Temporäre intravasale Shuntanlage (TIVS)

Background

The primary reconstruction of vascular injuries is not always possible. This is especially true for critical situations with a lack of expertise in vascular surgery and/or a necessary intensive care treatment of the lethal triad (i.e. hypovolemia, hypothermia and acidosis) in multiple traumatized patients. Nevertheless, even under such extreme conditions preservation of the extremities is given the highest priority.

Material and methods

In this article the possibility of using temporary intravascular shunts (TIVS) for maintaining perfusion in an injured extremity as an adjunct in the vascular damage control surgery concept is described and evaluated based on a review of the literature. The question of the necessity for a fasciotomy is also examined, especially taking into account that this approach follows the dogma of primum non nocere.

Results

Ligation or time-consuming reconstruction of vessels without a TIVS in primary care situations is associated with an unacceptably high mortality and secondary amputation rate. With the use of a TIVS and damage control surgery these rates can be substantially reduced.

Conclusions

The TIVS is a technique which in time critical situations and/or a lack of vascular surgical expertise contributes to preservation of injured extremities.     

Tempor?re Herz- und Lungenunterstützung

Since the invention of the first heart?Clung machine in the 1950s, there has been tremendous progress towards smaller and more efficient devices for extracorporeal circulation (ECC). Today, various types and models of assist devices for temporary support of cardiac and pulmonary function are available. These systems can be active (with a pump) or passive using arterial pressure to transport the blood through the extracorporeal components. Within this extracorporeal circulation, the blood is oxygenated and/or only CO₂ is eliminated from the blood. Finally, the blood is transported back into the venous or arterial system. This article explains the different modes of temporary extracorporeal life systems (ECLS) as well as their indications, risk and management.     

Temporäre Instrumentation bei Luxationen, Subluxationen und Frakturen der unteren HWS

The anterior interbody fusion with instrumentation seems to be the standard procedure in unstable traumatic lesions of the lower cervical spine. The goal of this study was to objective the outcome of patients, treated by only temporary stabilisation of the injured motion segment (without bone-graft fusion). Between 1990 and 1998 155 patients with traumatic lesions of the cervical spine were treated operatively, in 22 cases transfixation of the injured level without bone-graft application was performed, an implant-removal was carried out in 12 patients so long. Only patients were included into the study, who were less then 45 years old at trauma and who had no trauma related osseous or disc encrouchment of the spinal canal. Not included were patients with degenerative formations of the cervical spine at time of trauma. Until follow up all patients with implantat removal returned back to work in their former profession, 11 of 12 patients classified their result as excellent or good. No secondary instabilities or postraumatic disc prolapse were observed. Restmobility in flexion/extension of the injured level was demonstrated in 8 patients. The preservation of traumatized motion segments may reduce the incidence of degenerative alterations and hypermobilities in adjacent levels. The transfixation technique in anterior procedures leads to a reduced time of spinal exposure, complications as a result of spinal graft manipulation, pseudarthrosis or donor graft site problems are no more relevant.     

Temporäre mechanische Kreislaufunterstützung bei Kindern und Patienten mit angeborenen Herzfehlern

Ventricular assist devices (VAD) in children with terminal heart failure have been used as a bridge to transplantation or myocardial recovery for more than 20 years. The Berlin Heart Excor® Pediatric VAD is approved for use either as univentricular or biventricular support for children with a body weight less than 20 kg. Larger children can be supported with implantable continuous flow devices, e.g. HeartWare HVAD. Indications for support are cardiomyopathy, myocarditis and terminal heart failure in patients with congenital heart diseases. Due to the shortage of donors support time on VADs has greatly increased often lasting longer than 1 year. Although increased experience and technical modifications over the last decade have substantially improved the outcome of patients on VAD support, much is still dependent on the etiology of the heart failure. The survival rate in children with normal anatomy is approximately 80?% compared to 50?% in children with congenital heart diseases. The main complications during VAD support which occur in nearly 25?% of children weighing less than 20 kg are thromboembolic events. Miniaturization of the device to improve the quality of life for children on support and minimizing the risk of thromboembolic events are current fields of intensive research.     

Die transartikuläre C1-C2-Verschraubung

Background

Transarticular dorsal screw fixation of atlantoaxial instability in the elderly is seldom described in the literature. This study presents the results of this technique in patients aged at least 70 years. A modified method of indirect screw fixation is used in which soft tissue dissection is reduced compared to the classic procedure.

Patients and methods

Between 1998 and 2005 a total of 36 patients with acute or chronic traumatic instability of the atlantoaxial complex were treated surgically. The average age was 80.1 years (70–93 years). Seven patients (19.4%) had associated injuries. The operative technique was standard. The duration of radiological follow-up averaged 23 months (12–57 months) whereas clinical follow-up was for 38 months (12–72 months).

Results

There were no intraoperative complications. Of the total 72 screws inserted, 2 (2.8%) proved to be incorrectly positioned. There were complications not associated with the procedure in 16 patients (44.4%). Nosocomial infections and falls were the most common complications. Two deaths occurred within the first postoperative month. Four more patients died in the follow-up period as a result of diseases not associated with the trauma. Of the 30 surviving patients, 28 (93.3%) were followed up clinically and radiologically. Bony dorsal fusion was documented in every patient followed up. Further operation on the cervical spine was not required in any patient.

