Correlation between risk factors and subsequent surgical management following internal fixation of intracapsular femoral neck fractures in patients under the age of 60 years.

PURPOSE: Regarding intracapsular femoral neck fractures, the main focus of research is the correlation between fracture-related complications and prognostic factors. To evaluate the correlation between complications required surgery (fracture-related treatment) and, among others, several less extensively investigated prognostic factors (day of surgery, co-morbidities, hospital type) in a 2-year period following internal fixation in patients under the age of 60 years with intracapsular femoral neck fracture. METHODS: A retrospective analysis of femoral neck fractures occurring in Hungary in 2000 was undertaken, based on data obtained from the National Health Insurance Fund Administration. The data were validated and completed by a questionnaire carried out in all of the 60 institutions enrolled. The effects of prognostic factors were analyzed by uni- and multivariate logistic regression in three groups: all fracture-related treatments and non-prosthetic (NPT) and prosthetic treatments (PT). RESULTS: Out of 413 patients, 17.9% required further fracture-related treatment. In 7.7% of patients, NPT and in 10.2% of patients, PT was performed. Fracture displacement (odds ratio [OR] = 2.24), weekend surgery (OR = 2.35), infections (OR = 3.68), central nervous system-related co-morbidities (OR = 3.64), and the county hospital level of management (OR = 2.36) were associated with significantly increased risk for further surgery. CONCLUSIONS: To reduce the influence of risk factors, standardization of the substantive traumatologic and orthopedic professional guidelines, as well as the introduction of the "common orthopedic-trauma patient care" (British model) are suggested. To achieve high-quality standardized patient management, personal and material conditions are required to be accessible every day of the week. In the presence of co-morbidities, reduction of their harmful effects should be a major consideration by focusing on the patient in the peri-operative periods.

Transgingival lag-screw osteosynthesis of alveolar process fracture.

Fracture of the alveolar process is a common injury. In some cases, traditional fixation may not be possible. The teeth needed for splinting or mandibulo-maxillary fixation may be missing. The fracture line and soft tissue injury may jeopardize the blood supply of the broken bone. In these extreme and rare situations, the best rehabilitation is needed to avoid the loss of hard and soft tissues, and a secondary reconstruction is required. Between January 2003 and December 2006, of 468 cranio-facial trauma patients studied, alveolar process fracture was reported in 28 (6%) cases. In six (1%) cases, the anatomy of the fracture lines, and the position and number of the remaining teeth made splinting and mandibulo-maxillary fixation impossible. Patients were treated with a transgingival lag-screw (TLS) osteosynthesis. All patients healed well with no complications. There was no bone or tooth loss in the surgical area, and broken fragments were not absorbed. The TLS technique is recommended for alveolar fractures when the blood supply is jeopardized and dental splinting or mandibulo-maxillary fixation is not possible. There is no need for flap reflection.

[Modified submental endotracheal intubation in concurrent orthognathic surgery]. / Modifizierte submentale endotracheale Intubation bei kieferorthopädischen Eingriffen.

BACKGROUND: In 1986 Altemir described a method of submental endotracheal intubation in order to avoid tracheostomy in maxillofacial trauma cases where short-term intermaxillary fixation was required. His method has become widely established for airway maintenance in midfacial fractures. CASE: We present a 21-year-old male patient with cleft lip and palate on the left side. The patient underwent Le Fort I maxillary osteotomy. Nasal intubation was impossible due to nasal malformation. In this case we used submental endotracheal intubation for airway maintenance. We introduced new methods: a sterile nylon guiding tube and our new "2-2-2 rule" incision to make the procedure easier. RESULTS: The occlusion could be checked easily. There were no complications during and after the operation. The submental wound healed nicely. DISCUSSION: The described case shows that the technique is easy to use compared to "alternative" intubation methods. Submental scarring is acceptable. We recommend the technique for orthognathic use.

Modified carpal box technique in the diagnosis of suspected scaphoid fractures.

PURPOSE: To establish and test the clinical efficacy of a new diagnostic algorithm with the extensive utilization of modified carpal box radiography (mX-CB) in the detection of scaphoid fractures. MATERIAL AND METHODS: Initial and early follow-up radiographic evaluation of 146 suspected scaphoid fractures were carried out by mX-CB. Patients with unconfirmed diagnosis were referred to CT. Patients were followed for 1 year after injury. Sensitivity, specificity and interobserver agreement of reading mX-CB images were determined statistically. RESULTS: No non-union or avascular necrosis was seen at 1 year after the injury. 90% of the fractures were diagnosed by mX-CB, only 6.8% of the patients needed referral to CT. Sensitivity of mX-CB at initial presentation was 81.6%. Interobserver agreement was very high among evaluators of mX-CB images. CONCLUSION: Extensive utilization of mX-CB as primary and early follow-up investigation resulted in high initial diagnostic accuracy and low referral rate to a more expensive diagnostic modality.

Biomechanics of the human flexor tendon sheath investigated by tenography.

