the search of the origin of the hemorrhage. Diagnostic tools are ultrasound, computed tomography and angiography. After external fixation of the pelvis and persistent haemodynamic active bleeding is the percutaneous transcatheter embolization (PTE) in our opinion the treatment of choice. The introduced case is confirm with this statement.

Early psychological reactions to life-threatening injuries.

OBJECTIVE: To assess the prevalence of posttraumatic stress symptoms and coping patterns in severely injured accident victims; to study correlations between injury severity and psychosocial variables and the presence of posttraumatic stress symptoms; and to analyze intensive care unit (ICU) personnel's global clinical appraisals in relation to patient characteristics. DESIGN: A study of critically ill accident victims assessed within one month of the trauma. SETTING: ICU of the traumatology department at the University Hospital, Zurich. PATIENTS: 121 consecutive patients with accidental injuries (mean Injury Severity Score, 21.8; mean Glasgow Coma Scale score, 14.4) admitted to the ICU between January 1996 and June 1997, aged 18-68 yrs. Patients with severe head injuries, attempted suicides, and victims of physical assault were excluded. MEASUREMENTS: Extensive clinical interview, Impact of Event Scale, Clinician-Administered Posttraumatic Stress Disorder Scale, social support, life events, biographical protective and risk factors, Sense of Coherence questionnaire, Freiburg Questionnaire of Coping with Illness. RESULTS: 13.7 (SD, 6.8) days after the accident, 5 patients (4.1 %) met all criteria for posttraumatic stress disorder with the exception of the time criterion. A further 24 patients (19.9%) had subsyndromal posttraumatic stress disorder. Posttraumatic psychiatric symptomatology did not correlate with objective injury criteria, but rather with pretrauma variables (female gender, biographical risk and protective factors, life events), the patients' subjective appraisal of the severity and threat of the accident, their general attitude toward life ("sense of coherence"), and their current coping strategies. Surgeons' and nurses' global clinical appraisals did not correlate with injury severity or with the patients' coping strategies. CONCLUSIONS: Trauma surgeons and ICU personnel should pay special attention to the strains and stressors their patients have been exposed to when recording case histories and to the level of their patients' psychosocial adaptation before the trauma.

[Intramedullary nailing of humeral shaft fractures--initial experiences with an unreamed humerus nail]]. / Marknagelosteosynthese von Humerusschaftfrakturen--erste Erfahrungen mit dem unaufgebohrten Humerusnagel (UHN).

Interlocking intramedullary nailing has become the preferred method of internal fixation for diaphyseal fractures of the lower extremity. In shaft fractures of the humerus however open reduction and internal fixation with plates and screws is still considered the gold standard for operative treatment. The unreamed humerus nail (UHN) is a new implant for interlocking intramedullary nailing, which allows for stable fixation of humerus shaft fractures and immediate functional after treatment. The UHN could thus become an equal alternative to plate osteosynthesis. From this point of view we analyzed retrospectively 19 shaft fractures of the humerus, which have been treated at our institution with an UHN. Infections and iatrogenic nerve lesions did not occur. One patient with a rotational malalignment of 45 degrees underwent a secondary procedure. In two out of ten fresh fractures the bone healing failed and resulted in a non-union. In all cases of pathological fractures a good palliation could be achieved. With exception of two patients the range of motion of the shoulder and elbow was symmetric. We conclude that the UHN is a real alternative to plate osteosynthesis. Compared with most series of plate osteosynthesis published in the literature the risk for iatrogenic lesions of the radial nerve appears to be lower. Even in this small series we found however a rather high rate of non-unions.

Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures.

OBJECTIVE: To evaluate whether the implantation of the modular trochanter stabilizing plate (TSP) in addition to the dynamic hip screw (DHS) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures. DESIGN: Prospective clinical study. SETTING: The study was conducted at the trauma unit of the Surgical Department of the University of Basel, Switzerland. PATIENTS: Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP super-imposed on the regular DHS at our institution between July 1991 and July 1993. Five patients died before the first follow-up, one patient was lost to follow-up, and another patient refused follow-up. Thus, thirty-nine patients were followed for at least twelve months (mean 14 months, range 12 to 20 months). INTERVENTION: The fractures treated were classified according to the OTA classification, which is based on the AO classification. Seventeen were 31-A2.2, seven were 31-A2.3, and fourteen were 31-A3.3 fractures. RESULTS: Lateralization of the greater trochanter was successfully prevented in all fractures. Limited fracture impaction was found in 90 percent (n = 35) of the patients with telescoping of 9.5 millimeters (range 0 to 30 millimeters), resulting in mean limb shortening of 5.37 millimeters (range 0 to 14.9 millimeters). Four patients suffered limb shortening exceeding fifteen millimeters (range 15.6 to 21.3 millimeters). Functional results were excellent and good in 87 percent of patients and fair in 13 percent according to the Salvati-Wilson score. All fractures had healed six months after the operation. Three complications required a secondary procedure: one from not inserting a second screw parallel to the gliding hip screw to prevent rotation of the head-neck fragment ("antirotation screw"), one because of deep infection, and one because of a refracture after premature implant removal. CONCLUSION: In unstable pertrochanteric fractures with small or missing lateral cortical buttress, the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment. Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90 percent of these patients.

