[The value of ultrasound diagnosis in "acute appendicitis" patient admission]. / Der Stellenwert des Ultraschalls bei Einweisungsgrund "akute Appendizitis".

UNLABELLED: The rate of unnecessary appendectomy is frequently criticized. Today, sonography and CT-scan are helpful tools to minimize this rate. Which value has the ultrasonography in the decision making today? METHODS: Retrospective analysis of 132 patients undergoing appendectomy in respect of sonography and rate of histologically confirmed appendicitis from 1.1.95-31.12.98. Prospective analysis of 99 patients admitted for acute appendicitis in respect of pre- and posttest-probability (after sonography) by the responsible surgeon from 1.1.99-31.12.00. RESULTS: Retrospective part: 122/132 patients had an acute appendicitis (92%). Sonography was performed in 64% of the patients. There was only one wrongly positive sonography. Prospective part: 76/99 patients were operated on. 70/76 had an acute appendicitis (92%). Sonography was performed in 87%. Six patients presented a histologically normal appendix: In two of them no increase of the probability after sonography was noted, in three of them an slight increase of only 20%, and in one of them a decrease of 20% even. CONCLUSION: Sonography with a pre- and posttest-probability is recommended in clinically doubtful cases. In our experience the physician performing the sonography is almost always right. But the diagnosis of an acute appendicitis remains a combination of clinical and sonographic evaluation.

[Carpal tunnel syndrome after trauma]. / Das Carpaltunnelsyndrom nach Trauma.

UNLABELLED: The carpal tunnel syndrome is a frequent illness with several etiological factors. Its appearance after trauma is rare. In a retrospective study its incidence and the trauma pattern were analyzed. From 1.1.95 to 31.12.99 144 median nerve decompression procedures for carpal tunnel syndrome were performed in 114 patients. Twelve patients (10.5%) had suffered a trauma in the recent or more distant past. There were six distal radius fractures, three metacarpal fractures, one finger fracture, one humeral shaft fracture and one distal avulsion of the biceps tendon. In eight patients the symptoms appeared 1-3 months after trauma, in four patients there was an interval of several years. In all twelve patients electroneurography revealed pathological parameters on the symptomatic side, but in ten patients the contralateral side was also affected although there were no symptoms. According to the criteria given by Assmus and Frobenius [1], five patients showed an obvious and three patients a possible posttraumatic carpal tunnel syndrome. In four patients a distinct relation to the trauma could not be proven. CONCLUSION: The carpal tunnel syndrome after trauma is rare. Given the fact that the contralateral side in these patients was affected as well, a predisposition--due to a narrow carpal tunnel--is very likely. Its manifestation might be triggered by a pressure increase in the carpal tunnel as result of the trauma.

[Interdisciplinary complications conference--also a (simple) kind of quality assurance]. / Die interdisziplinäre Komplikationen-Konferenz--auch eine (einfache) Art der Qualitätssicherung.

Documentation of complications is a "must" today. Several societies have been formed and several systems of documentation exist to fulfill these requirements. But there are also very simple tools for quality management in every hospital. Since 1995 all surgical/orthopedic interventions have been prospectively recorded at the hospital of Frutigen. Every other month a list of all operations and their complications is put together by the two surgeons-in-chief. This list is then presented at the so-called interdisciplinary complications-conference. This meeting is open to all employees of the hospital and to all medical doctors of the region. From the 1st January 1995 to the 31st December 2001 7396 surgical interventions were performed on in- or outpatients. 134 complications (1.8%) occurred. These were: 49/7396 infections (0.7%), 14/1395 re-osteosyntheses (1%), 21/7396 hematomas requiring evacuation (0.3%), 8/7396 disturbances in wound healing (0.1%) and 42 other, postoperative complications. Postoperative infection occurred most frequently after appendectomies 10/251 (4%), the rate after internal fixation was 0.6% (9/1395). Hematomas were encountered most frequently after total joint replacement (hip and knee) 4/180 (2.2%), followed by inguinal hernias 4/287 (1.4%). The rate of re-osteosynthesis was highest after internal fixation of proximal humerus fractures 5/58 (8.6%). This systematic documentation of complications allows an analysis of the operative/perioperative management. By introducing specific measures (compression-bandage after operations of inguinal hernias and total hip prosthesis, new implant with rotational stability for proximal humerus fractures) an attempt can be made to reduce the rate of the most frequent complications. The public presentation of the complications at the meeting makes it possible to communicate good and bad results to the whole staff including the general practitioners, and the interdisciplinary mode of discussion permits the inclusion of not only the surgical but also all other possible aspects of the treatment of the patients.

