Zervikale Rückenmarkverletzungen bei stabiler unterer Halswirbelsäule mit Spinalkanalstenose

The aim of the study was to investigate the neurological outcome of spinal cord injuries in the traumatized cervical spine with a stenosis of the spinal medullary canal. From 1992 to 1999 we treated 145 spinal cord injuries and/or injuries with an unstable cervical spine, 138 were treated operatively, in 7 patients we found an injury of the spinal cord with a stable cervical spine and a stenosis of the spinal medullary canal. The radiological diagnostics consisted of anterioposterior X-rays of the cervical spine, an X-ray view of the dens axis and a stress roentgenogramm in extension and flection. An MRI was performed within the first 12 hours after the accident. The stenosis of the spinal medullary canal was evaluated by the quotient of the mid-sagittal diameter of the spinal medullary canal as well as the vertebral body (Torg-quotient) and ranged from 0.5 to 0.8. Pathological changed values were found in 4 patients within 2 segments and in 3 patients within 3 segments. In the T2-turbospin echo sequence hyperintense lesions of the spinal cord, accordingly to an edema were found in 6 patients. The neurological evaluation was performed according to the "Standard Neurological Classification of Spinal Cord Injuries". Treatment of these 7 patients was performed conservatively, consisting of NSAR as well as Methyl-Prednisolon according to the pattern of NASCIS-II and III. The follow-up was performed after 12 to 18 months. We evaluated the X-rays in anterioposterior and lateral view, stress roentgenogramms and neurological status. Radiological findings showed stable conditions of the cervical spine with block vertebras and increased osteophytes. The neurological outcome was evaluated according to the "Motor-Score" and showed an improvement from 8 to 63 points within 13 months in one case. In 6 cases, the average "Motor-Score" of 78 increased to 100 points within 2 to 5 months after injury. Most defunctionalization symptoms were found in the upper extremities. Disturbances in fine motor movement were unable to be examined with the "Motor-Score". We can conclude that spinal cord injuries in stable cervical spines with stenosis of the spinal medullary canal can be treated conservatively with a good outcome. A regression of the neurological deficiency can be expected within 2 to 5 months, but even after one year, deficiency regression is possible.     

Das schwere Schädel-Hirn-Trauma bei Mehrfachverletzten Eine Bestandsaufnahme zur Interaktion lokaler und systemischer Mediatorwirkungen

Isolated severe head trauma (SHT) or SHT in combination with multiple injuries are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanic brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in iscemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure (MOF). Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or cumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the central nervous system and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Our knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In this context, the effects of secondary surgical interventions which may additionally, stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies. This article tries to summarize some important aspects on this topic.     

Die Wertigkeit der Magnetresonanztomografie (MRT) bei der Diagnostik von Übergangsfrakturen im Bereich der distalen Tibia

The rare transitional fractures occur in adolescents at a time of incomplete desis of the epiphysis. The anatomy of this fracture type is complex with the fracture line running in multiple planes. Conventional plain film radiographs often underestimate the extent and geometry of the fracture due to its transverse components. This study was performed to asses the benefit of MR-imaging compared to plain film radiographs in diagnosis and analysis regarding fracture-type, anatomy and dislocation of fracture. During a time period of 18 months we treated 15 patients with a fracture of the distal tibial epiphysis. In addition to plain film radiographs they got MRI of the distal tibia. Plain film radiographs and MRI were anonymized and diagnosed by 2 surgeons and 2 radiologists. 12 transitional fractures were diagnosed in plain radiographs as well as MRI, but regarding our criteria as above, we found two wrong classifications of fracture-type, an underestimation of fracture dislocation of an average of 0,5 mm in plain film radiographs and two rotational dislocations were missed. The MRI was found to provide anatomical detail and information superior to plain film radiographs.     

Indikation und Ergebnisse nach Radiuskopfprothesen

Treatment of unreconstructible comminuted fractures of the radial head (Mason type III or IV) remains controversial. Radial head excision was advocated for the management of these severe fractures in the past. Complications such as valgus elbow instability, elbow stiffness, and proximal radial migration can be the result. There is limited information on the outcome of arthroplasty with a radial head implant. The functional outcomes of 19 patients with arthroplasty of the radial head were evaluated after an average of 40.4 months. According to the functional rating index (Broberg and Morrey), 2 results were graded as poor, 6 as fair, and 11 as good or excellent. The poor and fair outcomes were associated with concomitant injuries. Elbow flexion of the injured extremity averaged 121±15°, extension ?19±12°, pronation 76±17°, and supination 73±18°. Valgus stability was restored and proximal radial migration did not occur. Complications included two luxations, but no wound infection. Patients treated with radial head prosthesis for a severely comminuted radial head fracture have mild to moderate impairment of the elbow and wrist. Arthroplasty with a radial head prosthesis was found to have been a safe and effective treatment option.     

