Endovaskuläre Versorgung der traumatischen Aortenruptur im Akutstadium

Since March 1999, 52 thoracic endovascular aortic repair (TEVAR) procedures have been done acutely as part of primary polytrauma repair in 48 patients after thoracic aortic rupture. In the presence of aortic diameters of 12–30 mm, only the smallest thoracic stent graft systems available from Gore, Medtronic, and Cook—in one instance, an iliac extension limb—were used. The primary success rate (sealing of the aorta) was 100%. Three patients died from serious concomitant injuries unrelated to the aorta. Of three cases of acute stent compression syndrome, one proved to be lethal. Contemporary stent graft systems show conformability deficits at the narrow curvature of the juvenile aortic arch, with consequent disattachment phenomena and disattachment angles at the inner aortic curvature of up to 63° end-systolic. Nevertheless, the conversion rate up to 10 years was 0%, and no stent corrections were necessary after 30 days. Two additional patients died during the long-term observation period (after 3 and 5 years, respectively) after non-aorta-related trauma. All other patients are under supervision in a special magnetic resonance imaging assessment program; the majority are back to their normal activities and are seen regularly once a year. Ten years of follow-up is a long time, but not long enough in these young patients. Therefore, the definite role of TEVAR can be determined only after another 20 years.     

Arthroskopisch gestützte Techniken zur Versorgung der akuten und chronischen AC-Gelenk-Verletzung

Acute and chronic acromioclavicular (AC) joint dislocation is frequently encountered in the routine clinical practice. This injury can lead to significant impairment of shoulder girdle function. Therapy based on the severity of injury is recommended to re-establish correct shoulder function. The static radiographic Rockwood classification is used to define the degree of dislocation but the clinical aspects and functional x-ray imaging of horizontal AC joint instability should also be considered for selection of the appropriate procedure. Rockwood grades I and II injuries are treated non-operatively with early functional exercise. The approach for Rockwood grade III injuries should be individual and patient-specific, with non-surgical procedures for low functional requirement patients with a high risk for surgical interventions. For patients with high demands on shoulder function surgery is recommended. A detailed diagnostic assessment frequently reveals Rockwood grade III injuries to be type IV injuries. Rockwood types IV and V AC joint dislocations require surgery for sustained stability. Treatment of acute injuries is recommended within 1-3 weeks after trauma but there is no clear evidence of a cut-off for the presence of chronic injuries. Various surgical techniques have been described in the literature. This article presents an arthroscopically assisted technique that addresses both vertical and horizontal instability of the AC joint.     

Die arthroskopisch unterstützte Stabilisierung der akuten AC-Gelenksprengung

Background

The aim of this study was to compare the results of the single (STR) versus double TightRope? (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance.

Patients and methods

A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0–21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated.

Results

Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%).

Conclusion

The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.     

Die stentgestützte Aneurysmaausschaltung mit dem TALENT-System

Introduction The TALENT system has made it feasible for the first time to use endovascular stent placement in the treatment of infrarenal aneurysms of the abdominal aorta with neck diameters greater than 26 mm. The following paper presents the experience of 29 German vascular surgical centers using the TALENT system. Materials and Methods Between October 1996 and September 1997, a total of 123 aortic aneurysms in 122 patients were treated endovascularly. Ninety-five infrarenal aneurysms of the abdominal aorta were treated using bifurcated stents, while in 28 cases tube stents were implanted. In nine cases, tube stents were used to treat aneurysm of the thoracic aorta. A total of 111 patients (112 aneurysms) presented for follow-up. The average proximal diameter of the bifurcated stents in infrarenal aneurysms was 30 mm (range 24–36 mm), while the average iliac stent diameter was 14 mm (range: 10–20 mm). In tube stents, diameters ranged from 24–30 mm in abdominal stents and from 32–40 mm in thoracic stents, respectively. In this series, each stent was individually manufactured for the patient on the basis of findings from computed tomography (CT) and calibrated angiography. Results Endovascular treatment of aneurysms was successful technically in 96% of patients. During a follow-up period averaging 4.3 months, the following complications were observed: 5 perioperative death (4.1%), 4 conversions to open surgical therapy (3.3%), 7 endoleaks (5.7%), 2 stent dislocations, 2 iliac stent thromboses, 2 perforations of iliac arteries, 1 inguinal hematoma, and 1 inguinal infection. Conclusions These preliminary findings show that aneurysms with larger neck diameters are amenable to endovascular treatment. Despite the wide distribution of participating vascular surgery centers with varying degrees of experience and many first-time implantations, the results of the present multicenter study hardly differed from those reported in larger series in established institutions. Through the use of larger-diameter stents, up to 50% of all infrarenal aneurysms of the abdominal aorta may be possibly successfully treated using endovascular methods.     

