[Stabilization of inter- and subtrochanteric femoral fractures with the PFNΑ®]. / Stabilisierung sub- und pertrochantärer Femurfrakturen mit dem PFNΑ®.

OBJECTIVE: Intramedullary nail system fixation of inter- and subtrochanteric femoral fractures allows early weight-bearing, especially in osteoporotic bone. Restoration of anatomical shape and early return to function of the injured leg. INDICATIONS: All inter- and subtrochanteric fractures of AO type 31-A without limitation. CONTRAINDICATIONS: Open physes and unsuitable femoral shaft anatomy (increased anterior bow of femoral shaft or malunion after femoral fracture). SURGICAL TECHNIQUE: If possible closed, otherwise open fracture reduction on a fracture table and unreamed intramedullary nailing. Fixation of the fracture by insertion of a helical blade via a guide wire in the head-neck fragment of the femur. Option of static or dynamic locking at the femoral diaphysis. POSTOPERATIVE MANAGEMENT: Early mobilization immediately the day after surgery with full weight-bearing and use of assistive device, as tolerated. Thrombosis prophylaxis for 6 weeks with fondaparinux, rivaroxaban or a low molecular weight heparin (LMWH), alternatively oral anticoagulation. RESULTS: Between April 2004 and June 2005, the AO multicenter study at 11 European trauma centers included 313 patients (mean age 80.6 years, 77% women, 23% men) with 315 unstable trochanteric fractures treated with a Peroximal Femoral Nail Antirotation® (PFNΑ®) device for consecutive follow-up [24]. In 82%, the fractures were 31-A2, while in 18% the fractures were 31-A3. Average operation time for A2 fractures was 56 min and 66 min for A3 fractures. Average duration of hospital stay in the trauma center was 12 days. Surgical reduction and fracture fixation that permitted full weight-bearing immediately after operation was achieved in 72% of cases. Of 165 complications, 46 were surgery-related with unplanned revision surgery in 28 cases (including 7 femur fractures and 4 acetabular penetrations). Follow-up for more than 1 year was possible in 56% of patients. After 1 year, 89% of the fractures were consolidated. The highest complication rate was found in fractures type 31-A2.3 and in patients older than 90 years. The recorded number of implant-related complications (14.6%) is comparable to the results of other intramedullary and extramedullary implants.

Delayed union of a sacral fracture: percutaneous navigated autologous cancellous bone grafting and screw fixation.

Delayed or non-union of a sacral fracture is a serious clinical condition that may include chronic pain, sitting discomfort, gait disturbances, neurological problems, and inability to work. It is also a difficult reconstruction problem. Late correction of the deformity is technically more demanding than the primary treatment of acute pelvic injuries. Open reduction, internal fixation (ORIF), excision of scar tissue, and bone grafting often in a multi-step approach are considered to be the treatment of choice in delayed unions of the pelvic ring. This procedure implies the risk of neurological and vascular injuries, infection, repeated failure of union, incomplete correction of the deformity, and incomplete pain relief as the most important complications. We report a new approach for minimally invasive treatment of a delayed union of the sacrum without vertical displacement. A patient who suffered a Malgaigne fracture (Tile C1.3) was initially treated with closed reduction and percutaneous screw fixation (CRPF) of the posterior pelvic ring under CT navigation and plating of the anterior pelvic ring. Three months after surgery he presented with increasing hip pain caused by a delayed union of the sacral fracture. The lesion was successfully treated percutaneously in a single step procedure using CT navigation for drilling of the delayed union, autologous bone grafting, and screw fixation.

Prevalence of Helicobacter pylori infection in peptic ulcer perforations.

BACKGROUND: Most patients with chronic peptic ulcer disease have Helicobacter pylori (H. pylori) infection. In the past, immediate acid-reduction surgery has been strongly advocated for perforated peptic ulcers because of the high incidence of ulcer relapse after simple closure. Simple oversewing procedures either by an open or laparoscopic approach together with H. pylori eradication appear to supersede definitive ulcer surgery. METHODS: In 47 consecutive patients (mean age = 64 years, range 27-91) suffering from acute peptic ulcer perforation the preoperative presence of H. pylori (CLO test), the surgical procedure (laparoscopy or open surgery), the outcome of surgery, and the success of H. pylori eradication with a triple regimen were prospectively studied. RESULTS: Of these patients 73.3% were positive for H. pylori, regardless of the previous use of nonsteroidal anti-inflammatory drugs (NSAIDs). Thirty-eight per cent underwent a simple laparoscopic repair. Conversion rate to laparotomy reached a high of 32%. The main reasons for conversion were the size of the ulcer, and/or diffuse peritonitis for a duration of over 12 hours with fibrous membranes difficult to remove laparoscopically. In the H. pylori positive patients, eradication was successful in 96% of the cases. Mortality and morbidity rates were greater in the laparoscopic group (p < 0.05). Follow-up (median 43.5 months) revealed no need for reoperation for peptic ulcer disease and no mortality. CONCLUSION: We have found a high prevalence of H. pylori infection in patients with perforated peptic ulcers. An immediate and appropriate H. pylori eradication therapy for perforated peptic ulcers reduces the relapse rate after simple closure. Response rate to a triple eradication protocol was excellent in the hospital setting.

[Diverticulitis of the cecum and ascending colon]. / Diverticulitis des Coecum und Colon ascendens.

Right colon diverticulitis, representing 1-3.6% of cases of diverticular disease is an uncommon cause of right lower quadrant pain. Its presentation is difficult to distinguish from acute appendicitis. Patients are between 35 and 50 years old, have a history of 2-3 days of abdominal pain and few gastrointestinal symptoms. The diagnosis is best confirmed by computed tomography and colonoscopy. Conservative treatment is justified in uncomplicated disease, whereas perforations, abcesses and inflammatory tumors require resection. We describe the cases of six patients treated at our institution from 1991 to 1996. Presentation, geographic variations, diagnostic procedures and management are discussed.

[Reflux disease following gastropexy for para-esophageal hiatal hernia]. / Refluxkrankheit nach Gastropexie wegen paraösophagealer Hiatushernie.

From 1984 to 1992 28 patients with paraesophageal hiatus hernia underwent elective operation with crural repair and gastropexy. In the absence of severe reflux disease (6 patients had mild to moderate reflux symptoms) and of esophagitis at endoscopy, no antireflux repair was performed in these patients. Follow-up of 19 patients after 3 years (12-72 months) revealed reflux symptoms in 11 patients (58%) and moderate or severe reflux disease (need for medical treatment) in 6 (32%). 6 patients developed new reflux symptoms after operation. 3 patients had esophagitis at endoscopy. In elective cases, the repair of paraesophageal hernia should, regardless of the presence of reflux esophagitis, be combined with an antireflux procedure to avoid the high risk of postoperative reflux disease.