[Missed compartment syndrome after anterior cruciate ligament-plasty following continuous peridural anesthesia]. / Verpasstes Kompartmentsyndrom nach vorderer Kreuzbandplastik infolge kontinuierlicher Periduralanästhesie.

In this article we report a case of an early postoperative compartment syndrome of the anterior tibial compartment with complete sensomotoric palsy of the peroneal nerve after arthroscopic-assisted replacement of the anterior cruciate ligament (ACL) of the knee. The tourniquet pressure was 360 mm Hg and operation time was 1.75 h. After the operation the leg was bandaged to avoid swelling of the leg and as antithrombotic prophylaxis. Analgesic therapy was by continuous epidural bupivacaine infusion. Increasing pain of the lower leg was suppressed by additional analgesia. Due to persistent pain despite regular analgesia, the patient was sent to a main hospital on the 3rd postoperative day, where an extremely painful and swollen anterior tibial compartment with intracompartmental pressure of over 100 mm Hg was found. The compartment was released immediately. Despite the appearance of severe muscle damage, no extensive débridement was done. At the second examination, at 48 h, there was minimal perfusion of the muscles without contraction and islands of ischemic necrosis. Clinically, there was complete palsy of the dorsiflexors of the foot. The case shows the danger of a compartment syndrome when tourniquet of the limb, arthroscopy and a firm bandage are combined. Continuous epidural analgesia masks the classic symptoms of compartment syndrome.

Modification of the original Luque technique in the treatment of Duchenne's neuromuscular scoliosis.

Luque segmental instrumentation with Galveston technique for pelvic fixation is generally used in the correction of Duchenne's neuromuscular spinal deformities with pelvic obliquity. Particularly difficult is the control of the lumbopelvic junction. Instrumentation failures and only mediocre correction of pelvic obliquity are reported. To obtain better sacropelvic anchorage and to improve pelvic correction, this technique was modified with the introduction of sacral screws in each S-1 pedicle and a device for transverse traction between the caudal right-angle bends of the L-rods. From 1988 and 1993, 25 consecutive patients (mean age, 14 years) were operated on using this technique. Before surgery, mean spinal deformity measured 68 degrees (range, 46-90 degrees), and pelvic obliquity, 21 degrees (range, 7-45 degrees). At the last examination (mean follow-up, 36 months), mean spinal curvature was 18 degrees (range, 3-37 degrees), and pelvic obliquity was always <15 degrees (range, 0-15 degrees) with mean correction of 75%. No instrumentation failure or loss of correction >3 degrees could be observed in the entire series. In every patient, a good sitting balance could be restored after surgery.

Predominantly posterior instrumentation and fusion in neuromuscular and neurogenic scoliosis in children and adolescents.

We studied the results in 46 patients with neuromuscular and neurogenic scoliosis (average age 13.5 years, range 6-19 years) who had had posterior fusion with a modified Luque technique between May 1985 and June 1992. The main criteria to recommend surgery were curve progression, loss of balance when sitting, control of the head and difficulties in wearing an external orthotic support. The mean preoperative curve was 63 degrees, the postoperative value was 24 degrees, representing a correction of about 62%. The average number of stabilized segments was 13. In 39 out of 46 patients, lumbosacral fixation was included in the construct. Failure of implants, pseudarthroses and major losses of correction in purely neuromuscular scolioses could be avoided by using rigid segmental fixation and a dorsolateral fusion with a mixture of autologous and allogenous bone. The scoliosis most difficult to influence was found to be Friedreich's ataxia. In Duchenne muscular dystrophy the best method of treatment was surgery performed as early as possible, i.e. at the time of loss of walking capacity in the case of a scoliosis exceeding 20 degrees and with two consecutive X-rays proving curve progression. Analysis of our series does not confirm the morbidity and complication rates of previous studies.

[Accidents and injuries in hanggliding]. / Unfälle und Verletzungen beim Gleitschirmfliegen.

Between January 1987 and December 1988 36 patients with injuries resulting from hanggliding were admitted to the Interlaken hospital. 6 (17%) of them were women. 14 patients were between 20-30 years old. 24 patients presented injuries of the lower limb, in 10 cases the spine was affected. From the total 39 injuries 20 had to been treated by operation. The accidents occur equally while starting or landing, during the flight incidents are very rare. The majority of the patients had only little experience in hanggliding or underwent insufficient training, indicating the most important point to be dealt with in the future.