Appendizitis Moderne Diagnostik

At times, making the diagnosis of acute appendicitis may pose a considerable problem. However, prompt and accurate diagnosis is essential to obtain minimal morbidity. Diagnostic mistakes result either in delayed initiation of adequate therapy or unnecessary operations. During the past years, a number of new strategies and diagnostic procedures have been developed and refined, including structured patient interview pathways, scoring systems, ultrasound, computed tomography, and diagnostic laparoscopy. This review summarizes the diagnostic performance of these modalities and discusses their clinical impact. It is apparent that in everyday practice, none of the technical modalities can replace the skill and precision of surgical exploration.     

Dopplersonographisch unterstützte Hämorrhoidenarterienligatur Eine neue Therapie bei symptomatischen Hämorrhoiden

In 1995, Morinaga et al. (Japan) reported on a new technique in the treatment of hemorrhoids. We report the results of our first 105 patients thus treated. By a specially designed proctoscope coupled with a Doppler transducer, the hemorrhoidal arteries are looked for and ligated. All stages of hemorrhoid were treated. This method is painless, successful, and has a low rate of complications. It is for outpatients and is an alternative to all other methods in the treatment of hemorrhoids.     

Lebensqualität nach operativ behandelten BeckenringfrakturenSind Langzeitergebnisse vorhersagbar?

Patients with fractures of the pelvic ring and accompanying injuries special of the extremity make heavy demands on hospital resources and face difficulties in rehabilitation. From the patients point of view milestones in recovery are quality of live and return to productivity. We studied 64 patients with pelvic-ring-fractures in a period of 10 years. The follow up was taken 4 years after discharge. PTS-score and AO-classification correlate directly to long-term disability, based on Rosser-Index, and “return to productivity” figures but not always to radiological and clinical outcome. This study emphasizes the need for new injury scoring systems that better predict the recovery and ability to return to work of trauma patients after surviving unstable pelvic fractures. Proper follow-up evaluations should analyse the patient's quality of live and working activity beside traditional item like radiological and clinical findings.     

Welchen Einfluss hat die Größe und Platzierung des Patellarückflächenersatzes bei Knieendoprothesen?

The aim of this study was to document the changes in retropatellar pressure, contact area and forces due to different sizes and placement of the patella resurfacing in knee arthroplasty. Six cadaver specimens (after Thiel fixation) were examined after the implantation of the total knee arthroplasty Genesis I. The patella sizes "small" and "medium" were placed as the "onlay" version, centered as well as off-centered by 0.4 cm in all four directions. Pressure and area measurements were done with Fuji pressure measuring film, which was placed between the patellar fascia of the femur and the patella in a defined position. The pressure was measured by applying a predetermined force for 5 s. The examinations were done with 60 degrees knee flexion and a force of 280 N. In our results there were no significant differences between, patella sizes. No significant differences for the medial, distal and proximal placement were found for the small patella. The lateral placement led to a significant decrease in the contact area (P = 0.0277), maximum pressure (P = 0.0422) and force (P = 0.0277). The average pressure did not change significantly (P = 0.1159). For the medium size patella there were no significant differences for medial or distal placement. The comparison of lateral and central placement revealed a significant decrease in the contact area (P = 0.0446). Comparing distal and proximal positioning, a significant increase in contact area and significant decrease in force were found (P = 0.0277 and P = 0.0277 respectively). In conclusion, the choice of small or medium patella resurfacing does not seem to have a significant influence. In comparison to the results without patella implants, the implantation of the small patella caused a significant decrease in the retropatellar contact area (P = 0.03) and force (P = 0.03). Average and maximum pressure did not change significantly (P = 0.6 and P = 0.35) even though pressure increased slightly. For the medium size, maximum pressure (P = 0.03) increased significantly and force decreased significantly (P = 0.0277) whereas contact area and average pressure increased slightly. The results of the different placements of the patella implant do not support the recommendation for a medial shift. However, at least the lateralized implantation led to a reduction of contact area and force as well as to a slight increase of pressure which is considered as unfavorable.     