Tenography has been performed on eight detached fingers and two intact hands of cadavers. Bulging and overlapping of synovial pockets between the ligamentous structures during flexion, their flattening during extension and the continuous change in expansion of the proximal cul de sac suggests a possible mixing mechanism for the synovial fluid. During flexion and extension a physiological joint-type bowstringing of the flexor tendons was observed at the PIP and DIP joints. This finding supports the theory that the flexor tendon moment arm is increased at these joints.

[Laryngopharyngectomy and free jejunal graft reconstruction in the treatment of hypopharyngeal tumors]. / Laryngopharyngectomia és szabad jejunum transzplantátummal végzett pótlás hypopharynx tumor kezelésében.

The authors performed a total laryngopharyngectomy due to a hypopharyngeal neoplasm. The continuity of the alimentary tract was restored by the insertion of a vascularized free jejunal graft, using microsurgical technique. On the occasion of this case the authors give a survey of the therapeutical methods used in the therapy of hypopharyngeal tumors, of the indications of the free jejunal transplant and of the technical issues and complications of this procedure.

[Substitution of the thumb by transplantation of the second toe]. / Hüvelykujj-pótlás második lábujj átültetésével.

Authors perform for the substitution of the thumb beside several other operations the transplantation of the second toe. The transplantation is carried out with the reconstruction of the arterial circulation, built on the I. metatarsal artery. Until now 18 substitutions of the thumb were carried out. The etiology of the lack of the toe is variable, in the great majority it is of traumatic origin however purulent process and attempt of suicide occur. With the observation of the rules of structural reconstruction good functional result may be reached. In more than a third of the cases both the sensitivity and the mobility are excellent. The use of this method is suggested first of all in cases where alternative substituting operations are out of question.

[Use of a distally pedicled radial artery as an island flap for covering traumatic skin losses]. / Disztálisan nyelezett artéria radiális szigetlebeny alkalmazása akut traumás börhiányok fedésére.

Authors performed plastic operation using lower arm insulated flap with distal pedicle in 2 cases for covering traumatic skin defects on the dorsal side of the hand. Attention is called to the advantages of this method. Beside the shorter time of treatment in many cases a series of operations can be avoided by the primary covering with an insulated flap.

[Substitution of soft tissue defects of septic origin on the back of the hand by transplantation of a free composite flap]. / A kézhát szeptikus eredetü lágyrész defektusának pótlása komposit lebeny szabad átültetésével.

Authors report on substitution of severe skin and extensor tendon defect on the back of the hand, developed after a II. grade open septic metacarpal fracture. For the covering of the defect of the soft tissue the paratenon--tendon--skin free flap unit was used, supplied by the a. dorsalis pedis. In one operation the skin in full thickness and the extensor tendons could be substituted at the same time the suppuration was eliminated and the pseudarthroses stabilized with lamellar osteosynthesis.

[Finger replantation]. / Ujj replantációk.

Authors performed from 1979 to 1989 on 89 fingers of 65 patients replantation or revascularization operations after total or partial amputations. The procedure was unsuccessful in 16 cases. The operation was successful in 82 per cent and this corresponds to the literary data. It is stressed that the operative result depends not from the survival of the finger but from the functional end result.

[Complex evaluation of hand function]. / Die komplexe Bewertung der Handfunktion.

The authors offer a method of assessment of hand function which renders numerical data, in which all functions of the hand are represented with appropriate emphasis. The result of the examination is expressed as a percentage of perfect function. The method, which seems on first reading somewhat complicated, can be simplified very much with a computer aided work-up of data. The method is suggested first of all for the assessment of the results of healing in severe complex hand injuries. It is also suitable for the expression of hand function in all cases (for example, judgement of the decrease of working capacity and decisions on insurance claims, etc.).

[Possibilities of finger substitution]. / Ujjpótlások lehetöségei a kézen.

Authors deal, in connection with their clinical cases, with the replacement of the fingers of the hand. Attention is called to the fact, that a minimal requirement of the reconstruction, performed on the severe, multiply amputated hand, should be the formation of a "basic hand", and that at the planning of such operations the aim may be the reconstruction of the function of the hand only. Among the methods presented the most modern methods, requiring microvascular surgical technique, are also shown. Although the right of using these is obvious, the older, however well proved methods should not be forgotten either. The possibilities of finger replantation are described didactically; considering the extent of this theme however authors did not strive to completeness.

[Restoration of movement after irreparable nerve damage caused by injury]. / A mozgás helyreállítása a kéz irreparábilis idegsérülései után.

Authors made a late follow-up of their motion improving operations, performed on the Department of Traumatology of the I Department of Surgery, Pésci University of Medical Science. The indication and technique of these operations in case of paralysis of the opponens, interosseal-lumbrical muscles and of the extensors of the hand are described in details.

[Results of replantation of limbs]. / Végtag-replantációink eredményei.

Authors describe 7 cases of limb replantation in their material. The field of indication is reviewed, the early postoperative complications and the possibilities of their treatment are discussed. The means of reaching the possible best results are examined. The ways of performing the possible optimal limb replantation are scheduled on the basis of their own experiences.