[Surgical treatment of acetabulum fractures in the elderly. Osteosynthesis or endoprosthesis]. / Operative Therapie der Acetabulumfraktur beim älteren Patienten. Osteosynthese oder Endoprothese.

BACKGROUND: Anatomical reconstruction of acetabulum fractures and rigid osteosynthesis are required to achieve good postoperative results. In the 7(th) decade of life changes of bone quality impair stability of fixation devices in bone. PATIENTS AND METHODS: This retrospective study evaluates and compares results of osteosynthesis and implantation of total hip arthroplasty in patients with acetabulum fractures. A total of 24 patients older than 65 years who sustained acetabular fractures type A, B and C according to AO classification were examined using several clinical measurements. Different scores for physical function, pain, general health and subjective assessment including psychosocial aspects were used. The outcome criteria were evaluated 1.5-10 years after surgery. RESULTS: Good reconstruction of the acetabulum was only achieved in 40 % of patients which corresponded with radiological long-term results. Pain relief and mobility were slightly better in patients who received primary alloarthroplasty of the hip joint, and periarticular ossification was observed more frequently following osteosynthesis. Surgical revisions were necessary more often after osteosynthesis of the acetabulum. The small number of cases showed no significant differences. The functional outcome did not show significant differences between primary alloarthroplasty and reconstruction of the acetabulum. CONCLUSION: Primary implantation with alloarthroplasty of the hip joint in case of a complex fracture of the acetabulum can be recommended for elderly patients if an anatomic or good reconstruction of the hip joint cannot be achieved.

[Cross sectional study of structural quality of German intensive care units. A reevaluation of the DIVI register]. / Querschnittstudie der Strukturqualität deutscher Intensivstationen. Eine Reevaluation der Strukturdaten des DIVI-Registers.

BACKGROUND: Effectiveness of intensive care treatment is essential to cope with increasing costs. The German national register of intensive care established by the German Interdisciplinary Association for Intensive Care Medicine (DIVI) contains basic data on the structure of intensive care units in Germany. A repeat analysis of data of the DIVI register within 8 years provides information for the development of intensive care units under different economic circumstances. METHODS: The recent data on the structure of intensive care units were obtained in 2008 and compared with the primary multicenter study from 2000. The hospitals selected were a representative sample for the whole of Germany. Data on the status of the hospital, staff and technical facilities, foundation of the hospital and the statistics of mechanically ventilated patients were analyzed. RESULTS: The technical facilities and the number of staff have improved from 2000 to 2008. A smaller availability of diagnostic procedures and staff remain in hospitals for basic treatment outside normal working hours. The average utilization of intensive care unit beds was not altered. The existence of intermediate care units did not significantly change the proportion of patients with artificial ventilation or ventilation times. The number of beds in intensive care units was unchanged as was the average number of beds in units and the number of patients treated. A relevant number of beds of intensive care units shifted towards hospitals with private foundation without changes in the overall numbers. The structure of the hospitals was comparable at both time points. CONCLUSIONS: The introduction of intermediate care units did not alter ventilation parameters of patients in 2008 compared with 2000. There is no obvious medical reason for the shift of intensive care beds towards private hospitals. The number of staff and patients varied considerably between the intensive care units. The average number of patients treated per bed was not different between the periods or between hospitals with different structures. Overall availability of medical staff and diagnostic procedures increased during the study period. An increase of availability of fully trained medical staff in intensive care medicine is desirable to increase the quality of treatment.

[Biocompatibility of polymer-bioglass cement Cortoss®: in vitro test with the MG63 cell model]. / Biokompatibilität von Polymer-Glaskeramik-Zement Cortoss®: In-vitro-Testung mit dem MG63-Zell-Modell.

