Anatomie und Verhalten von Sehnen und Bändern

Zusammenfassung Sehnen und Bänder bestehen vorwiegend aus Kollagenfasern vom Typ I. Diese werden durch lockeres Bindegewebe zu Bündeln zusammengefasst. Sie zeigen ein komplexes mechanisches, viskös-elastisches Verhalten mit Kriechphänomenen und Stressrelaxation. Eine Sehne ist stets Teil einer komplexen Einheit mit der zugehörigen Muskulatur. Bei der Anpassung an mechanische Belastungen spielen neurosensible Rezeptoren, freigesetzte Wachstumsfaktoren und Zellkontakte zwischen den Tenozyten eine entscheidende Rolle. Diese beeinflussen den Metabolismus der Zellen und somit die Synthese der Extrazellulärmatrix. Bedingt durch die unterschiedlichen Anforderungen (direkte Zugsehnen bzw. Gleitsehnen mit Umlenkfunktion), das Ausmaß der Bewegungsfunktion und Besonderheiten in der Gefäßversorgung finden sich ausgeprägte Besonderheiten im Aufbau und Reaktionsverhalten von Sehnen und Bändern. Eine kurzzeitige Immobilisation kann die Belastbarkeit der Faserstrukturen deutlich vermindern. Darüber hinaus verändern Reifungs- und Alterungsprozesse die Morphologie und das Stoffwechselverhalten des Bindegewebes.     

12.Schädel- und Gesichtsverletzungen und Folgen

Ohne Zusammenfassung     

Propofol und postoperative Übelkeit und/oder Erbrechen

The objective of this prospective, randomised study was to investigate the incidence of postoperative nausea and/or vomiting (PONV) during the first 24 h postoperatively. For a quality assurance study on PONV, we compared two established general anaesthetic procedures in 239 patients undergoing four different types of surgery (subtotal thyroidectomy, laparotomy for gynaecological procedures, laparoscopy, and surgery for extra-abdominal procedures). Methods: All eligible patients provided informed consent. For premedication temazepam 10–20 mg was administered orally. We used propofol (1.5–2 mg/kg) for induction of anaesthesia in all patients, followed by 0.1–0.3 mg fentanyl, 2.5–5 mg droperidol, and for muscular relaxation atracurium or pancuronium according to body weight. Maintenance of general anaesthesia in group A was by administration of isoflurane in a maximum concentration of 0.6 vol.% in 70% nitrous oxide and 30% oxygen and in group B by continuous infusion of propofol (5–8 mg/kg·h) and normoventilation with oxygen in air (Fi0₂=0.3). In both groups additional analgesia was provided intraoperatively by equal dosages of fentanyl up to a maximum of 0.6 mg and clonidine up to 200 μg. Episodes of PONV were registered following extubation, during the first 4 h postoperatively, during the period 4–24 h postoperatively, and after the first mobilisation. Pain scores were recorded with the aid of a visual analogues scale. The statistical evaluation was performed using the chi-square or Wilcoxon test. Results and Discussion: In patients undergoing thyroidectomy or laparotomy, continuous infusion of propofol drastically reduced the incidence of PONV in the first 24 h postoperatively, particularly during the first 4 h (25/41 vs 10/41, resp. 20/32 vs 11/31). The overall incidence of PONV was higher in the first half of the menstrual cycles decreased with patient age, increased with the duration of anaesthesia, and was higher in patients with a history of motion sickness. With the same level of analgesia in both groups, the differences disappeared in the further postoperative course. The use of similar dosages of opioids for pain control in these groups might explain this observation. PONV occurred extremely rarely in patients undergoing laparoscopy (1 resp. 2 of 34), and in those undergoing surgery for extra-abdominal procedures did not occur at all. The explanation may be that the induction of anaesthesia with propofol was followed only by a relatively short duration of general anaesthesia for these surgical procedures, and postoperative pain control was performed solely with non-opioids. Conclusions: We found that the antiemetic effect of propofol was considerable in the early postoperative period. The higher cost of propofol as compared to other induction agents can be covered by not using nitrous oxide for maintenance of anaesthesia and by the decreased need for antiemetic drugs postoperatively. According to the calculations of our clinical pharmacy, the costs of the propofol infusion regimen exceeded those of balanced anaesthesia by 8.50 DM/h; the need for antiemetics was one-half that of the non-propofol group. Considering a cost of 16 DM for cleaning the bed after vomiting, improvement of the patient′s condition during the postoperative period can be achieved without additional expense.     

