[Primary hemiarthroplasty of complex fractures of the humeral head - results for different prosthetic designs]. / Primäre Hemiarthroplastik bei Humeruskopfmehrfragmentfrakturen - Ergebnisse in Abhängigkeit der Prothesengeneration.

AIM: Primary hemiarthroplasty of the shoulder is an alternative method for the treatment of complex fractures of the humeral head as compared to humeral head-preserving methods. This study compares the results of two different prosthetic designs. A first generation design, the Neer prosthesis (SGE 1 G) and a third generation design, the Aequalis prosthesis (SGE 3 G) were investigated. METHOD: The data (patients' charts, X-ray, and ultrasound) were collected and analysed in a retrospective manner. Self assessment was performed using the visual analogue scale (VAS), functional outcome was determined using the Constant score. For data analysis, methods of descriptive statistic were applied. RESULTS: 29 patients were treated with the SGE 1 G and 49 patients were treated with the SGE 3 G. Patients' age in the mean was 76 years, more women than men were affected. According to the Neer fracture classification, four-part fractures were the most frequent type of fracture. 64 % of the patients in the Neer (SGE 1 G) group and 68 % in the Aequalis (SGE 3 G) group were satisfied with the result according to VAS. The average Constant score in the Neer group was 50 points and in the Aequalis group 59 points. Better results were detected for the subjective parameters pain and activity than for the objective parameters motion and strength. The postoperative deviation from the age- and sex-related Constant score was smaller in the Aequalis group (5 points) than in the Neer group (17 points). Ultrasound examinations revealed in nearly all patients atrophy of the rotator cuff resulting in disturbances of motion between the corresponding gliding tissues. CONCLUSIONS: The SGE 3 G shows better results in the VAS and Constant score than the SGE 1 G. The advantages of the modular design of SGE 3 G are underlined by the clinical results.

[Concomitant vascular complications in supracondylar humerus fractures in children]. / Begleitende Gefässkomplikationen bei suprakondylären Humerusfrakturen des Kindes.

From January 1st 1990 to December 31st 1997, 614 children were treated for supracondylar humerus fracture at the Department of Orthopedic Surgery in the Olga Hospital, Stuttgart. Ten of these children had concomitant vascular complications. The concept of treatment we had chosen was analysed retrospectively. The median patient age of the seven girls and three boys with vascular complications was six years. The vascular injuries were diagnosed after admission to the hospital by palpation of the wrist pulse, clinical appraisal of the vascularity and by registration of the Doppler signal via the arteries of the wrist. The emergency operations carried out initially comprised fragment reposition and fixation with crossed K wires via an access route on the extensor side in all ten children. The subsequent appraisal of the blood flow revealed a pulse restoration (transient vascular occlusion due to dislocation) in two out of the ten children. In eight out of the ten children, the pulse did not return, which is why the vessel had to be explored under emergency conditions. Intraoperatively, we saw a vascular spasm with functional vascular occlusion in one of these eight children. Mechanical vascular occlusion were diagnosed in five of these eight children. In adventitial strangulation (two of these five children), the pulse transmission to the hand occurred immediately after severance of the strangulation connective tissue. In intimal damage (three of these five children), the vascular segment concerned was resected and reconstructed, mostly in the form of an end-to-end-anastomosis with venous patch grafting. We observed a combined vascular occlusion (mechanical-functional occlusion) in two out of these eight children. In the follow-up investigation, the wrist pulses could be palpated in nine children. Nine children had a physiological signal in color duplex sonography, and one child had a pathological monophasic signal over the brachial artery, radial artery as well as the ulnar artery. Late ischemic damage (cold intolerance, claudicatio, Volkmann's contracture) were not detected in any of the children. Appraisal of elbow joint mobility revealed a median extension deficit of 0 degrees (range 0-10 degrees ), a median flexion deficit of 0 degrees (range 0-15 degrees ) and a normal pronation and supination equal on each side. The load-carrying joint axis was normal in a comparison of the sides in all children.

[Seidel humerus intramedullary nailing. Clinical results of 100 surgeries]. / Die Humerusverriegelungsmarknagelung nach Seidel. Klinische Ergebnisse nach 100 Anwendungen.

