Kahnbeinfrakturen – Diagnostik, Klassifikation und Therapie

Die Einteilung der Kahnbeinfrakturen nach Stabilit?tskriterien liefert die Basis für ein differenziertes Therapiekonzept. Wegen der besonderen Form des Kahnbeins ist eine sichere Unterscheidung zwischen stabiler und instabiler Fraktur anhand der R?ntgenbilder h?ufig nicht immer m?glich, so dass erg?nzend ein CT parallel zur L?ngsachse des Kahnbeins angefertigt werden sollte. Hiermit gelingt eine exakte Beurteilung der Fraktur. Zur Vermeidung der oft sehr lange notwendigen Gipsruhigstellung bei konservativer Behandlung sollten instabile Frakturen (Typ B) operativ stabilisiert werden.     

Kahnbeinfrakturen – Diagnostik, Klassifikation und Therapie

Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type. A CT bone scan in the long axis of the scaphoid is the best means of differentiating between stable and unstable fractures. This is difficult from conventional X-rays due to the particular three-dimensional anatomy of the scaphoid. To avoid long-term plaster immobilization and to diminish the risk of a nonunion, unstable fractures of type B should be fixed operatively. With headless screws such as the Herbert screw, which are now available in a cannulated shape, the majority of scaphoid fractures of type B1 and B2 can be stabilized using minimally invasive procedures. Severely displaced fractures require the classical open palmar approach. Proximal pole fractures (B3) are best managed from the dorsal approach, using the Mini-Herbert screw. Stable fractures of type A2 can be treated conservatively in a below-elbow cast or, alternatively, stabilized percutaneously, which allows early mobilization.     

Surgical strategies – anastomosis or stoma, second look – when and why?

Introduction: The indication for performing a primary anastomosis or an intestinal stoma has to be confirmed or negated for every individual case of intestinal ischemia. Discussion: In right-sided colonic emergency, primary anastomosis is possible except when associated with generalized peritonitis. In left-sided colonic ischemia and necrosis, delayed anastomosis is the preferred alternative. In ischemia following surgery for abdominal aortic aneurysms, primary anastomosis is contraindicated. In ischemia of the small bowel, an end-to-end anastomosis should be established whenever possible. Conclusion: In the case of intestinal ischemia, a second-look laparotomy is mandatory 24–48 h after initial surgery to ensure bowel viability. This second look should be performed regard-less of the patient's postoperative clinical status. Laparoscopy has been successfully used for reexploration in intestinal ischemia, but one has to be aware of the present limitations of experience using this technique. Received: 23 October 1998 Accepted: 7 November 1998     

Der Schockraum – Diagnostik-, Therapie- und Managementzentrale

Background:

In the treatment of the polytraumatized patient ,time is crucial. New technical developments such as multislice CT, which can finish the polytrauma spiral in 90–240 s, shorten the duration of trauma treatment considerably. In the past, CT diagnostics have been used after the initial diagnostics.

Methods:

To obtain the full advantage of the new multislice CT, it is important to put carry out CT diagnostics in the first minutes of clinical care. After the installation of a multislice CT in the emergency room, we developed an algorithm in which CT diagnostics are made in these first minutes.

Results:

The new algorithm was performed on 118 patients. At 8 min (±5,7 SD) after the patient’s arrival CT was started. It was completed 13 min (±8,4 SD) after the arrival of the patient. The time in the emergency room decreased from 87 min to 38 min (±19,1 SD).

Conclusions:

Early CT diagnostics can save time for the trauma patient, with life threading injuries being recognized within minutes.     

Das HPV-getriebene Oropharynxkarzinom – Inzidenz,Trends, Diagnose und Therapie

A rising incidence of oropharyngeal squamous cell carcinoma (OPSCC) is reported by many countries worldwide and OPSCC associated with human papillomavirus (HPV) has been recently defined as a new class of head and neck cancers. Besides tobacco and alcohol consumption, HPV is an accepted risk and prognostic factor for OPSCC. Although the incidence increase of HPV-associated OPSCC is convincing, cancer registry studies and studies based on cohorts often have drawbacks regarding data linkage to comparable experimental data, comparable anatomical definitions or HPV diagnostics. Patients with HPV-associated OPSCC have remarkably better prognosis and the tumors differ from HPV-negative OPSCC with respect to molecular and genetic aspects. Nevertheless, choice of therapy is independent of HPV, and rather is subject to the individual patient’s condition, local preference and anatomic characteristics. New concepts emerge in immune-checkpoint oncology, which might be a valuable add-on to established concepts. Also, treatment de-escalation (e.g., by reduction of radiation dosage) might be suitable for patients with certain risk profiles. Prophylactic vaccination can contribute to reducing HPV-induced disease, likewise OPSCC. Prerequisite is a high rate of vaccination, which is currently not sufficient in Germany. Because of currently low vaccination rates and the rather long time between initial infection and HPV-induced carcinogenesis, reduction of incidence increase or prevalence of HPV-associated OPSCC is not expected in the near future.     

