[Single-port VATS-assisted internal fixation of serial rib fractures]. / "Single-port-VATS"-assistierte Osteosynthese von Rippenserienfrakturen.

This article describes the operative stabilization of a flail chest due to traumatic serial rib fractures with extensive chest wall deformation and respiratory insufficiency. Initial conservative treatment including systemic and regional pain management and non-invasive positive pressure ventilation did not improve the pain or ventilation. Therefore, a single-port video-assisted thoracoscopic surgery (VATS) assisted internal fixation of the ribs was performed. The thoracoscopy enabled easy repositioning of the ribs and additionally an estimation of intrathoracic injuries.

[Evolution and principles of intramedullary locked nailing]. / Entwicklung und Prinzipien der Verriegelungsmarknagelung.

Key factors for successful osteosynthetic fracture stabilization are anatomical fracture reduction, restoration of axis and torsion alignment as well as tissue-preserving operative techniques. In long bone fractures, the use of intramedullary long bridging nailing offers ideal conditions for bone healing, as axial and rotational stability is provided by canal-filling nails and locking screws. In addition, the tissue in the fracture region is protected as the intramedullary nail insertion is distant from the fracture. The indication spectrum for modern intramedullary locked nailing includes diaphyseal fractures of long bones, metaphyseal fractures and reconstructions, as well as treatment of nonunion, osteotomy and arthrodesis of the lower extremities. Continuous improvements in nail design and instrumentation as well as the introduction of anatomical reconstruction nails will optimize the spectrum and effectiveness of intramedullary osteosynthesis even further.

[The Postero-Lateral Approach--An Alternative to Closed Anterior-Posterior Screw Fixation of a Dislocated Postero-Lateral Fragment of the Distal Tibia in Complex Ankle Fractures]. / Der posterolaterale Zugang--eine Alternative zur geschlossenen anterior-posterioren Schraubenosteosynthese bei komplexen Sprunggelenkfrakturen.

BACKGROUND: The dislocated posterolateral fragment of the distal tibia is considered as a key fragment for the successful reduction of comminuted ankle fractures. The reduction of this fragment can either be achieved indirectly by joint reduction using the technique of closed anterior-posterior screw fixation, or directly using the open posterolateral approach followed by plate fixation. The aim of this study was to compare the outcome after stabilization of the dislocated posterolateral tibia fragment using either closed reduction and screw fixation, or open reduction and plate fixation via the posterolateral approach in complex ankle fractures. PATIENTS/MATERIAL AND METHODS: In a prospective study between 01/2010 and 12/2012, all mono-injured patients with closed ankle fractures and dislocated posterolateral tibia fragments were assessed 12 months after osteosynthesis. Parameters included: size of the posterolateral tibia fragment relative to the tibial joint surface (CT scan, in %) as an indicator of injury severity, unreduced area of tibial joint surface postoperatively, treatment outcome assessed by using the "Ankle Fracture Scoring System" (AFSS), as well as epidemiological data and duration of the initial hospital treatment. RESULTS: In 11 patients (10 female, 1 male; age 51.6 ± 2.6 years [mean ± SEM], size of tibia fragment 42.1 ± 2.5 %) the fragment fixation was performed using a posterolateral approach. Impaired postoperative wound healing occurred in 2 patients of this group. In the comparison group, 12 patients were treated using the technique of closed anterior-posterior screw fixation (10 female, 2 male; age 59.5 ± 6.7 years, size of tibia fragment 45.9 ± 1.5 %). One patient of this group suffered an incomplete lesion of the superficial peroneal nerve. Radiological evaluation of the joint surface using CT scan imaging demonstrated significantly less dislocation of the tibial joint surface following the open posterolateral approach (0.60 ± 0.20 mm) compared to the closed anterior-posterior screw fixation (1.03 ± 0.08 mm; p < 0.05). Assessment of the treatment outcome using the AFSS demonstrated a significantly higher score of 97.4 ± 6.4 in the group with a posterolateral approach compared to a score of 74.4 ± 12.1 (p < 0.05) in the group with an anterior-posterior screw fixation. CONCLUSION: In comparison to the anterior-posterior screw fixation, open reduction and fixation of the dislocated, posterolateral key fragment of the distal tibia using a posterolateral approach resulted in a more accurate fracture reduction and significantly better functional outcome 12 months after surgery. In addition, no increased rate of postoperative complications, or extended hospital stay was observed but there was less severe post-traumatic joint arthritis. The results of this study suggest that in complex ankle factures the open fixation of the dislocated posterolateral fragment is recommended as an alternative surgical procedure and may be beneficial for both clinical and radiological long-term outcomes.