Brust- und Lendenwirbelsäulenverletzungen im Kindes- und Jugendalter

Spinal injuries are generally very rare in childhood. Fractures of the thoracic and lumbar spine occur mainly in older children and adolescents. Exact knowledge of the anatomy is essential for accurate diagnosis in still incomplete ossification. With increasing age the classification can be performed by using the AO classification over the age of 8 years. Neurological symptoms in the thoracic and lumbar spine occur mainly in adolescence. Conventional radiography is the standard diagnostic tool for thoracic and lumbar spinal injuries. With the appearance of abnormal neurological deficits magnetic resonance imaging (MRI) diagnostics should also be performed and for operative cases computed tomography (CT) scans are mandatory. The most common fractures of the thoracic and lumbar spine are compression fractures (type A) which can generally be treated conservatively due to the stable situation but unstable fractures of the thoracic and lumbar spine (types B and C) are stabilized dorsally (internal fixation). Ventral stabilization with vertebral body replacement is occasionally necessary in adolescents. Spinal injuries in children have a good overall prognosis.     

Schuss- und Stichverletzungen in Deutschland – Epidemiologie und Outcome

Background

The management of gunshot wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. Penetrating injuries occur with an incidence of 5% in Germany. They are caused by gunshots or more commonly by knives or other objects, for example during accidents. Since even the number of patients who are treated at level 1 trauma centres is limited by the low incidence, the objective of this study was to assess the epidemiology and outcome of gunshot and stab wounds in Germany.

Material and methods

Since 2009, the trauma registry of the German Trauma Society (TraumaRegister DGU®) has been used to assess not only whether a trauma was penetrating but also whether it was caused by a gunshot or a stabbing. On the basis of this registry, we identified relevant cases and defined the observation period. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2011. We did not specify exclusion criteria in order to obtain as comprehensive a picture as possible of the trauma entities investigated in this study. As a result of the high incidence of gunshot wounds to the head and the implications of this type of injury for the entire group, a subgroup of patients without head injuries was analysed.

Results

From 2009 to 2011, there were 305 patients with gunshot wounds and 871 patients with stab wounds. The high proportion of suicide-related gunshot wounds to the head resulted in a cumulative mortality rate of 39.7%. Stab wounds were associated with a lower mortality rate (6.2%). Every fourth patient with a gunshot or stab wound presented with haemorrhagic shock, which was considerably more frequently seen during the prehospital phase than during the inhospital phase of patient management. Of the patients with gunshot wounds, 26.9% required transfusions. This percentage was three times higher than that for patients with blunt trauma.

Conclusion

In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicide. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required which can provide the basis for an evaluation of the long-term quality of the management of patients with stab or gunshot wounds.     

Lokalrezidiv- und Überlebensraten nach Rektumkarzinomoperationen und multimodaler Therapie