Spontanatmung – Schnappatmung – Beatmung?

The value of mouth-to-mouth ventilation is currently discussed because of a wide-spread fear of transmission of infectious diseases. An expert committee of the American Heart Association even considered to recommend chest compressions. In paralyzed volunteers, however, ventilation induced by chest compressions was not able to provide a sufficient gas exchange. Laboratory investigations studying ventilation during CPR showed controversial results. Animal models that prevented gasping during cardiac arrest favored ventilation during CPR, whereas gasping animals seemed to be satisfactorily ventilated with chest compressions alone. The question whether spontaneous gasping after a cardiac arrest in humans may be sufficient for oxygenation and carbon dioxide elimination remains unanswered at this point in time. Therefore, mouth-to-mouth ventilation remains the therapy of choice during basic life. If a rescuer chooses to not perform mouth-to-mouth ventilation, at least chest compressions should be administered. The value of cricoid pressure during ventilation with an unprotected airway has to be emphasized to all healthcare professionals to avoid disastrous stomach inflation. If intubation can not be performed right away, the airway may be secured with the laryngeal mask airway, combitube, larynx tube, or intubating laryngeal mask airway. Rapid intubation and ventilation with oxygen remains the state-of-the-art therapy during CPR.     

Suizid – Suizidversuch – Suizidalit?t

Background

Suicide attempts and suicidal ideation are a challenge for emergency physicians and emergency departments. These disorders are time consuming and often overwhelm staff not familiar with its diagnosis and treatment.

Medical care

The first goal of care is the establishment of a therapeutical relationship which enables a subsequent crisis intervention. Acute pharmacological treatment may be necessary, in many cases only once.

Psychiatric treatment

First, the danger of continuing self-harm must be evaluated in order to determine whether inpatient psychiatric care is required. If outpatient treatment is deemed sufficient, concrete psychiatric and psychotherapeutic support should be suggested and offered, including the help of family members.     

Sevofluran, Desfluran – und immer noch kein Ende!

Ohne Zusammenfassung     

Laparoscopic hernia repair – the facts, but no fashion

Background: For about 10 years now, laparoscopic hernia surgery has been introduced as an additional mode of therapy in the treatment of inguinal hernias. This method is being reproached with higher costs of surgery and rate of complications, as well as missing long-term results. Materials and methods: Within a literature research, data from 25 randomised trials and 16 prospective observational studies on endoscopic and conventional hernia surgery were evaluated. Statistics were calculated using the chi² test. Results: Compared with the conventional suture technique and tension-free surgery, the endoscopic repair proved to be advantageous with regard to postoperative pain and period of disablement. There was no significant difference between the methods when evaluating the rate of complications. In two randomised trials, there was a significant difference in favour of endoscopic repair with regard to the recurrence rates, whereas in the other studies a significant difference could not be shown. In the prospective series, recurrence rates were 0.71% for totally preperitoneal repair (TEP) and 1.06% for transabdominal preperitoneal repair (TAPP) repair. Conclusion: Endoscopic hernia surgery (TAPP and TEP) represents an efficient method of treatment in the therapy of inguinal hernias. Recurrent and bilateral hernias can be seen as an absolute indication for endoscopic repair. Received: 14 December 1998 Accepted: 29 March 1999     

MRT des Sprunggelenks – Technik,anatomische Normvarianten und Pitfalls

Magnetic resonance imaging (MRI) is an important imaging modality in the examination of the upper and lower ankle joints. In conjunction with clinical findings it is essential for a reliable diagnosis. The complex anatomy and the frequent occurrence of anatomical norm variants often complicates the assessment of MRI images. This article shows important and common MRI-morphological features of the bones, joint structures, tendons and ligaments. In addition, relevant technical aspects are pointed out in order to avoid misinterpretations. The knowledge of the MRI morphology, technical aspects and frequent pitfalls listed in this article is intended to increase confidence in the assessment of MRI images of the rear foot.     