[Auxiliary cerclage-wiring in internal fixation of displaced acetabular fractures]. / Auxiliäre Cerclage zur Reposition und Retention dislozierter Acetabulumfrakturen.

BACKGROUND: Displaced fractures of the acetabulum involving the quadrilateral plate continue to be a surgical challenge. In this study, we describe our operation technique of auxiliary acetabular cerclage-wiring combined with plate osteosynthesis and present our results as well as short-term outcome. PATIENTS AND METHODS: All patients aged 18 years and older treated with auxiliary cerclage-wiring between 2007 and 2012 were included in this study. Fractures were classified according to Letournel. Cerclage wiring was used when reposition and retention of the fracture was insufficient with plates and screws alone. Short-term outcome was evaluated by the German Short Musculoskeletal Functional Assessment (SMFA-D) questionnaire. RESULTS: Data from 23 patients were collected. The follow-up period was 7 months (range 2-23 months). Of the 23 patients, 22 showed excellent fracture reduction and retention. One patient had to undergo revision surgery due to loss of reposition. Patients showed good functional outcome. CONCLUSION: Auxiliary acetabular cerclage-wiring is a safe and effective method for fracture reduction and retention especially in displaced acetabular fractures involving the quadrilateral plate.

[Severe polytrauma with an ISS ≥ 50]. / Das schwere Polytrauma mit einem ISS ≥ 50.

In Germany 427,500 persons per year are injured in traffic accidents. So we analysed in a retrospective study the post-traumatic quality of life of patients suffering from a severe trauma (ISS ≥ 50). Highlights of interest were: (i) pattern of injury, (ii) injured part of the body, (iii) days in ICU, (iv) outcome, (v) actual state of health, (vi) mental health. Between 1/2000 and 12/2005, 1,435 patients with multiple trauma were hospitalised in the Trauma Center Murnau. 88 suffered from a severe trauma with ISS ≥ 50. 23 % of these patients had a good outcome and 36 % died. Actually, more than half of the patients were physically handicapped or suffered from pain. 41 % showed characteristics typical for a post-traumatic stress disorder. In conclusion the patients with severe trauma had a good survival rate, but they showed a poor post-traumatic quality of life. Thus, in the time after trauma it is important to treat the "whole patient" and not only the physical lesions.

[Is polytrauma affordable these days? G-DRG system vs per diem charge based on 1,030 patients with multiple injuries]. / Ist ein Polytrauma heutzutage noch bezahlbar? G-DRG-System vs. Tagessätze anhand 1030 polytraumatisierter Patienten.

UNLABELLED: The introduction of diagnosis-related groups (DRG) in Germany comprises the risk of a non-cost-effective reimbursement in complex medical treatments. The aim of this study was to compare the reimbursement between the DRG system and the system of hospital per diem charge in effect until now. MATERIAL AND METHODS: The G-DRG (Version 2004) reimbursement was calculated for 1,030 polytrauma patients (average ISS 26.4) treated at the BGU Murnau from 2000 to 2004, using a base value of 2900 euros, and compared to the reimbursement of hospital per diem charge. RESULTS: Just half of all polytrauma patients are classified as a polytrauma according to the DRG (18.7%) or as requiring artificial respiration based on the DRG (29.1%). The average G-DRG reimbursement was 27,157 euros vs 36,387 euros (74.6%). Patients with minor trauma, increasing age, high GCS, ICU stay without artificial respiration, trauma of the upper extremity and patients who survived show the greatest discrepancy. CONCLUSION: A revision of the G-DRG definition of polytrauma is necessary to ensure adequate reimbursement for management of patients with multiple injuries. The severity of a trauma has to be considered in the DRG system.

[Management of complications after angularly stable locking proximal humerus plate fixation]. / Komplikationsmanagement nach winkelstabiler Plattenosteosynthese am proximalen Humerus.

PURPOSE: In this prospective study, complications observed after angularly stable proximal humerus plate fixation (locking proximal humerus plate) were analysed by deriving specific therapies. PATIENTS: Fifty patients (median age 65 years, range 25-84 years, 39 female, 11 male) with displaced proximal humerus fractures (seven single, 36 double, and seven triple fractures) were evaluated 3, 6, and 12 months after angularly stable plate fixation using a standard protocol. RESULTS: Age- and gender-matched median constant scores 12 months postoperatively showed for the three fracture types 86, 87, and 55 points and complication rates of 14, 19, and 100%, respectively. There were seven primary and seven secondary implant displacements, five humeral head necroses, four osseous malalignments, two nonunions, two deep infections, and one heterotopic ossification. Nine reoperations were required in six patients: implant removal (n=3), reosteosynthesis (n=2), revision because of nonunion (n=2), and deep infection (n=2). CONCLUSIONS: Differentiated analysis of complications and the development of specific prevention and therapeutic strategies considering surgical technique, implant, fracture morphology, and humeral head perfusion minimize the rate of complications observed after angularly stable locking proximal humerus plate fixation.

