[Therapy of unstable sacrum fractures in pelvic ring fractures with dorsal sacrum distraction osteosynthesis]. / Die Therapie instabiler Sakrumfrakturen bei Beckenringbrüchen mit dorsaler Sakrumdistanzosteosynthese.

Unstable pelvic ring injuries AO type C ("vertical shear") with a fractured sacrum are treated operatively in less than 50% of the cases (DGU pelvis study group). Furthermore, only 12% of these ORIF involve the sacrum bone itself. No specific technique has gained wide acceptance in treating transsacral instability. In accordance with earlier publications (Käch, Josten) suggesting an internal fixator, we developed the dorsal sacrum fracture distantly anchored ORIF (DSDO). This procedure closes the dorsal pelvic ring by joining the two dorsal iliac crests (fixed-angle screws inserted in the posterior superior iliac spine) and additionally anchors in a lumbar pedicle. Thus, a three-dimensional reduction and stable fixation device with optional local nerve decompression and even plating possibility is achieved. Between January 1996 and July 2001, 35 unstable sacrum disruptions were treated with DSDO in 180 patients operated for pelvic trauma. This allowed immediate mobilization in all cases. The radiologic follow-up examination ( n=20) revealed a solid union in all patients. Complications focused on management of the soft tissue degloving injury (Morel-Lavalleé lesion), which needs special attention.

[Early functional after-care of surgically treated fresh ruptures of the Achilles tendon]. / Zur frühfunktionellen Nachbehandlung der operativ versorgten frischen Achillessehnenruptur.

Functional treatment regimens in favour of the idea of keeping up regular limited use of the extremities instead of immobilisation have continuously gained influence in orthopedic surgery. The knowledge that inconsistently used biological systems degenerate has now widely become accepted. Immediate Achilles tendon tension reconstruction by means of minimal surgical incision and simple suture in addition with fibrin-glue was performed in 51 patients. Age, sex-distribution, etiology, preexisting pain, rate of degenerative histologic findings and side of rupture were similar to those reported in former studies with large numbers of patients [2, 6, 7, 8, 10, 12, 13]. Non weightbearing functional walking in a side supported "basketball" sports shoe (Adimed) with gradually reduced heel support (initially 3 cm; complete removal regaining neutral position of the ankle joint after 4 weeks) was advised for 6 weeks, after acute postop swelling has resolved. All tendons healed and up to now (follow up period: 14-48 months - average: 26) no rerupture occurred. One insufficiency resulted from non compliance due to alcoholism.

[Catheter epidural analgesia in serial rib fractures]. / Katheterepiduralanalgesie bei Serienrippenfrakturen.

According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. Deep breathing and expectoration were easier, so that the use of respirators and other artificial breathing aids could be avoided or at least reduced in duration in some cases. This makes the method particularly suitable for use in the management of polytraumatized patients. The standard dose was a mixture of 3.3 mg morphine and 37.5 mg bupivacaine (= 1/3 ampoule morphine + 15 ml Carbostesin 0.25%) every 12 h. When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).