BACKGROUND: Polymethylmethacrylate (PMMA) cement has been used for fixation of joint replacements for more than 50 years and cement augmentation of vertebrae has become a popular procedure since the first description in 1987. New cements have now been developed which are better suited to the requirements of minimally invasive application techniques for vertebral bodies. The combination of good mechanical properties and biocompatibility is the concern of present research. This study compared the features of a polymer-bioglass cement with a calcium phosphate cement used for vertebral augmentation. METHODS: The human osteoblast-like cell culture MG63 was used to study the polymer-glass ceramic cement Cortoss® and the hydroxyapatite cement Kyphos®. Every 24 h for 5-6 days a defined volume of the culture medium was harvested in the presence of the bone cements and added to 16 cell cultures for each time period. The viability of cells was determined photometrically at 550 nm with the MTT assay and cell morphology was studied using light and electron microscopy. RESULTS: In the presence of the calcium phosphate cement an early and small reduction of cell activity was found compared with the controls. At the end of 1 week the viability parameter improved nearly reaching the control level. Electron microscopy showed crystals with a 3-dimensional shape. The cell cultures with Cortoss® showed no cellular activity and the microscopic examinations were negative. This effect was not different at days 1-5 after polymerization of the cement. CONCLUSIONS: The calcium phosphate cement studied showed a good biocompatibility and allowed morphological signs of apatite formation. At least within the first 5 days the polymer-glass ceramic cement showed a reasonable cytotoxic effect. There was no sign of recovery of cell function within that period. The biocompatibility of the polymer-glass ceramic cement appeared significantly worse compared with the calcium phosphate cement. An ideal composition of biomechanical properties and biocompatibility has not been achieved so far.

[Transoral vertebroplasty: an alternative for operative treatment of metastases of the upper cervical spine]. / Die transorale Vertebroplastie: Eine Alternative in der operativen Behandlung von Metastasen der oberen HWS.

Analogue to the demographic changes and the accompanying increased incidence of tumorous diseases, the number of patients with metastatic bone tumors of the spine is also increasing. Metastatic bone tumors are the most significant cause of pain in cancer patients. Pain and instability are the main indications for surgery. Minimally invasive procedures are recommended in patients with a poor medical condition and with a poor prognosis.Transoral vertebroplasty can be successfully used to reduce pain and provide stability in the palliative treatment of metastases of the vertebral axis. This procedure has the advantage of providing rapid pain relief and spinal stabilization.The operative technique is described and discussed with reference to the current literature. As an example the case of a 67-year-old patient is described, who was suffering from prostate cancer and a painful metastasis of the dens axis. After interdisciplinary consensus, transoral vertebroplasty was performed. The procedure was effective in achieving pain relief and providing stability and 7 months after the operation no further spinal metastases had occurred.

[Treatment management of a multiply injured patient with HIV infection]. / Behandlungsmanagement eines polytraumatisierten Patienten mit HIV-Infektion.

In orthopaedic surgery and emergency medicine, patients of the age groups with a HIV risk represent the largest part of the entire population. As necessary steps have to be taken immediately at the scene of an accident and in the emergency room, contact with HIV-positive blood is often unavoidable, so that there is an increased risk of transmission for doctors and personnel. Due to the immunological state, the HIV patient is exposed to considerable post-operative complications such as wound infection, pneumonia and even sepsis. With the case of a 35-year-old HIV-positive patient who was multiply injured in a traffic accident, we want to present an interesting example of the problems that occur in the treatment of this patient group.

[Risk management--a new aspect of quality assessment in intensive care medicine: first results of an analysis of the DIVI's interdisciplinary quality assessment research group]. / Risk-Management--Ein neuer Aspekt der Qualitätssicherung in der Intensivmedizin: Erste Ergebnisse einer Analyse der IAG Qualitätssicherung Intensivmedizin der DIVI.

Patient security has become one of the major aspects of clinical management in recent years. The crucial point in research was focused on malpractice. In contradiction to the economic process in non medical fields, the analysis of errors during the in-patient treatment time was neglected. Patient risk management can be defined as a structured procedure in a clinical unit with the aim to reduce harmful events. A risk point model was created based on a Delphi process and founded on the DIVI data register. The risk point model was evaluated in clinically working ICU departments participating in the register data base. The results of the risk point evaluation will be integrated in the next data base update. This might be a step to improve the reliability of the register to measure quality assessment in the ICU.