Introduction. In the guidelines of the German specialist medical societies, postoperative chemoradiotherapy is recommended for rectal carcinomas in stages II and III. In the meantime, there are important study findings favoring preoperative radiotherapy as against postoperative irradiation. In the present unicentric study, the clinical results after preoperative irradiation and postoperative chemotherapy are to be determined. In period I, sandwich radiation without total mesorectal excision was applied. In period II, the treatment was developed further with exclusive preoperative radiation and total mesorectal excision. Since from 1994 the therapy regimen has changed with the introduction of total mesorectal excision and improved radiotherapy, the present study was carried out to check whether this has led to better results of therapy. Patients and Methods. Over a period of 7 years, data from 607 patients with rectal carcinoma were recorded and stored in an Excel file. The carcinomas were grouped into lower, middle and upper segment levels and classified endosonographically. Multimodal treatment was administered in stage uT3. In period I, sandwich radiation was carried out with 24 Gy preoperatively and 24 Gy postoperatively, followed by adjuvant chemotherapy. Total mesorectal excision was not performed. In period II, 50.4 Gy were applied preoperatively, followed by adjuvant chemotherapy. The operation comprised total mesorectal excision of the lower two thirds of the rectum. Calcium folinate and 5-fluoroucil were administered in six chemotherapy cycles. Primarily inoperable patients received preoperative irradiation with up to 50.4 Gy in both periods to attain down-staging. The following surgical procedures were applied: abdominal perineal extirpations, deep anterior resections, coloanal anastomoses, colon pouch anal anastomoses and transanal microsurgical resections. Results. In 469 curatively operated patients, including primarily inoperable patients after down-staging radiotherapy, the rates of local recurrence were 5.8% with a mean follow-up observation of 4.29 years, and the carcinoma-specific 4-year actuarial survival was 84%. The rate of recurrence was highest in the lowest segment level of the rectum (7.6 as compared to 2.4%, P=0.042). The rates of local recurrence were 7.4% in period I and 4.3% in period II (P=0.44). The carcinoma-specific 4-year actuarial survivals were 81% in period I and 87% in period II (P=0.202). Investigation of the subgroups of irradiated patients showed complete freedom from recurrence after a mean follow-up observation time of 3.58 years for patients in stage uT3 with total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy (n=51). The difference from patients without postoperative chemotherapy was significant (P=0.018). After radiotherapy, the complication observed was a raised rate of sacral cavity infections after total resection of the rectum (p=0.039). Conclusion. Total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy can effectively influence the rate of local recurrences after rectal carcinoma operations (0–4.3% after a mean period of follow-up observation of 3.58 years). No appraisal can be made with regard to the benefit resulting from the individual measures.     

Anatomie und Verhalten von Sehnen und B?ndern

Sehnen und Bänder bestehen vorwiegend aus Kollagenfasern vom Typ I. Diese werden durch lockeres Bindegewebe zu Bündeln zusammengefasst. Sie zeigen ein komplexes mechanisches, viskös-elastisches Verhalten mit Kriechphänomenen und Stressrelaxation. Eine Sehne ist stets Teil einer komplexen Einheit mit der zugehörigen Muskulatur. Bei der Anpassung an mechanische Belastungen spielen neurosensible Rezeptoren, freigesetzte Wachstumsfaktoren und Zellkontakte zwischen den Tenozyten eine entscheidende Rolle. Diese beeinflussen den Metabolismus der Zellen und somit die Synthese der Extrazellulärmatrix. Bedingt durch die unterschiedlichen Anforderungen (direkte Zugsehnen bzw. Gleitsehnen mit Umlenkfunktion), das Ausmaß der Bewegungsfunktion und Besonderheiten in der Gefäßversorgung finden sich ausgeprägte Besonderheiten im Aufbau und Reaktionsverhalten von Sehnen und Bändern. Eine kurzzeitige Immobilisation kann die Belastbarkeit der Faserstrukturen deutlich vermindern. Darüber hinaus verändern Reifungs- und Alterungsprozesse die Morphologie und das Stoffwechselverhalten des Bindegewebes.     

Form- und Lageveränderung intra- und extrathorakal gelegener Organe nach Pneumonektonie und deren klinische Bedeutung

Ohne ZusammenfassungMit 9 Textabbildungen.     

Qualitätsstrukturen und Mindestmengen in der Kolon- und Rektumchirurgie

Applying the principle "practice makes perfect" to interventional medicine would mean that surgeons and departments with high treatment volumes for special procedures should have better results than low-volume institutions. In the last three decades several studies were published dealing with the association of therapy volume and treatment quality, e.g. in oncologic and vascular surgery as well as interventional cardiology. Concerning colorectal cancer it has been shown that an individual surgeon's case load is important but by far not the only therapy-associated prognostic factor. For example interdisciplinarity and multimodality including adequate pathological classification are no less important. For continual improvement of clinical outcome, quality management and control will grow in importance. Thus, it is necessary to develop structures and to specify standards for colorectal surgery. Based on the data available it is not yet possible to define minimum volumes for colorectal surgery.     