Ultraschallgestützte thorakale Paravertebralblockade beim akuten Thoraxtrauma

Paravertebral blocks have experienced a renaissance because ultrasound-guidance is becoming common practice. The method is often presented as an alternative to thoracic epidural anaesthesia, mainly in the field of elective thoracic surgery. It is also propagated as an opioid-saving analgesic procedure in breast tumor surgery. In this case report it was successfully used as a continuous intervention for acute pain therapy of a severe injury of the left thorax. A transverse probe position in the fifth intercostal space was combined with an in-plane needle technique from lateral to medial. An ultrasound-enhanced needle positioning was used due to the steep angle of puncture. The absolute limit for medial needle advancement is the acoustic shadow of the transverse process. A catheter was placed 2 cm beyond the needle tip and its correct position was verified by hydrolocation. The excellent and continuous analgesia enabled non-invasive patient ventilation to be achieved directly after extubation and was continued for 6 days.     

Ergebnisse der stentgestützten Aortenrekonstruktion im Rupturstadium

ZusammenfassungStudienziel Untersuchungen über den Stellenwert der notfallmäßigen endovaskulären Behandlung von Patienten mit gedeckten Rupturen im Bereich der Aorta descendens sowie im infrarenalen Aortenabschnitt.Studiendesign. Prospektive, nichtrandomisierte Studie in einer Universitätsklinik.Material und Methoden Im Zeitraum zwischen 1995 und 2003 wurde bei insgesamt 338 Patienten eine stentgestützte aortale Rekonstruktion durchgeführt. 274 Eingriffe erfolgten elektiv (81%). In 64 Fällen (19%) wurde die endovaskuläre Versorgung notfallmäßig im Stadium der Ruptur durchgeführt. Bei 29 Patienten handelte es sich um ein gedeckt rupturiertes infrarenales Aortenaneurysma, bei 11 Patienten um ein rupturiertes Aneurysma im Bereich der Aorta descendens, bei 3 Patienten um eine Ruptur eines thorakoabdominalen Aortenaneurysmas, bei 5 Patienten um eine Ruptur im ersten Segment der Aorta descendens bei akuter Typ-B Dissektion und bei weiteren 16 Patienten um eine traumatische thorakale Aortenruptur loco typico. Die Diagnose wurde bei allen 64 Patienten jeweils durch eine präoperative Spiral-CT-Untersuchung gesichert.Ergebnisse Der rupturierte Aortenabschnitt konnte bei 62 Patienten endovaskulär sicher versorgt werden. Eine primäre Konversion zum offenen Eingriff wurde bei 2 Patienten (3,1%) notwendig. Die postoperative 30-Tage-Letalität betrug bei 7 Todesfällen 10,9%. Keiner der Patienten entwickelte postoperativ ein vorübergehendes oder dauerhaftes neurologisches Defizit. Bei 8 Patienten (12,5%) waren Zweiteingriffe zum Verschluss primärer Endoleaks erforderlich und 6 Patienten (9,3%) bedurften eines zweiten chirurgischen oder kombinierten endovaskulären und offenchirurgischen Vorgehens. Die mittlere Nachbeobachtungszeit (Follow-up) betrug 37 Monate (1–93).Schlussfolgerung Unsere Ergebnisse zeigen, dass die stentgestützte Rekonstruktion bei Patienten mit rupturierten Aortenläsionen technisch durchführbar ist und diese Technik zudem mit einer ausreichenden Sicherheit angewandt werden kann. Angesichts der im Vergleich zum offenen Vorgehen reduzierten Morbidität und Letalität stellt das endovaskuläre stentgestützte Verfahren bei Patienten, die anatomisch und pathomorphologisch für eine Stentbehandlung geeignet erscheinen, ein alternatives, viel versprechendes Behandlungskonzept dar. Unsere Ergebnisse lassen zudem vermuten, dass bei rupturiertem mykotischem Aneurysma bzw. bei aortobronchialen und aortointestinalen Fisteln die endovaskuläre Therapie nur als "Bridging"-Maßnahme angewandt werden sollte.