Über Brückenvenenverletzungen bei tödlich verunglückten Kraftfahrzeuginsassen

Experimental data and clinical as well as postmortem experiences have indicated that subdural hematomas are less frequent in acceleration injuries in traffic accidents compared to falls or assaults. The present report demonstrates that this does not hold true in the same way for bridging vein ruptures (one of the predominant causes for subdural bleedings). Ruptures of these vessels without subdural bleeding (SDB) are only seldom mentioned in the literature. However, if no SDB is present, no one will look for these structures. In our institute a systematic analysis of the bridging veins in all cases of lethal blunt head injury is made: prior to the careful morphological preparation we investigate these vessels by radiographic imaging after filling with contrast medium. 6 car passengers (age between 4 and 31 years) which suffered a lethal head injury were examined in the last year. 2 victims had impressed fractures with cerebral compression injuries. In 1 case the base of the skull was broken and in 3 cases no skull fracture was present; no serious focal brain injury had occurred in these 4 cases, but 3 victims had signs of diffuse brain injury. In 5 cases a direct impact of the head against the interior of the car was obvious. In 5 cases ruptures of several bridging veins could be demonstrated. In one case (survival for 3 days) a minor SDB (20 ml) was present and the ruptures had been closed by thrombosis; another victim died at the scene. The other 3 victims survived between 4 and 15 hours without developing SDB and without closing of the ruptures by thrombosis. This combination is surprising and shows that our knowledge concerning the relationship between bridging vein ruptures and SDB is restricted. The frequency of bridging vein lesions in severe head injuries is likely underestimated in the clinical as well as in the postmortem literature. A rapid increase of intracranial pressure after the accident resulting in a collapse of the cerebral circulation is probably responsible for the absence of the SDB in the presented cases.     

Ultrasound in local anaesthesia. Part II: ultrasound-guided blockade of peripheral nerve channels

Recent developments in blockade techniques are based on the possibilities offered by modern sonography. With high frequency linear probes, the smallest tissue structures, such as peripheral nerves, in areas close to the surface can be visualised. This is the prerequisite for ultrasound-guided blockade techniques which has now been established for available peripheral blockades. These techniques are basically far superior to all other assist methods of peripheral blockades, because they allow a success rate close to 100%, a short preparation time and a reduction in the use of local anaesthetic agents. Apart from these, one particularly important aspect is that they reduce the risks of local anaesthesia procedures by direct imaging of neighbouring anatomical structures. In this article the theoretical basis of ultrasound techniques and their practical use in local anaesthesia will be presented.     

Zelladhäsion Molekulare Grundlagen und erste Aspekte für die Chirurgie

Zusammenfassung. Die Adh?sion zirkulierender Zellen an Endothelzellen wird durch Zelladh?sionsmoleküle vermittelt und l?uft kaskadenf?rmig ab. Die ersten Schritte dieser Zelladh?sionskaskade (rolling, tethering) werden vornehmlich durch Selektine (P-, E- und L-Selektin) reguliert, w?hrend an der stabilen Zelladh?sion und der anschlie?enden Migration haupts?chlich Integrine (LFA-1 u. a.) und Mitglieder der Immunglobulinsupergenfamilie (ICAM-1 u. a.) beteiligt sind. Die Leukocytenendothelinteraktion l?uft unter physiologischen und pathophysiologischen Bedingungen sowie in verschiedenen Organen sehr ?hnlich ab; m?glicherweise wird die Zellwanderung in individuelle Gewebe/Organe (z. B. beim homing) durch zus?tzliche organspezifische, topische Adh?sionsmoleküle (wie MAdCAM) erg?nzt. Die m?gliche klinisch-chirurgische Bedeutung von Zelladh?sionsmolekülen kommt insbesondere in der Transplantationsmedizin (Isch?mie/Reperfusion und Rejektion), bei Entzündungen (z. B. chronisch entzündliche Darmerkrankungen) und in der Tumormetastasierung zum Tragen. Die Ergebnisse tierexperimenteller Untersuchungen zur Antiadh?sionstherapie zeigen, da? durch Blockade der Leukocytenendothelinteraktion die Entstehung von Entzündungsinfiltraten und die Absto?ungsreaktion verhindert werden k?nnen – Erfahrungen im Humansystem liegen bisher nur vereinzelt vor. Voraussetzung für die klinische Umsetzung ist u. a. ein besseres Verst?ndnis der Regulation von Zelladh?sionsmolekülen (Cytokine, chemotaktische Substanzen etc.) und der Spezifit?t dieser Prozesse. Schon heute legen die experimentellen Daten nahe, da? durch Interaktion mit dem Zelladh?sionssystem durch frühe Beeinflussung eines grundlegenden pathophysiologischen Prinzips ein innovatives Therapiekonzept etabliert werden kann.      