Between 01.01.88 and 30.07.94 we treated 81 traumatic and 19 pathologic humeral shaft fractures with the Seidel humeral locking nail (HLN). The majority of the 100 patients (60 women, 40 men) were older than 60 years of age. The dominant fracture type according to AO was type A. Operative stabilization was considered indicate because of fracture distraction during functional bracing in most cases. In general, patients choose surgical intervention in preference to conservative management. Radiological consolidation was observed within 10 weeks. In 48 cases sonography revealed motor disturbances between the gliding sheath of the rotator cuff, but there was no correlation between this and the shoulder mobility. In 7 cases an additional fracture was created during introduction of the nail. This complication can be avoided by using the right technique. There were no cases of non-union or radial nerve lesion. There were 2 patients who developed an infection, which disappeared after removal of the nail and introduction of antibiotic-loaded beads. Functional results were recorded in 63 patients: 53 patients (84%) had an excellent or satisfactory result (NEER score > 80). Among the others, problems at the site of nail insertion predominated. In our view, the Seidel humeral locking nail is an implant that provides exercise stability without intraoperative positioning problems or risk of injury to nerves or vessels. Nevertheless, this method needs a skilled surgeon with special training to handle typical technical nailing problems.

[Craniocerebral trauma in fall from bicycles--what is the effect of a protective helmet?]. / Schädel-Hirn-Trauma nach Fahrradsturz--welchen Einfluss hat der Schutzhelm?

A prospective study was performed to analyze the particular injuries of 76 cyclists who required in-patient treatment in our department in 1994. There were 50 male and 26 female cyclists, with a median age of 33 years (range: 4-87 years). The most frequent diagnosis, in 50% (n = 38), was head injury. The series included 63 cyclist (83%) who had not been wearing helmets, and 33 of these sustained a head injury; in the helmet group head injury was found in only 38% (5 out of 13). It is remarkable that more serious head injuries did not occur in the helmet group. In 24 of these 33 head-injured patients (73%) without helmets additional intra- and extracranial diagnoses were made: pathologic EEG in 18 patients (55%), skull fracture in 13 patients (39%), intracerebral haemorrhagic contusion in 4 patients (12%) and an increase in intracerebral pressure (edema) in 3 patients (9%). In contrast to these findings, only 2 of the 5 head-injured patients (40%) in the helmet group showed slight changes in the EEG. In our opinion the bicycle helmet can reduce the incidence and the grade severity of head injuries significantly, particularly as we had 2 deaths in the non-helmet group and none in the helmet group. The use of a bicycle helmet is therefore strongly advocated.

[Ultrasound imaging of the anterior cruciate ligament. Possibilities and limits]. / Sonographie des vorderen Kreuzbands: Möglichkeiten und Grenzen.

We carried out sonography of the femoral origin of the anterior cruciate ligament in the dorsal cross section with a 7.5-MHz linear scanner in 25 test subjects with healthy knee joints. A physiological difference between the sides in the size of the hypoechoic region of the origin could be defined on the basis of the measurements obtained in both knee joints. Values outside a reference range which could be evaluated from this difference were rated as pathological in terms of an anterior cruciate ligament rupture. The reliability of this method in definitively diagnosing an anterior cruciate ligament rupture was analysed statistically as compared to the golden standard of arthroscopy on 65 patients by means of the two-by-two frequency table test. The femoral origin of the cruciate ligament in 25 test subjects had a median width of 3.1 mm (range 1.7-5.8 mm) on the right and 3.4 mm (range 1.7-4.4 mm) on the left. The median difference between the sides is 0.4 mm (range 0-1.8 mm). If the 3rd to the 97th percentile is selected as the reference range, our data show a physiological difference between the sides of 0-1.5 mm. The median age of the 65 patients was 31 years (range 14-74 years). Two thirds of all patients were men. A rupture of the anterior cruciate ligament was diagnosed sonographically in 19 patients. The result was confirmed arthroscopically in 15 patients. In 4 patients, there was a false positive sonographic finding. Forty-six patients did not fulfil the sonographic criteria of a rupture of the anterior cruciate ligament. Of these, 38 showed an intact anterior cruciate ligament on arthroscopy. Eight patients had a false-negative sonographic finding. The corresponding statistical analysis showed sensitivity of 65%, specificity of 90% and precision of 79%. Accordingly, the diagnostic reliability of knee joint sonography in diagnosing a rupture of the anterior cruciate ligament appears to be unsatisfactory, since old ruptures, above all, cannot be imaged with certainty (sensitivity 65%). On the other hand, a positive sonographic finding points with relative certainty to a rupture of the anterior cruciate ligament even before the operation (precision 79%). Histological analysis of the cruciate ligament preparations obtained intraoperatively showed that in particular the fresh anterior cruciate ligament rupture can be imaged sonographically. Retrospectively, knowledge of the history is thus crucial for interpretation of the sonographic image. After acute trauma to the knee, a side difference in the femoral region of origin of the anterior cruciate ligament of more than 1.5 mm, as revealed sonographically, is a certain indication that the anterior cruciate ligament is ruptured. When there is a positive sonographic finding, ligament strain, synovial bleeding and partial ruptures of the anterior cruciate ligament as well as plica ruptures must be considered as possible diagnoses.