Surface charge reversal for inorganic anion determination in capillary electrophoresis with an ion-selective microelectrode as detector.

The effect of surface charge reversal of a fused-silica capillary was investigated for the conditions used in the determination of inorganic anions with potentiometric detection. A 25-micron-i.d. capillary was coated with permanently bonded polyacrylamide incorporating a quaternary amine, and a sodium sulfate solution was employed as electrolyte. As expected, it was found that the analysis time is reduced in comparison with an uncoated column of the same length. However, the effect is much less pronounced than that for the common chromate buffer. Since the reduction in analysis time also causes a loss of resolution, the effect is very close to that obtained simply by using a shorter capillary; therefore, coating was not found to be of benefit here. This is in contrast to results reported for the conditions usually employed for the indirect photometric detection of anions.

The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation.

The unstable shoulder girdle--a combination of a scapular neck fracture with a clavicular fracture, acromioclavicular dislocation, or sternoclavicular dislocation--represents a rare and often underestimated injury. Sufficient treatment to permit early function is necessary to avoid a frozen shoulder as well as to treat concomitant thoracic injuries. This is possible only by open reduction and internal fixation. In most cases this can be achieved by a sole osteosynthesis of the clavicular injury. We retrospectively analyzed 12 cases and classified the results according to the Constant Score. This analysis showed excellent functional results in nearly all cases.

[Intestinal drug transport: a surgical problem?]. / Intestinaler Drogentransport: ein chirurgisches Problem?

The case of a 35-year-old man is reported, who presented himself in the emergency room with anxiety and hallucinations. He then passed a small oval pack consisting of a dark paste wrapped in cellophane with his stool. This led to the suspicion of a "body packer syndrome" with cocaine intoxication. The plain abdominal X-ray revealed multiple oval structure scattered over the entire gastrointestinal tract. Cocaine metabolites in the urine confirmed the diagnosis. During the following whole-bowel irrigation the patient had a grand mal seizure. In order to accelerate the retrieval of this threatening load, surgical evacuation was immediately executed. 78 packs containing 650 grams cocaine were removed through a gastrotomy and a coecotomy, respectively. Two of these packs were leaking. Following an uneventful postoperative course the patient was discharged from the hospital 11 days later. According to the literature the recommended treatment for cocaine body packers is whole bowel irrigation. Operative treatment is mandatory in cases of small bowel obstruction or drug intoxication due to leaking packs.

[Treatment of displaced and comminuted multifragment fractures of the head of the radius: is resection a therapeutic option?]. / Traitement des fractures plurifragmentaires déplacées et comminutives de la tête du radius: la résection est-elle une option thérapeutique?

The treatment of displaced comminuted fractures of the radial head type III of the Mason classification is still controversial. The restoration of anatomy including additional lesions with a stable fixation is a prerequisite of early mobilisation. Removal of the radial head, in case of severe comminution, and complete separation of the fragments from the radial neck remain the exception. Insertion of a prosthesis as a spacer is only recommended if there is a remaining instability of the elbow after resection of the radial head. With this treatment modality we have 22/29 good to very good results evaluated by the Morrey score after a follow-up period of 8 years (4-11 years).

[Stable joint-bridging extension of malleolar dislocations and pilon fractures with the AO pinless external fixator]. / Stabile gelenküberbrückende Extension von Malleolarluxations und Pilonfrakturen mit dem AO Pinless Fixateur Externe.