Anatomie und Ätiologie von SLAP- und Bizeps-Pulley-Läsionen

Lesions of the long head of the biceps tendon (LHB) and the biceps reflection pulley (BRP) are frequently seen as source of anterosuperior shoulder pain in clinical routine. Thorough acknowledgement of the anatomy and it’s normal variants allows an accurate diagnosis. Moreover consideration of potential etiopathogenetic mechanisms can guide proper identification of concomitant injuries of the adjacent anatomic structures, e.g. the subscapularis and supraspinatus tendons and the rotator interval. This is particularly true for lesions of the BRP, which are usually not seen as isolated tears. The LHB itself is in most cases injured at the very origin as so called SLAP lesions that can occur either due to micro- or macrotrauma. The intraarticular portion of the LHB is frequently seen with degenerative changes.     

Chirurgie und Zeitgeist: Wo bleiben Ethik und Moral?

Ethical and moral topics have always been an integral part of surgery. The rapid progress of highly advanced medicine has induced public discussions about medico-ethical problems as well as respective legislation. Interdisciplinary ethical committees, appointed by political as well as professional associations, have published guidelines concerning current ethical topics. However, what about the doctor’s attitude and the influence of the ever changing “Zeitgeist”? With the surplus of unproven health information on the web, modern information technologies have changed the doctor-patient relationship. Active leadership of the doctor is still required. For the benefit of the patient the physician should confront increasing economic pressures and the requirements of higher performance levels with competence. Indications have to be based on the results of valid quality controls. Special moral standards should be applied for working within the surgical community and for the pursuit of a career in academic surgery. By strengthening mutual respect and the community spirit surgery will remain attractive for aspiring young doctors.     

Diagnostik und Therapie von perilun?ren Luxationen und Luxationsfrakturen

Perilunate dislocations, dislocation fractures and lunate dislocations are rare injuries predominantly resulting from hyperextension of the wrist during high-energy trauma. Early recognition and treatment of these injuries usually results in good functional outcome despite degenerative changes on radiographs. Immediate reduction and adequate restoration of normal alignment are the key to successful healing. Surgical intervention with open reduction and ligament repair aims at stable reconstruction of the carpus. It requires broad surgical experience and a profound knowledge of normal anatomy.     

131. Makro- und Mikroreplantationen an Unterschenkel und Fuß

Zusammenfassung Für Replantationen geeignete Amputationsverletzungen am distalen Unterschenkel und Fuß sind selten. Keine Indikation besteht, wenn die Verkürzung 5 cm überschreiten wird oder eine asensible Fußsohle zu erwarten ist. Vorfuß- und Zehenreplantationen sind dominierend unter aesthetischen Gesichtspunkten zu sehen. Befriedigende Resultate unter 10 eigenen Fällen wurden erzielt, wenn die Indikation für Unterschenkelreplantationen auf glatte Abtrennungen, Kinder, teilweise auch beidseitige Läsionen beschränkt wurde. Bei Polytrauma besteht in der Regel keine Indikation.     