[Advantage of load-bearing osteosynthesis of pertrochanteric fractures in geriatric traumatology]. / Stellenwert einer belastungsstabilen Osteosynthese pertrochanterer Frakturen in der Gerontotraumatologie.

The problems experienced by most patients with trochanteric fractures are caused by their advanced age, particularly multimorbidity and osteoporosis, and due to this early postoperative functional treatment is only possible with full weight-bearing ability. To avoid perforation of the femoral head by overstress and collapse of the weak cancellous bone, any stabilizing device should be designed with an H-beamed blade, providing a large load-bearing surface. In our experience the 130 degrees-Double-T-blade-Plate is an effective implant for the treatment of pertrochanteric fractures, offering high stability, a large load-bearing surface, comparable complications with those known in other devices, easy and fast implantation, and low costs.

[Necrotizing enterocolitis: a 12-year retrospective study]. / Die nekrotisierende Enterokolitis: eine 12-Jahres-Retrospektive.

UNLABELLED: Necrotizing enterocolitis (NEC) is the most relevant intestinal acquired complication during the neonatal period. Due to the improvements in perinatal medicine during the last decade, we wanted to work out possible differences in the incidence, diagnosis and clinical courses of NEC during a 12 years period. PATIENTS AND METHODS: All premature or term newborns were eligible for the study, if a necrotizing enterocolitis > or = stage 2a according to Bell was diagnosed between January 1980-December 1991. RESULTS: During the study period, 90 preterm or term newborns were treated for necrotizing enterocolitis, 19 infants were admitted to our hospital for therapy of established NEC from other hospitals. Forty-five infants had a birthweight of < or = 1500 g. During the years 1987-1991 there was an increase in the incidence (4-12/year, median 9/year, compared to 0-6, median 3/year during the period 1980-1986). This was paralleled by an increase in very low birthweight infants admitted to the NICU (1980-1986: 35-45/year, 1987-1991: 83-108/year). Prominent clinical signs: abdominal distension (85 infants), increased gastric residuals (72), bright blood from rectum (56). Median time of manifestation in infants < or = 30 weeks was 17 days, for infants of 31-34 weeks 8 days and for infants of > or = 35 weeks of gestation 4 days. Eleven infants were fed parenterally exclusively before NEC, 12 infants received exclusively breast milk, 67 formula. Surgical treatment was indicated in 51 infants (indication: intestinal perforation or peritonitis diagnosed by abdominal paracentesis). Seventy-one infants survived, in 17 infants who died, NEC or secondary disorders were the main cause. CONCLUSION: With increasing numbers of very preterm infants, the relevance of NEC becomes more and more important. Concepts of prevention and early diagnosis further have to be worked out.

Diagnosis and treatment of necrotizing enterocolitis. A retrospective evaluation of abdominal paracentesis and continuous postoperative lavage.

From 1980 to 1991, 70 preterm and 20 term infants suffering from necrotizing enterocolitis (NEC) were treated at the University of Ulm hospitals. NEC was primarily suspected from clinical signs. The diagnosis was established by plain abdominal X-rays, infection markers and abdominal paracentesis. Indication for surgery resulted from paracentesis, from radiologically proven perforation, from ileus symptoms and from rapid clinical deterioration; 44 preterm and 7 term infants underwent surgery. Bowel resections were performed in 5 of the term and in 16 of the preterm infants. An enterostomy was fashioned in 33 cases. Total necrosis of the gut was apparent in 8 infants. A continuous peritoneal lavage was performed in 34 babies. One term and 18 preterm babies, all with a birth weight less than 1000 g, died. This results in a NEC-related overall mortality of 19%.