[Computed tomography for the assessment of posterior pelvic injuries in patients with isolated fractures of the pubic rami in conventional radiography]. / Häufigkeit hinterer Läsionen bei vorderen Beckenringfrakturen Ergebnisse der Computertomographie bei der Erstdiagnose "isolierte vordere Beckenringfraktur" im konventionellen Röntgenbild.

To investigate the incidence of occult posterior injuries of the pelvic ring in patients with isolated fractures of the pubic rami, additional computed tomography (CT) was performed. Data from 70 patients were collected within a prolective study. Solitary fractures of the anterior pelvic ring based on conventional radiographic diagnosis were included. Spiral CT, slice thickness 5 mm, was carried out in all patients. In only 47% of cases was the diagnosis of isolated fractures of the pubic rami confirmed. A further 35 fractures of the sacrum and two partial disruptions of the sacroiliac joint were diagnosed using CT. All sacral fractures were incomplete, most were found at the anterior part of the bone. Furthermore, CT revealed three acetabular fractures. Dorsal injuries were significantly more frequent after high energy accidents. Clinical examination did not assist in the prediction of posterior injuries of the pelvic ring. There was no correlation between the extent of the anterior injuries in conventional x-ray and incidence of the posterior injuries in CT. None of the patients with dorsal injuries underwent operative treatment. In conclusion, CT is not required for the routine diagnosis of supposed isolated fractures of the pubic rami.

[Evaluation and results of the gliding nail in the elderly patient]. / Ergebnisse der Gleitnagelosteosynthese beim alten Menschen.

Evaluation of the gliding nail in the elderly patient with unstable fracture of the proximal femur. Primary aims of the study were the description of surgical procedure, the specific complications, postoperative pain, recovered mobility and social status after nailing procedure. The observation period of this prospective non-randomized observational cohort study was from 10/97 to 07/00. 121 patients (90 female, 31 male) with unstable femoral fracture were included. Data evaluation included type of fracture, surgical data, procedure specific complications and pre and post surgical development (pain, mobility and social status). The evaluation of the outcome was performed at least 3 months (median 10.4 months) after surgical intervention by telephone-interview. A subgroup of 20 patients was re-examined. 24 A1-, 65 A2-, 16 A3-, 11 subtrochanteric and 5 other fractures were stabilized with a gliding nail. The mean time of surgery was 77 minutes. In 15 out of 121 patients complications lead to a second surgical intervention. In the follow-up examination we were able to obtain following findings: 33.9 % vs. 56.2 % (preoperative) of patients were self-contained. The need for professional care was unchanged. 23.5 % vs. 58.7 % (preoperative) showed unlimited mobility. 20.3 % vs. 12.8 % complained light or moderate pain. According to our experience the gliding nail is a safe and minimal invasive system with a low complication rate. In consideration of patient based outcome the gliding nail shows good results compared to other treatment options. For the given reasons the authors prefer the gliding nail as treatment of choice for proximal femoral fractures.

Procalcitonin versus interleukin-6 levels in bronchoalveolar lavage fluids of trauma victims with severe lung contusion.

OBJECTIVE: To examine whether measurement of procalcitonin (PCT) in comparison with interleukin-6 is a reliable marker to score the extent of lung contusion in bronchoalveolar lavage (BAL) fluids in polytrauma patients. DESIGN: Prospective, nonrandomized, observational study. SETTING: Twelve-bed intensive care unit in a 1,100-bed primary care university hospital. PATIENTS: Fourteen trauma victims presenting with severe lung contusion and acute lung injury or acute respiratory distress syndrome were enrolled in the study. INTERVENTIONS: Bronchoscopy with collection of lavage fluid and serum blood samples. Samples were obtained on days 1 and 2 after severe chest trauma, and lung contusion was assessed by computed tomography scan. MEASUREMENTS AND MAIN RESULTS: PCT was detectable in BAL fluids of all 14 patients. A significant correlation for PCT serum and BAL levels was found on day 2 (p =.0063). For PCT, no significant correlations (Spearman rank) were found to the lung injury score (p =.93), the abbreviated injury scale-lung (p =.33), or the sepsis-related organ failure assessment score-lung (p =.38). Also, for interleukin-6 there was no significant correlation to the lung injury score (p =.62), abbreviated injury scale-lung (p =.45), or the sepsis-related organ failure assessment score-lung (p =.54). CONCLUSIONS: PCT and interleukin-6 BAL levels cannot be considered as reliable parameters to assess the extent of lung contusion.