[Shock trauma room management of spinal injuries in the framework of multiple trauma. A systematic review of the literature]. / Schockraummanagement bei Verletzungen der Wirbelsäule im Rahmen eines Polytraumas. Eine systematische Literaturübersicht.

Injuries to the spine are often part of life-threatening multiple trauma. In this review diagnostics and emergency room management were investigated in order to formulate effective recommendations for the emergency strategy. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The patient's history and clinical symptoms have low rates for specificity and positive predictive value, whereas their negative predictive value and sensitivity are high between 90 and 100%, respectively. CT imaging reaches higher rates for sensitivity, specificity, and positive and negative predictive values in comparison to conventional radiographic series. The patient's history should be asked and clinical investigation should be done in any case. Imaging diagnostics preferably as multislice spiral CT should be performed after stabilization of the patient's general condition and before admission to the intensive care unit.

[The unstable patient with pelvic fracture]. / Die hämodynamisch wirksame Beckeninstabilität.

For the hemodynamically unstable patient with pelvic fracture a target focussed and rapid diagnostic and therapy is mandatory. After hemorrhage control at crash site the direct transport in a trauma center follows. Primary therapy in the emergency room sometimes includes stabilization by a pelvic clamp or an external fixator. If the patient is still hemodynamically unstable the life threatening bleeding is packed. After that simple internal osteosynthesis is allowed. The presented article shows the possible options of the therapy. The main message is: hemorrhage control is not possible without stabilization of the pelvic ring.

Mycobacterium avium infection in CD14-deficient mice fails to substantiate a significant role for CD14 in antimycobacterial protection or granulomatous inflammation.

CD14 is a pattern-recognition receptor implicated in the inflammatory response to microbial components such as lipopolysaccharide, peptidoglycan and lipoarabinomannan. In this work, we made use of CD14-deficient (CD14-/-) mice to evaluate the relative importance of CD14 in response to infection with viable, intact cells of Mycobacterium avium in vitro and in vivo. Following co-incubation of either bone marrow-derived macrophages (Mphi) or thioglycollate-elicited peritoneal Mphi from CD14-/- mice with viable M. avium, tumour necrosis factor (TNF) production was significantly reduced and delayed compared to TNF secretion by infected CD14+/+ Mphi. However, following intravenous infection with a M. avium strain of either high virulence (TMC724) or intermediate virulence (SE01), there was no difference in the bacterial loads of lungs, livers or spleens at 3, 5 and 8 weeks postinfection in CD14-/- mice when compared with syngeneic CD14+/+ mice. At these time-points, TNF and interferon-gamma (IFN-gamma) mRNA expression in the liver was similar in infected CD14+/+ and CD14-/- mice, and granuloma formation and expression of inducible nitric oxide synthase within granuloma Mphi was the same in both mouse groups. In conclusion, although the absence of CD14 results in significantly reduced and delayed TNF production in response to stimulation with M. avium in vitro, there is no evidence that CD14 plays a significant role in either the antibacterial defence or the chronic granulomatous reaction to M. avium infection in vivo.

[The stoma in peritonitis and pancreatitis]. / Das Stoma bei Peritonitis und Pankreatitis.

Today, there are 3 indications for a stoma in peritonitis and pancreatitis: 1) A defunctioning loop ileostomy to protect the anastomosis of the colon in case of intra-abdominal sepsis. 2) A proximal colostomy after resection of the perforated distal colon and closure of the rectal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis and 3) a loop ileostomy to prevent bacterial translocation in case of pancreatitis. After having eliminated the source of infection, the surgeon is able to create a convenient starting-point for further therapy of the intra-abdominal sepsis through a stoma. The most favorable prognosis is attested to patients of group 1): Only 2 out of 9 patients with intraabdominal sepsis died. In contrast, patients of group 2) with severe generalized peritonitis had a mortality of 59% (13/22). At this time, it is not possible to give any certain results about patients of group 3) because of an ongoing study.

[Surgical management of peritonitis and sepsis]. / Chirurgisches Management bei Peritonitis und Sepsis.