Über die Pathologie und Klinik der Divertikulose und Diverticulitis

Ohne ZusammenfassungMit 7 Textabbildungen     

Serumeiweiß und Prognose beim Carcinom und Sarkom des Magens

Zusammenfassung Bei 96 Kranken mit einem Carcinom (77) oder Sarkom (19) des Magens wurde eine vergleichende katamnestische Untersuchung über das Verhalten der Serumproteine zum Zeitpunkt der Diagnosestellung und verschiedener Überlebenszeiten durchgeführt. Dabei ergab sich, daß dysproteinämische Veränderungen nur bei jedem zweiten Tumorkranken in dem Stadium der klinisch vermeintlichen Kurabilität bestanden. Ein regelrechtes Verhalten der Serumproteine schließt also das Bestehen einer bösartigen Erkrankung des Magens nicht aus. Sofern aber Abweichungen im Elektropherogramm vorhanden waren, ließ sich eine gute Übereinstimmung zwischen dem Grad der Vermehrung der Alpha₁-Globulin-Fraktion und bestimmten Überlebenszeiten feststellen. Eine deutliche Zunahme der Alpha₁-Globulin-Fraktion war bei 73% der Kranken mit einem Carcinom und bei 79% derjenigen mit einem Sarkom des Magens, ungeachtet der durchgeführten Therapie, jeweils mit einer ungünstigen Prognose verbunden. Diese Abweichung war signifikant unterschieden von dem entsprechenden Verhalten dieser Fraktion bei den länger Überlebenden und bei dem hier herangezogenen Kollektiv von 20 gesunden Probanden. Eine entsprechend gesicherte Korrelation bestand nicht für das Verhalten der Alpha₂-Globulin-Anteile und den Überlebenszeiten. Bei der Gruppe der langfristig überlebenden Sarkomkranken mit einem Reticulosarkom des Magens ergaben sich in Übereinstimmung mit früheren Untersuchungen auch auf Grund des Verhaltens des Elektropherogramms weitere Anhaltspunkte, die für eine relative Benignität dieser Tumoren sprechen. Histologisch differenzierende Kriterien zwischen diesen biologisch sehr unterschiedlichen Verhaltensweisen wurden bislang nicht gefunden (Kay 1964). Damit erlaubt also die Kenntnis des Elektropherogramms eine Gruppenprognose, die der wünschenswertenIndividualprognose näher zu kommen scheint, als dies bisher bei den bekannten anderen entsprechenden Kriterien der fall ist. Diese Untersuchungen und ihre Ergebnisse eröffnen der Tumorchirurgie wesentliche neue Aspekte.Herrn Professor Dr.H. Hamperl, auf dessen Anregung hin die folgende Untersuchung zustande kam, in Verehrung gewidmet.     

Ausbildung und Training des Rettungsfachpersonals und der Notärzte

Background

General threats, such as killing sprees and terror attacks, have moved into the focus of emergency medicine, with the consecutive adaptation of education and training.

Methods

Narrative review and expert assessment.

Result

Terrorist attacks are rare in Germany but should be taken into account due to their special safety requirements and rare patterns of injuries. There is a need for increased awareness among the emergency medical services regarding the threat and attention to the environment and the possibility of a threat situation. Communication channels and stand-by procedures at the scene must be clarified, triage must be regularly trained, and knowledge about the treatment of these patients and appropriate tactical strategies must be taught. The training of skills is essential and leads to a higher level of safety. As human factor resources, tools such as checklists can help with preparation. Mental support and debriefing concepts are needed to maintain the health and performance of the staff.

Discussion

It is important to train relevant competencies for rare events. A variety of topics should be taught during regular training, regardless of the threat situation.

     

Angeborene Zwerchfellhernie und Relaxatio diaphragmatica beim Neugeborenen und Säugling

Ohne ZusammenfassungMit 2 Abbildungen     

Technik und Ergebnisse von Nagelungen schwieriger Tibiabrüche und Pseudarthrosen

Ohne Zusammenfassung Mit 3 Textabbildungen     

Diagnostik und Therapie der frischen und chronischen hinteren Kreuzbandl?sion

Rupturen des hinteren Kreuzbandes geh?ren zu den schwerwiegenden Bandverletzungen des Kniegelenks. Problematisch ist hier eine oft unzureichende Einsch?tzung und versp?tete Diagnostik der Verletzungsschwere als auch der Begleitverletzungen. Zus?tzlich ist die Versagerquote der bisherigen Rekonstruktionsverfahren unbefriedigend hoch. Das Ziel dieser übersichtsarbeit ist es, auf der Basis der eigenen Erfahrungen und dem Wissen aus dem internationalen Schriftum, einen umfassenden Einblick in die Anatomie und Biomechanik, die Unfallmechanismen und die Pathobiomechanik zu geben. Ein weiterer Schwerpunkt liegt in der Kl?rung diagnostischer Schwierigkeiten. Zur ad?quaten Berücksichtigung der Begleitverletzungen, wie z. B. der posterolaterale rotatorische Instabilit?t oder zus?tzlichen Verletzungen des vorderen Kreuzbandes wird ein differenziertes Therapiekonzept vorgestellt, um das konservative und perioperative Management zu optimieren, mit dem Ziel die hohe Quote unbefriedigender Ergebnisse weiter zu reduzieren.