[A minimally invasive technique of intramedullary femoral nailing using the RDS system. A new technique for insertion of retrograde femoral nail]. / Die minimalinvasive Technik der Femurnagelung mit dem RD-System. Vorstellung einer neuen Technik der Implantation retrograder Femurnägel.

A total of 72 patients with femoral fractures was treated between July 1997 and November 1999, 41 of them with retrograde intramedullary fixation. A minimally invasive technique was performed in 18 cases using a recently designed retrograde dilatator system (RDS) for the insertion of ACE-nail (DePuy), the reaming of the femoral canal and the locking of the distal screws. The mean age of the 18 patients (7 men and 11 women) was 49 (+/- 21) years. 8 type A, 6 type B and 4 type C fractures of the femoral shaft according to the AO classification were observed. 5 of the patients had sustained a severe polytrauma. The mean ISS of the total collective was 18 (+/- 19). No nail failed, no infection occurred, and no nerve palsies were recorded. The follow-up time was 10 (+/- 7) months. All fractures healed uneventfully. 16 patients were mobilized under full weight-bearing and regained a full range of motion without pain. In 2 cases of very old patients nursing was possible without pain. In 5 cases an implant removal was carried out in the same technique. The performed minimally invasive technique using the RDS minimizes damages to the patella ligament and the articular cartilage. It facilitates the control of rotational deformities and length discrepancies of the femur also under difficult conditions, e.g. polytrauma and obese patients.

[Thromboembolism complication in multiple trauma patients: an underestimated problem? Results of a clinical observational study of 50 patients]. / Thromboembolische Komplikationen bei mehrfachverletzten Patienten: ein unterschätztes Problem? Ergebnisse einer klinischen Beobachtungsstudie mit 50 Patienten.

INTRODUCTION: The incidence of thromboembolic complications in patients with severe polytrauma in the ICU is not well known. Only a few publications deal with this problem. Systematic investigations in this high-risk patient group are not routinely used. METHOD: From January 1996 to January 1998, 50 polytrauma patients with a mean ISS > 15 were included in a clinical study to evaluate the incidence of thromboembolism in this patient group. Further inclusion criteria were a minimum stay of 72 h in the ICU and mechanical ventilation for a minimum time of 72 h. All patients were examined with color-coded duplex sonography according to a standardized protocol. The duplex sonography was performed before the patients were first mobilized in the ICU (15 +/- 12.8 days). RESULTS: If not otherwise indicated all values are given as mean +/- SD. The age of the patients was 38 years (range 17-77 years), the severity of trauma was characterized by an ISS of 40 (range 16-70). Eight of the included patients died during their stay in the ICU after developing a multiple organ failure. According to autopsy data none of them had a deep venous thrombosis or pulmonary embolus. Eight patients (19%) developed deep venous thrombosis, and 4 patients with thrombosis developed pulmonary embolism. CONCLUSION: The incidence of deep venous thrombosis in polytrauma patients seems to be much higher than expected reviewing the results of other publications. The low detection rate of other authors results from using only clinical signs. The routine use of color-coded duplex sonography is effective in detecting unsuspected deep vein thrombosis.

[Continuous stroke volume monitoring as "hemodynamic online monitoring" in polytrauma intensive care patients: technically possible--clinically necessary?]. / Die kontinuierliche Herzminutenvolumenmessung als "hämodynamisches Online-Monitoring" bei polytraumatisierten Intensivpatienten: Technisch möglich--klinisch sinnvoll?