The intraabdominal sepsis is one of the major surgical problems today. The Systemic Inflammatory Response Syndrome in peritonitis often leads to multiple organ failure. The surgical eradication of the infectious focus is the most important prerequisite for a successful treatment. Dependent on the form and severity of the local inflammation, different forms of abdominal lavage can be applied. Using surgical and physiological as well as organ failure scores like the Mannheimer-Peritonitis-Index (MPI), the APACHE-II and the Septic-Severity-Score (SSS), the prognosis can be objectively assessed and different clinical studies can be compared. However, in 88 own patients suffering from diffuse purulent peritonitis with sepsis (May 1990 to December 1996), all the above mentioned scores significantly allowed to discriminate surviving (mean MPI: 25, APACHE-II day 1: 19, SSS day 1: 28) from non surviving patients (mean MPI: 31, APACHE-II day 1: 26, SSS day 1: 45). Furthermore, mortality increased significantly with increasing score ranges (< 20, 20 to 30, and > 30 points) for MPI from 0% to 28% to 81%, for APACHE-II day 1 from 20% to 46% to 100%, and for SSS day 1 from 10% to 37% to 71%.

[Peritoneal lavage in standardized peritonitis models]. / Die Abdominal-Lavage im standardisierten Peritonitismodell.

The peritoneal lavage in peritonitis can be studied in a standardized manner only in animal models, because peritonitis is too variable and dependent on too many patient related factors. In this article answers are given to questions on the influence of different lavage substances on survival, local and systemic concentrations of bacteria, endotoxin, and TNF as well as on mesothelial adherence of bacteria. These data refer to results from acute models of infection published in the literature. Furthermore, we show from our own chronic peritonitis model the influence of the peritoneal lavage on abscess formation and translocation. After inoculation of a Bacteroides fragilis suspension, a chronic abscess forming peritonitis was induced. At day 3/7/14 intraabdominal abscesses were found in 2/4/6 of 8/5/6 animals in an untreated, in 1/3/5 of 5/5/5 animals in a saline lavaged, and in 5/0/2 of 5/5/5 animals in a Taurolidin lavaged group, respectively. Both, the intraabdominal and the systemic bacterial dissemination were more effectively inhibited by the Taurolidin lavage than by the saline lavage.

Reduced bacterial dissemination and liver injury in CD14-deficient mice following a chronic abscess-forming peritonitis induced by Bacteroides fragilis.

The CD14 myelomonocytic differentiation antigen plays a major role in acute Gram-negative infections with Escherichia coli; however, its role in chronic infections has not yet been analyzed. To address this question, we studied the role of CD14 in a chronic abscess-forming peritonitis, induced by Bacteroides fragilis. B. fragilis (3x10(8) CFU/ml) were resuspended in a liquid nutrient agar and injected into the peritoneal cavity of CD14-deficient (CD 14-/-) and normal C57BL/6J (CD 14+/+) mice, respectively. After 3 days there was a severe phlegmonous intra-abdominal inflammation in both groups. After 7 days an abscess-forming peritonitis developed and by 14 days the infectious foci were compartimentalized. These observations were indistinguishable between CD14-/- and CD14+/+ mice. Although no differences were seen in abscess formation, CD14-/- mice were able to clear B. fragilis more efficiently from the blood than CD14+/+ mice. After 3, 7, and 14 days blood cultures were B. fragilis positive in 11% (1/9), 20% (2/10), and 0% (0/9) in CD14-/-compared with 90% (9/10), 78% (7/9), and 20% (2/10) in CD14+/+ mice, respectively (P<0.05). Furthermore, although the infection resulted in hepatocellular necrosis and severe hepatitis in both groups, at day 14 the liver cell damage was more severe in CD14+/+ than in CD14-/- mice (P<0.05). These results show that the chronic abscess formation induced by B. fragilis capsular polysaccharides is CD14 independent; however, bacterial clearance and/or dissemination and liver cell damage are at least partially influenced by CD14-dependent mechanisms.

Molecular mechanisms of sepsis.

Today a great number of problems in the field of bacterial sepsis remain to be solved. Understanding the molecular mechanisms of one of the most important bacterial products in the pathogenesis of sepsis - endotoxin may contribute to innovative and more effective therapies. Therefore, this review focuses on the structural and functional elements of endotoxin, its interaction with immune cells, and its biological activity. Finally, other bacterial components and their impact on sepsis are discussed.

[Is a 3-month USA sojourn of value for a German university surgeon?]. / Lohnt sich ein dreimonatiger USA-Aufenthalt für einen deutschen Universitätschirurgen?