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Results of stent graft repair of ruptured aortic lesions

Objectives To evaluate endovascular repair in ruptured aortic lesions.Design Prospective nonrandomized study in a university hospital.Material and methods Of 338 endovascular aortic repairs, 64 (19%) procedures were conducted as emergencies (29 ruptured infrarenal aortic aneurysms, 11 ruptured descending thoracic aortic aneurysms, 3 ruptured thoracoabdominal aortic aneurysm, 5 patients with descending aortic rupture due to acute type B dissection, and 16 patients with acute descending aortic transection). Preoperative spiral computed tomography was performed in each patient, and based on these findings the feasibility of endovascular treatment and appropriate size of stent grafts were determined.Results Endovascular operations were completed successfully in 96.8% (62 patients). The primary conversion rate to open repair was 3.1% (two patients). The 30-day mortality rate was 10.9% (seven deaths). In no patient did temporary or permanent paraplegia result. Of the primary endoleaks, 12.5% (eight patients) required additional intervention and 9.3% (six patients) required secondary surgical procedures. The mean follow-up was 37 months (1–93 months); three deaths occurred within 3 months after stent graft placement. Six patients (9.3%) required secondary conversion to open repair.Conclusion Endoluminal treatment of ruptured aortic lesions is feasible and safe and may offer the best means of therapy in selected cases. Compared with open repair, endoluminal treatment holds tremendous potential in terms of reduced morbidity and mortality and confers protection against secondary aortic rupture. Continued surveillance is essential.

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Arthroskopisch gestützte Behandlung der aseptischen Hüftkopfnekrose

Objective

Preservation of the hip joint function by treatment of the avascular necrosis of the femoral head in adults or at least avoiding progression.

Indications

Avascular necrosis of the femoral head in adults in Steinberg stages I–III. In patients with Steinberg stage IVa (subchondral collapse ≤?15% of the articular surface, depression <?2 mm) hip joint salvage therapy in early stages of femoral head collapse.

Contraindications

Manifest osteoarthritis of the hip joint. Joint infection. Relative contraindications: subchondral collapse >?15% of the articular surface or depression >?2 mm (Steinberg stage IVb and above). Persisting risk factors for a progression of avascular necrosis (e.g., alcohol abuse, chemotherapy, local irradiation, high-dose cortisone therapy) and obesity (BMI >?40).

Surgical technique

Arthroscopy of the hip joint in case of cartilage defects and/or potential collapse of the femoral head. Without collapse of the femoral head and absence of severe damage of the cartilage: core decompression using a guiding sleeve through a lateral approach (Steinberg II, III). Subsequently curettage of the necrotic area through a central drill hole and insertion of autogenic bone cylinders using an OATS harvester (Steinberg II b/c, III b/c). In Steinberg stage IVa, reconstruction of the outline of the femoral head is attempted by reduction of the impressed portion (under intraoperative fluoroscopy).

Postoperative management

Limited weight bearing (10 kg) of the operated leg for 6 weeks. In cases of large necrotic defects located directly beneath the subchondral bone (Steinberg IIIc) as well as subchondral collapse with flattening of the femoral head (Steinberg IVa) limited weight bearing (10 kg) for 12 weeks.

Results

Early results of femoral head preserving therapy in 53 patients (56 hips, consecutively treated between June 2004 and December 2009) after 33?±?20 months: success rate (no arthroplasty, no reoperation, no radiological progress associated with clinical symptoms) 86% for patients treated with Steinberg stages I–III. Failure of the head preserving therapy with concern to the mentioned criteria depending on the initial Steinberg stage: 0 (0%) for stage I, 2 (10%) for stage II, 3 (25%) for stage III, and 4 (31%) for stage IVa.     

Computergestützte fallbasierte Lehre in der Chirurgie

INTRODUCTION: Computer technology is well established in the fields of medical diagnosis and monitoring. In recent years, there has also been an increase in the use of computers for the purpose of medical education. METHODS: With the aid of the "author's-system" CASUS, investigation of a case of acute abdominal pain was integrated into the practical medical training for students in the 4th. year of clinical studies. For patient history, clinical examination and laboratory tests, the method involves the use of 41 cards with pictorial and acoustic information (text, graphics, sound recordings and videos), including 23 questions to be answered by the students. At the end of the session, the acceptance, effectiveness and practicability of the computer-based training was evaluated by a questionnaire. RESULTS: In 356 students, a high rate of acceptance and satisfaction was achieved (positive judgement of various aspects: 55%-98%). Technical difficulties which occurred initially were overcome during the course of the evaluation. Some questions were answered more positively by female students. CONCLUSION: Most students share the view that computer-based training, though not able to take the place of bedside teaching, is a valuable addition to the armamentum of medical teaching.     