PURPOSE: Is the measurement of continuous cardiac output useful for the management of polytrauma patients? METHODS: In a prospective non randomized study (ethic commission file 43/96) we evaluated the diagnostic and therapeutic impact of the CCO (continuous cardiac output measurement) for polytrauma patients on the ICU. The Baxter Vigilance System was used for measuring the continuous cardiac output. The CCO values were controlled once a day by the conventional "cold" thermodilution technique. RESULTS: All values are given as mean +/- standard deviation. The Patients were scored on the first day for ISS (injury severity score) (47 +/- 17) and APACHE II (15 +/- 5). The CCO was used no later than 12 hours after the initial treatment in 20 polytrauma patients. As clinical outcome parameters were chosen: days on ventilation (23 +/- 23 days), days on the ICU (31 +/- 26 days) and mortality (20%). The treating ICU physicians were asked in a standardized questionnaire, whether or not there was an impact of the CCO measurement on their therapy. Seven different surgeons were working with the system. CONCLUSION: The unique opinion was that the CCO device had an impact on their decision making in the fluid and drug management of the study patients. Our first experience, however, suggests that this device may become an important improvement in the management of haemodynamics in the early trauma phases. Before a wide-spread application of this method on the ICU an evidence based prospective randomized trial should be performed.

[The dilatation technique with the novel trocar system for minimally invasive implantation of intramedullary nails at the proximal femur]. / Die Dilatationstechnik mit dem TNS zur gewebeschonenden Implantation von Marknägeln am proximalen Femur.

A new technique of a minimally invasive approach to the proximal femur was developed for the management of per- and subtrochanteric fractures using intramedullary nail blade systems. For creating the entry portal at the proximal femur a transcutaneously applied Kirschner-wire is used. Subsequently, a new developed trocar system (TNS) for the protection of the soft tissue during reaming procedures is placed via a small cutaneous incision. The reaming of the femoral shaft can be performed through this trocar system. A new targeting jig especially adapted to the gliding nail was used in this first series. From December 1998 to June 1999 12 patients were treated with this new technique in the Department of Trauma Surgery of the Philipps-University in Marburg. The mean age of the 8 female and 4 male patients was 78 (+/- 12) years. The majority of the total group were old patients with a mean ASA score of 3-4. Relevant intraoperative complications using the new dilatation approach were not observed. All patients were mobilised after few days. Postoperative complications or infections were not found. In the clinical practice of the management of per- and subtrochanteric femoral fractures the new dilatation approach has proved to be more comfortable and minimally invasive than the standard technique existing to date.

[Dilatation technique with the TNS (transcutaneous nail insertion system) for minimally invasive implantation of intramedullary nails at the proximal femur]. / Die Dilatationstechnik mit dem TNS zur gewebeschonenden Implantation von Marknägeln am proximalen Femur.

A new technique of a minimally invasive approach to the proximal femur was developed for the management of per- and subtrochanteric fractures using intramedullary nail blade systems. For creating the entry portal at the proximal femur a transcutaneously applied Kirschner-wire is used. Subsequently, a new developed trocar system (TNS) for the protection of the soft tissue during reaming procedures is placed via a small cutaneous incision. The reaming of the femoral shaft can be performed through this trocar system. A new targeting jig especially adapted to the gliding nail was used in this first series. From December 1998 to June 1999 12 patients were treated with this new technique in the Department of Trauma Surgery of the Philipps-University in Marburg. The mean age of the 8 female and 4 male patients was 78 (+/- 12) years. The majority of the total group were old patients with a mean ASA score of 3-4. Relevant intraoperative complications using the new dilatation approach were not observed. All patients were mobilised after few days. Postoperative complications or infections were not found. In the clinical practice of the management of per- and subtrochanteric femoral fractures the new dilatation approach has proved to be more comfortable and minimally invasive than the standard technique existing to date.

Comminuted pelvic ring disruption in toddlers: management of a rare injury.

Pediatric pelvic fractures are rare injuries. The clinical management, classification, and operative treatment of this type of injury was presented in two toddlers ranging in age from 1 to 3 years. The CT examination proved to be the most reliable diagnostic tool for the assessment of the fracture morphology. The findings of the CT examination provide the possibility for an exact classification and operative planning. The surgical treatment was performed with the AO instrumentation for small fragments by using the approved standard approaches of adult surgery. The postoperative management has to be adapted to the physiology of the children. It is important to remove the osteosynthesis material in due time to avoid the risk of epiphysiodesis at the pelvis. To detect late sequelae of the trauma, follow-up should be performed regularly until growth is completed.