The pinless external fixator, introduced into clinical practice for open tibial fractures, suggested itself for use as a traction substitute because of its pinless frame. The aim of this feasibility study was to replace the conventional calcaneal pin traction by a joint-bridging pinless fixator, inserted under local anesthesia. 10 patients with 6 malleolar dislocation fractures, 3 pilon tibial and 1 open distal tibial fracture were immobilised by a joint-bridging pinless fixator during 10.4 days (5-16 days) till swelling had subsided and definitive fracture treatment, consisting of plate fixation, took place. The implantation of the joint-bridging pinless fixator in local anaesthesia was well tolerated by all patients. This traction substitute offered good patient comfort and easy care. Although the provided stability was less than a conventional fixator, all patients were able to lift up their fractured extremity without pain.

[Quality of emergency admission (resuscitation, REA) and first aid in multiple trauma]. / Qualität von Notfallaufnahme (Reanimation, REA) und Erstversorgung nach Polytrauma.

Undue delay between hospital admission and the beginning or urgent operative procedures is considered as a major mortality risk for polytraumatized patients in any trauma center. As part of a quality control study at our institution (Kantonsspital, University of Basel), the time spent for early resuscitation and diagnostic procedures was therefore prospectively recorded in 20 patients (mean age 38 years) with a mean ISS of 26.9 (range: 13 to 43). Time spent in the resuscitation room averaged 31.4 min (range: 10 to 50 min). Conventional radiographic diagnostic procedures took 34.7 more min (range: 20 to 60 min). An additional CT scan was performed in 15 patients requiring 19.5 min per region (head/thorax/abdomen/spine). Four patients underwent angiography necessitating 28 more min (mean). Time elapsed between admission and arrival of the patient in the OR or the ICU respectively accounted for an average of 89 min (range 22 to 200 min). For comparable injury severities this interval was shorter during the day than during the night (77 and 103 min respectively). Diagnoses established during this period were both accurate and comprehensive, as detectable from the low rate of missed diagnosis (three minor fractures). Although our results match favorably with figures reported in the literature we feel that further improvements could be achieved by performing the conventional radiographic procedures simultaneously with the early resuscitation in the resuscitation room. At present time, for reasons of X-ray protection, this is not possible in our institution.

[Quality control and cost-benefit analysis in surgical fracture treatment]. / Qualitätskontrolle und Kosten-Nutzen-Analyse in der operativen Frakturbehandlung.

In recent years quality assurance is gaining increasing importance in all parts of medicine. In this article, different quality control measures in the field of operative fracture treatment are reviewed and illustrated. As in most other therapeutic specialties, the most commonly used measures are sporadic quality control studies. The Documentation Center of the association for the study of internal fixation [AO] offers in addition to all its contributing clinics an extraordinary measure for a continuous control of their treatment results. So far only a few instances of cost-benefit analysis have been published. Besides direct comparison of costs of different treatment options, improved quality of life may be calculated as well, using the method of Quality-Adjusted Life Years [QALY].

[Proximal femoral fractures: trochanteric area (classification 31 A1-A3)]. / Proximale Femurfrakturen: Trochanterregion (Klassifikation 31 A1-A3).

The increasing incidence of trochanteric fractures renders their treatment a challenging task concerning both medical and increasingly socio-economical questions as well. The majority of these fractures occurs in elderly patients compromised by various preexisting medical problems. The primary goal of treatment therefore has to be early mobilisation to avoid secondary complications. This can only be achieved by operative treatment. Regarding the perioperative management an antibiotic as well as an antithrombotic prophylaxis is advisable. Recent data also suggest to add an enteral nutritional supplement during the postoperative period. The social reintegration depends however primarily upon the rapid restoration of the walking capacity. In this concern the Dynamic Hip Screw (DHS) is an optimal implant for ORIF, since it allows early full weight-bearing and shows a lower complication rate than static implants (e.g. the condylar blade plate).

[The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures]. / Die DHS-Abstützplatte für die Versorgung der instabilen proximalen Femurfrakturen.

The DHS-implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4-part fractures rotation of the head and neck fragment around the lag screw and significant impaction might lead to lateralisation of the greater trochanter and therefore to marked shortening. To prevent these effects we treated 17 patients with 4-part fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of telescoping, with less shortening even with immediate full weight bearing.

[The dynamic hip screw support plate for management of unstable proximal femoral fractures]. / Die DHS-Abstützplatte für die Versorgung der instabilen proximalen Femurfrakturen.

The DHS-Implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4 part-fractures rotation of the head and neck fragment around the lag screw and a significant impaction might lead to a lateralisation of the greater trochanter and therefore to an important shortening. To prevent these effects we treated 17 patients with 4 part-fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant the lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of the telescoping, with less shortening even with immediate full weight bearing.