Chemoprävention des Prostatakarzinoms

Chemoprevention of prostate cancer is the administration of agents to prevent, inhibit, or delay progression of prostate cancer. Asian men have a much lower incidence of prostate cancer than men in Europe or the USA. Asian food includes low-fat, high-fiber diets, which provide a rich supply of weak dietary estrogens. These estrogens have been proposed as chemopreventive agents. In addition to their estrogenic activity, many of these plant compounds can interfere with steroid metabolism and bioavailability and can also inhibit enzymes, such as tyrosine kinase or topoisomerase, which are important for cellular proliferation. In addition, nutritional factors such as reduced fat intake, vitamin E, vitamin D, and selenium may have a protective effect against prostate cancer. The fact was proven in large epidemiological studies as well as experimental observations. In the animal model, the progression of established tumors can be inhibited by these agents. A number of studies to investigate the effect of possible chemopreventive agents for men at high risk of prostate cancer are established. End points for evaluation are mainly based on changes in PSA, changes of histological precursors, or time of onset of clinical disease. The concept of chemoprevention in prostate cancer might have a significant impact on the incidence and mortality of this disease.     

Mikrohämaturie – Wie weiter?

Asymptomatic microhematuria is a common reason for a urological consultation. Uncertainty prevails as to how meticulous the work-up must be, to not miss relevant or even life-threatening underlying diseases. To date, the Urological Associations have not released any guidelines to which extent patients need to be examined for asymptomatic microhematuria, which therefore is managed individually by each urologist. There are various potential examinations that can be applied, ranging from a clinical examination to a kidney biopsy. After reviewing the literature, an algorithm has been developed, which should assure diagnosis of serious disease and at the same time avoid costly, unpleasant and unnecessary examinations.     

Multimodale interdisziplinäre Therapie als Voraussetzung für Verbesserungen von Funktion und Langzeitüberleben bei Patienten mit einem hochmalignen Osteosarkom der Extremitäten

Introduction. The probability for survival of patients with highly malignant osteosarcoma of the extremities was essentially improved by (neo-)adjuvant chemotherapy. The goal was to further improve survival rates by introducing operative treatment of metastases. In the last 20 years, the percentage of limb-preserving operations has increased. Patients and methods. A consecutive series of 23 patients with localized highly malignant osteosarcoma of the extremities received (neo-) adjuvant chemotherapy according to the Cooperative Osteosarcoma Study (COSS) protocol. Local treatment was performed by wide (22 patients) or radical (1 patient) resection (17 limb salvage procedures, 5 amputations, and 1 rotationplasty). In four of seven patients who developed pulmonary metastases, the metastases (up to four) were resected. The patients did not receive salvage chemotherapy. Results. The cumulative survival was 87% at 174 months. The four patients who underwent metastasectomy survived between 42 and 116 months without evidence of disease. One local recurrence developed outside the operative field and could be resected without influencing the functional or oncological outcome. After limb salvage procedures, the mean score according to the Musculoskeletal Tumor Society (MSTS) was 83%, and after rotationplasty 67%. Conclusions. In patients with osteosarcoma of the extremities, limb salvage is possible in a high percentage of cases with a low risk of local recurrence by an effective interdisciplinary cooperation between diagnostic radiologists, oncologists, and orthopedic surgeons. The midterm survival could be improved by the multimodal therapy from about 20% up to about 80%. Metastasectomy gives patients with a limited number of pulmonary metastases a realistic chance to survive.     