Videounterstützte Selbstkontrolle in der chirurgischen Lehre

Background

Image and video-based results and process control are essential tools of a new teaching concept for conveying surgical skills. The new teaching concept integrates approved teaching principles and new media.

Method

Every performance of exercises is videotaped and the result photographically recorded. The quality of the process and result becomes accessible for an analysis by the teacher and the student/learner. The learner is instructed to perform a criteria-based self-analysis of the video and image material by themselves.

Results

The new learning concept has so far been successfully applied in seven rounds within the newly designed modular class “Intensivkurs Chirurgische Techniken” (Intensive training of surgical techniques). Result documentation and analysis via digital picture was completed by almost every student. The quality of the results was high. Interestingly the result quality did not correlate with the time needed for the exercise. The training success had a lasting effect.

Conclusion

The new and elaborate concept improves the quality of teaching. In the long run resources for patient care should be saved when training students according to this concept prior to performing tasks in the operating theater. These resources should be allocated for further refining innovative teaching concepts.     

Kontrastmittelgestützte Diagnostik in der Orthopädie

The diagnostic competence of the orthopaedist not only allows him to perform adequate therapy concepts, but also to meet the current structural challenges, both social and health related. In addition to clinical diagnosis, machine-aided diagnosis is becoming more important due to technical advances. In this context, contrast-enhanced examination has a special place, as it has an important diagnostic advantage in difficult or unclear cases. Current improvements in the areas of phlebography, myelography, arthrography and angiography are reviewed. Indications, risks and complications as well as the technical procedure are critically discussed.     

Bildwandlergestützte Injektionstechniken an der Lendenwirbelsäule

Spinal injections are an important treatment option in the conservative management of many spinal disorders. A large number of imaging techniques are available to achieve a precise and safe needle placement in interventional procedures. Fluoroscopy-guided injections are safe, cost effective and available in most institutions. The following article presents an overview of common fluoroscopy-guided spinal injection therapy of the lumbar spine.     

Das Tantalnetz bei der Versorgung von Bauchnarbenbrüchen

Ohne Zusammenfassung     

Zur Ausführung der Rippenresektion beim akuten Pleuraempyem

Ohne Zusammenfassung     

Die Röntgenbestrahlung der akuten Entzündungen

Ohne Zusammenfassung Herrn Geh.-RatPels Leusden zum 60. Geburtstage.     

Fehler und Gefahren bei der Frühbehandlung der traumatischen Querschnittslähmung

Ohne Zusammenfassung a.E Mit 8 Textabbildungen in 24 Einzeldarstellungen     

Der IT-gestützte Behandlungspfad als Routinearbeitsinstrument in der Unfallchirurgie

Background

Today clinical pathways are established as a basis for the operational and organizational structure of surgical, interventional and conservative treatment in many hospitals. In our study we evaluate the establishment and systematic applicability of IT-based clinical pathways in a tertiary care facility.

Methods

We evaluate and compare the treatment of coxarthrosis with hip joint endoprosthesis either following an IT-based clinical pathway or without clinical pathway.

Results

All patients who had received a hip joint endoprosthesis from 1 January 2006 to 31 October 2009 were included. The duration of stay is significantly longer in the group without pathway. Furthermore there was a significant increase in the documentation of wound inspection after surgery in the ??pathway patients??. The preoperative urinalysis was done significantly more often in the pathway group.

Conclusion

IT-based clinical pathways are applicable for routine use in trauma departments. For certain surgical procedures they are a suitable management device, even in a tertiary care facility. Clinical pathways lead to an improved operational structure of medical treatment and moreover to a complete and continuous documentation through the electronic file.     

Letale aortoösophageale Fistel als Spätkomplikation einer traumatischen Aortenruptur

We report on a case of a 23 years old man who was polytraumatized in a car accident. He survived with excellent clinical outcome, but 113 days after the accident he collapsed, massive bleeding out of the mouth started and the patient died within a few minutes. A gastric ulcer bleeding was assumed, but autopsy showed the break-in of a posttraumatic aortic aneurysm into the esophagus. The difficulties of in time diagnosis of thoracic aorta lesions are discussed.