Achsenfehlstellung, Knorpelschaden und Kreuzbandruptur – Begleiteingriffe bei der VKB-Plastik

Background. Osteochondral lesions and osteoarthritis in young patients are often caused by chronic knee instability and varus malalignment. We present the indications, operative technique, and results for the combined operation of high tibial osteotomy and cruciate ligament reconstruction. Materials and methods. From April 1996 until December 2000, 58 patients (average age: 33 years) underwent simultaneous osteotomy (57 correcting valgus, 1 valgus malalignment) and cruciate ligament reconstruction (49 ACL, 7 PCL, 2 ACL &; PCL) which was routinely performed with an arthroscopic technique after completion of the osteotomy (closed wedge technique). Average correction angle of the osteotomy was 7° (4–10°) with a mean malalignment of 5° (0–10°). Thirteen patients underwent additional cartilage surgery (osteochondral autograft transplantation, autologous chondrocyte transplantation, microfracturing), and two patients were implanted with a collagen meniscus (CMI) at the same time. Results. Preoperatively the Lysholm score was 66 (35–81) points and increased to 81 (74–95), 87 (79–99), and 93 (88–99) points 3, 6, and 12 months after surgery, respectively. Subjectively all patients reported an improvement of preoperative swelling, pain, and instability. Additional cartilage surgery or meniscus implantation did not significantly alter the clinical score values. Complications were noted in four patients. Conclusions. Unstable knees with varus malalignment can be sufficiently treated by osteotomy and cruciate ligament reconstruction at the same time, suggesting that unicompartimental decompression and treatment of instability is a causal and cost-effective therapy delaying the progression of osteoarthritis and minimizing clinical symptoms. Performing both operations in one procedure facilitates early rehabilitation and the return of these patients to the activities of daily living and sports.     

Sepsis – weltweit steigende Fallzahlen,aber auch neue Strategien

With the numbers of cases rising worldwide and consistently high mortality, sepsis is one of the world’s most significant health issues. The Jena Symposium was dedicated to the challenges in research and development, new approaches to treatment, internationally successful strategies, and a potentially successful new initiative for improving the quality of prophylaxis, early diagnosis, and therapy. The importance of intensifying efforts in the fight against sepsis is becoming increasingly recognized by health care policy. Knowledge of lay people/the public about sepsis is lacking and the standards of quality are in need of improvement.     

Isolated revision meniscal repair – failure rates,clinical outcome,and patient satisfaction

Background

Failure of isolated primary meniscal repair must be expected in approximately 10–25% of cases. Patients requiring revision surgery may benefit from revision meniscal repair, however, the results of this procedure remain underreported. The purpose of this study was therefore to evaluate the outcome and failure rates of isolated revision meniscal repair in patients with re-tears or failed healing after previous meniscal repair in stable knee joints.

Methods

A chart review was performed to identify all patients undergoing revision meniscal repair between 08/2010 and 02/2016. Only patients without concomitant procedures, without ligamentous insufficiency, and a minimum follow-up of 24?months were included. The records of all patients were reviewed to collect patient demographics, injury patterns of the meniscus, and details about primary and revision surgery. Follow-up evaluation included failure rates, clinical outcome scores (Lysholm Score, KOOS Score), sporting activity (Tegner scale), and patient satisfaction.

Results

A total of 12 patients with a mean age of 22?±?5?years were included. The mean time between primary repair and revision repair was 27?±?21?months. Reasons for failed primary repairs were traumatic re-tears in 10 patients (83%) and failed healing in two patients (17%). The mean follow-up period after revision meniscal repair was 43 (± 23.4) months. Failure of revision meniscal repair occurred in 3 patients (25%). In two of these patients, successful re-revision repair was performed. At final follow-up, the mean Lysholm Score was 95.2 (± 4.2) with a range of 90–100, representing a good to excellent result in all patients. The final assessment of the KOOS subscores also showed good to excellent results. The mean Tegner scale was 6.8?±?1.8, indicating a relatively high level of sports participation. Ten patients (83%) were either satisfied or very satisfied with the outcome.

Conclusion

In patients with re-tears or failed healing after previous isolated meniscal repair, revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction. The failure rate is slightly higher compared to isolated primary meniscal repair, but still acceptable. Therefore, revision meniscal repair is worthwhile in selected cases in order to save as much meniscal tissue as possible.

     

Der schwere Tauchunfall Pathophysiologie – Symptomatik – Therapie

Decompression injuries are potentially life-threatening incidents, generated by a rapid decline in ambient pressure. Although typically seen in divers, they may be observed in compressed air workers and others exposed to hyperbaric environments. Decompression illness (DCI) results from liberation of gas bubbles in the blood and tissues. DCI may be classified as decompression sickness (DCS) or arterial gas embolism (AGE), depending on where the gas bubbles lodge. DCS occurs after longer exposures to a hyperbaric environment with correspondingly larger up-take of inert gas. DCS may be classified into type 1 with cutaneous symptoms and musculoskeletal pain only or type 2 with neurologic and/or pulmonary symptoms as well. AGE usually results from a pulmonary barotrauma, and with cerebral arterial involvement, the symptoms are similar to a stroke. The most important therapy, in the field, is oxygen resuscitation with the highest possible concentration and volume delivered. The definitive treatment is rapid recompression with hyperbaric oxygen therapy. Additional therapeutic measures are discussed.