From 06/02/97 until 08/29/97, I was working at the division of Molecular Medicine at the North Shore University Hospital/Cornell University Medical College in New York on a research project concerning the role of CD14 in a chronic Gram-negative experimental infection model. On the one hand I had to accept three months absence from my family and my own hospital, as well as high travel expenses. On the other hand, I looked forward to important experiences abroad, contacts to international scientists, publication in a highly regarded journal, and last but not least to get to know a breathtaking city.

[Does heparin modify the course of chronic abscess-forming peritonitis in the animal model?]. / Beeinflusst Heparin den Verlauf einer chronischen abszedierenden Peritonitis im Tiermodell?

After laparotomy and inoculation of a Bacteroides fragilis suspension (2 ml with 10(8) CFU/ml), we induced chronic abscess-forming peritonitis in rats (n = 19, untreated). Fifteen animals were treated with heparin 30 IU, administered s.c. from day 1 after inoculation of the bacteria onwards. The main groups were divided into three subgroups (n = 8/5/6 and n = 5/5/5), which were observed for 3/7/14 days, respectively. On days 3 and 7, abdominal swabs were not only B. fragilis positive, but also showed severe polyvalent mixed infection after translocation of intestinal bacteria into the abdominal cavity. In the heparin group, B. fragilis positive swabs were reduced and translocation was inhibited (P < 0.05 for days 3 and 7). In the untreated group, blood cultures were B. fragilis positive on days 3/7/14 in 3/2/1 animals versus 0/1/1 in the heparin group. Adhesions were found in the untreated group in 1/4/5 animals, whereas in the heparin group there were no adhesions (P < 0.05 for days 7 and 14). However, intra-abdominal abscesses were also diminished in the heparin group (0/2/1) compared with the untreated animals (2/4/6, P < 0.05 for day 14). Therefore, heparin was shown to have a favourable influence on chronic abscess-forming peritonitis in an animal model.

[Morphologic parameters for quantitative determination of inflammatory activity of the peritoneum]. / Morphologische Parameter zur quantitativen Bestimmung der entzündlichen Aktivität des Peritoneums.

The morphology of the inflammatory activity of the peritoneum has been measured qualitatively but quantitative assessments are not common. In a standardized rat model we induced chronic abscess-forming peritonitis after laparotomy and inoculation of 2 ml Bacteroides fragilis suspension at a concentration of 10(9)/ml colony-forming units. The morphological inflammatory activity was determined quantitatively by staining the specimen of the peritoneum with naphthol-AS-D-chloracetate-esterase (NASDCE); through this staining the cytoplasm of granulocytes and tissue mast cells were marked. The peritonitis group (n = 53) and controls (n = 15) were randomly divided into three subgroups (nPeritonitis = 17/18/18 vs. ncontrol = 5/5/5) and observed for 3/7/14 days, respectively. On days 3/7/14 we diagnosed intra-abdominal abscesses in 2 of 17, 13 of 18, and 12 of 18 animals in the peritonitis group. In controls there were no abscesses (P < 0.05). The total cellularity and NASDCE-positive rates on days 3/7/14 in the peritonitis group were 301/409/280 (vs. 155/240/273 in controls) and 1.8/2.9/3.6% (vs. 0.7/0.9/1.4%) in the non-abscess-forming regions and 392/661/625 and 14.4/12.9/11.5% in the abscess-surrounding regions in the infected animals, respectively (P < 0.05). We conclude that the qualitative histological evidence of the morphological inflammatory activity of the peritoneum in the form of an abscess can be supplemented by a quantitative method. Through NASDCE staining the granulocyte and tissue mast cell proportion of the total cellularity as main indicators of the local inflammatory activity can be estimated in peritonitis. This method can be helpful in deciding when to definitively close the abdomen in the course of a programmed lavage treatment in peritonitis.

[Laparoscopic staged lavage in CAPD catheter peritonitis--an alternative to open treatment?]. / Laparoskopische Etappenlavage bei CAPD-Katheter-Peritonitis--eine Alternative zur offenen Behandlung?

Three patients suffering from severe CAPD peritonitis underwent laparoscopically programmed lavage after removal of the catheter. After an average of four laparoscopic lavage operations all patients had to be treated using conventional open procedures; a mean of ten programmed lavage procedures were carried out because of increasing peritoneal inflammation and worsening of the clinical situation during minimal invasive therapy. One patient did not survive. Laparoscopic treatment is thus not recommended for diffuse peritonitis.