[Kinetic therapy for therapy and prevention of post-traumatic lung failure. Results of a prospective study of 111 polytrauma patients]. / Kinetische Therapie zur Therapie und Prophylaxe der posttraumatischen Lungeninsuffizienz. Ergebnisse einer prospektiven Studie an 111 Polytraumatisierten.

The effects of kinetic therapy on the oxygenation in the injured lung of 111 polytrauma patients were analysed in an open prospective study. The patient collective comprised 82 men and 29 women. For the total group, the average age was 38.3 years (+/- 16.1). The initial ISS was 39.3 points (+/- 18.9), and the APACHE II evaluated 24 h after including the patient into the study was 13.1 (+/- 5.2). The data of 3 treatment groups were evaluated: 1, acute respiratory disease (ARDS, n = 42); 2, acute lung injury (ALI, n = 36); and 3, prophylaxis (n = 33, a group of prophylactically treated patients with a PaO2/FiO2 ratio > or = 300 and an ISS > or = 15). Positioning therapy was administered in group 3 in order to prevent atelectases, and respirator-induced lung injuries during a foreseeable, relatively long period in the intensive care unit in view of the severity of the trauma. The mean treatment time in the kinetic bed was 6.3 days (+/- 3.9), the time on respirator 18.5 days (+/- 15.4). The patients stayed in the ICU 22.4 days (+/- 15.4) and left the hospital after 35.1 days (+/- 27.7). For scoring the severity of respiratory failure, the lung injury score (LIS) according to Murray and the SOFA score lung (sepsis-related organ failure assessment) according to Vincent were evaluated. The LIS at time of recruitment into the study was 2.2 (+/- 1.0), the SOFA score lung 3.0 (+/- 0.9). In the ALI and ARDS groups a significant improvement in oxygenation was observed (p < 0.0001). No patient of the prophylaxis group developed an ALI or ARDS. The mortality rate in the total group of 10.8% was relatively low in comparison with other published data. Consistent kinetic therapy integrated in a standardised treatment regimen contributes towards improving the negative outcome to date of patients with severe respiratory failure after major trauma.

[Marburg modular prone positioning system (MBS) for positioning therapy]. / Modulares Marburger Bauchlagerungssystem (MBS) für die dorsoventrale Wechsellagerung.

Despite the many benefits of prone positioning in critically ill patients with respiratory failure and ARDS in the ICU, its technical problems have not yet been adequately resolved. Different approaches with special beds for prone positioning do exist, but these devices are difficult to handle, often not available and involve high costs. With this in mind, we developed an easy handling prone positioning system (MBS) that requires no special beds and runs at low cost. The MBS is a cost-effective device, yielding many benefits for prone positioning in critically ill patients with severe athelectasis and ARDS.

[Blunt thoracic trauma with aortic rupture and lung contusion caused by hoof kick in a 15-year-old girl. Diagnostic and therapeutic management]. / Stumpfes Thoraxtrauma mit Aortenruptur und Lungenkontusion durch Hufschlag bei einem 15jährigen Mädchen. Diagnostisches und therapeutisches Management.

The number of published cases of adolescents surviving thoracic aortic injuries with accompanying severe thoracic injuries is small. Only 20-30% of all these patients reach the trauma center alive. In the present case we demonstrate the diagnostic, operative and intensive care management in a 15-year-old girl. The exact interpretation of the AP thoracic X-ray in connection with a typical mechanism of injury led to the detection of a haemomediastinum. This is very important in the further development of diagnostics, because the conventional X-ray picture does not show significant signs in the case of an incomplete aortic rupture. Diagnostic hints have to be derived from the detection of the haemomediastinum. The girl was operated on under left heart bypass. Spinal ischaemia was absent after surgery, and renal failure also did not occur. The adjacent severe lung confusion healed under kinetic therapy with a kinetic treatment table without pulmonary complications.