Fehldiagnosen bei verspätet erkannter beidseitiger simultaner Ruptur der Quadrizepssehnen

Es wird über den seltenen Fall einer beidseitigen, simultanen Quadrizepssehnenruptur bei einem 38j?hrigen Patienten berichtet. Die initiale Diagnose lautete dabei ,,Bandscheibenprolaps`` und es dauerte trotz intensiver Diagnostik, einschlie?lich mehrerer operativer Eingriffe sowie einer neurologischen und psychiatrischen Abkl?rung, fast 3 Monate bis das Krankheitsbild erkannt und kausal behandelt wurde. Im speziellen wird dabei die gipsfreie, intensive postoperative Mobilisation des Patienten dargestellt.      

Injury prevention in the elderly population

Injuries in the elderly population have more considerable consequences (more difficult treatment, higher costs,worse outcome) than in the younger population. Therefore, the prevention is especially important. The majority of the injuries are caused by traffic accidents and falls. TRAFFIC ACCIDENTS: An analysis of the current injury situation in elderly road users (65 years and older) involved in road traffic accidents was intended to allow conclusions regarding future prophylaxis. FALLS: Falls are mostly caused by numerous factors.The most important predictors for falls are dementia,Parkinson-Syndrome and neurologic deficits after cerebrovascular insults.The most important symptoms, that indicate an increased risk for fall are gait abnormalities, balance lack and underweight. The most important anamnestic indications are more than one falls in the recent 90 days, need for assistance in daily living and prevailing medication.Another important factor is the residential setting (lighting, stairs, floor conditions,bath installations).The most affective protective interventions involve multiple factors.The incidence of falls could be reduced by 30%.The hip protector is an effective protection against proximal femur fractures. which is the most frequent fracture in the elderly population that requires treatment as an inpatient. Injury prevention in the elderly population is an interdisciplinary task as for example shown by the successful fall clinics in the anglo-american area.     

Kontaktfläche und Druckbelastung im Implantat-Knochen-Interface bei Press-Fit-Hüftpfannen im Vergleich zum natürlichen Hüftgelenk

Zusammenfassung Die Implantation einer alloarthroplastischen Hüftpfanne ver?ndert die mechanischen Spannungsverh?ltnisse im Bereich des Acetabulums gegenüber dem natürlichen Hüftgelenk. Initiale Stabilit?t für die Osseointegration und eine an das natürliche Hüftgelenk angepa?te biomechanische Wechselwirkung sind bei zementfreien Hüftgelenksendoprothesen für eine dauerhafte kn?cherne Integration notwendig. In einer in-vitro Untersuchung mit Beckenpr?paraten wurde die Druckverteilung an 8 Acetabula intraartikul?r und nach Implantation von 2 Press-Fit-Pfannen im simulierten Einbeinstand mit der Druckme?folie bei K?rperlasten zwischen 350 und 1400 N gemessen. Mittels digitaler Bildauswertung zeigt sich, da? die Kontaktfl?che im natürlichen Hüftgelenk von 39.0 % der acetabul?ren Gelenkfl?che auf 56.9 % ansteigt. Zwischen Pfannenoberfl?che und gefr?stem Acetabulum betr?gt die Kontaktfl?che beim Press-Fit-Cup unbelastet 44.7 %, bei 700 N 53.0 % und bei 1400 N 64.2 %. Die entsprechenden Werte des PCA-Cups sind 45.1 %, 48.9 % und 57.1 %. Der zun?chst ?quatornahe druckübertragende Kontakt wird bei Laststeigerung zum Pfannenpol ausgeweitet. Beim PCA-Cup tritt dann am Pol Kontakt zur Fossa acetabuli auf, die beim Press-Fit-Cup infolge der Polabflachung wie beim natürlichen Gelenk lastfrei bleibt. Die Druckbelastung tritt im Sinne einer 3-Punkt-Abstützung im natürlichen Gelenk und im Pfannen-Knochen-Interface dort auf, wo das Acetabulum vom Os ileum, dem Os ischii und dem Os pubis gestützt wird.      

Untersuchungen zur mechanischen Aktivität frei transplantierter Dünndarmabschnitte beim Hund

Zusammenfassung Nach freier Transplantation einer Dünndarmschlinge bei 6 Hunden wurden im Wachzustand die intraluminalen Druckschwankungen registriert. Dabei konnten die für den Dünndarm typischen Aktivit?tsmuster, weiters eine zeitliche Koppelung der segment?ren Kontraktionen sowie Unterschiede zwischen dem nüchternen Tier und nach Fütterung festgestellt werden.