Conclusion

The presented technique of transarticular C1-C2 screw fixation is associated with reliable fusion rates and good functional results. The procedure can be recommended for atlantoaxial instability in the elderly.     

Spondyloepiphysäre und metaphysäre Dysplasie

Spondyloepiphyseal, metaphyseal and spondylometaphyseal dysplasias are a group of hereditary skeletal diseases, which lead to small stature, axial deformities of the lower extremities and spinal deformities. They differ in pathophysiology, heredity and in their clinical and radiologic appearance. The orthopaedic surgeon treats the spinal manifestations and the axial malalignment of the disease. Among the spinal deformities there are instabilities of the upper cervical spine as well as structural deformities like kyphosis and scoliosis. More frequently, the axial malalignment caused by congenital coxa vara, severe genu varum or genu valgum requires treatment. These deformities are managed by corrective osteotomies of the proximal femur, supracondylar or proximal tibial osteotomies around the knee and by temporary epiphyseodeses. Despite a high recurrence rate requiring repeated surgery the patients report great satisfaction with the treatment results. Well-timed orthopaedic treatment helps avoid or delay the inevitable long-term sequelae of untreated patients such as painful degenerative changes of the spine or early onset of severe osteoarthritis.     

3D-BV-adjustierte perkutane trianguläre Stabilisierung der geriatrischen Beckenringfraktur

Die Unfallchirurgie - Die 3D-Bildverstärker(BV)-adjustierte perkutane trianguläre Stabilisierung der geriatrischen Beckenringfraktur vermeidet implantatassoziierte perioperative...     

Primäre und sekundäre plastische Eingriffe an Gesicht und Schädel

Ohne Zusammenfassung Mit 4 Textabbildungen in 9 Einzeldarstellungen     

Chronische capsuläre und pericapsuläre Schulterversteifungen und ihre Beseitigung mittels Plexusanästesie

Ohne Zusammenfassung Mit 4 Textabbildungen.     

Radiolunäre und radioskapholunäre Arthrodese bei chronischer Polyarthritis

INTRODUCTION: In 75% of all cases of rheumatoid arthritis the wrist is affected and in 12% is the region of initial manifestation of this chronic inflammatory joint disease. To prevent destruction of the wrist through carpal dislocation, radiolunate and radioscapholunate arthrodeses have increased in importance. METHODS: During a 6.5-year period, 28 radiolunate and 4 radioscapholunate arthrodeses were performed in 30 patients. The indication for operation was progressive carpal translation and increasing subluxation of the wrist in which existent radiological damage had not reached more than grade III according to the classification of Larsen and co-workers. RESULTS: The results obtained during the follow-up study (median: 17.3 months) showed in most treated patients after partial arthrodesis of the wrist no or fewer complaints concerning swelling and pain and an acceptable remaining range of motion of the wrist in everyday life. In patients with preoperatively existing ulnar deviation less than 15 degrees progressive carpal collapse and dislocation could be mostly prevented. CONCLUSION: All told radiolunate and radioscapholunate arthrodeses successfully stabilized the wrist in patients suffering from rheumatoid arthritis.     

Periprothetische und interimplantäre Femurfrakturen

Die Unfallchirurgie - Mit steigendem Patientenalter nimmt die Anforderung an die Versorgung von Femurfrakturen zu. Unklar ist, inwieweit die Implantate die femorale Stabilität beeinflussen....     

Osteosynthese und primäre Knochenheilung

Ohne ZusammenfassungMit 7 Abbildungen in 19 Einzeldarstellungen     

Celluläre Immunität und Krankheitsdisposition

Ohne Zusammenfassung Aus Hofrat Dr. A. Theilhabers Frauenheilanstalt. Mit 2 Abbildungen.     

Intraartikuläre Punktionen und Injektionen

Joint punctures and injections are a widely used approach to obtain a differential diagnostic assessment for the formation of a treatment concept for recurrent joint effusions, to exclude a periprosthetic infection in painful and loosened endoprostheses before a planned revision, to assign the origin of pain symptoms to a specific joint or to provide a treatment for arthritis of any kind. In all medical fields the standardization of processes has progressed. Therefore, for joint punctures there are standards relating to the implementation and hygiene of intra-articular punctures or injections in order to prevent the occurrence of complications, such as joint infections.     

Suprakondyläre und subkapitale Humerusfrakturen

Osteochondral lesions can be found in joint surfaces and affect the cartilage covering, in particular also the subchondral bone layer. During pressure stress on the joint surface the laws of force parallelograms apply which lead to resulting injuries of the joint surface. Damage caused in this way can result in osteoarthritis if the healing process is prolonged but can also occur due to disease or overuse. Necrosis (osteonecrosis) in the subchondral region results from fractures, spontaneously for idiopathic reasons, as a result of underlying diseases, due to risk factors and as damage to the growing skeleton resulting in osteochondrosis dissecans (osteonecrosis). This can also result in osteoarthritis as it also promotes osteochondrosis.     

Extraartikuläre Skapula- und Skapulafortsatzfrakturen

Extra-articular scapula fractures are rare injuries, which are often associated in high-energy trauma or in multiple injured cases. In the past extra-articular scapula fractures were treated conservatively and randomized treatment studies had been rare for those cases. However, biomechanical studies of the scapula, newly designed anatomical implants as well as minimal invasive approaches to the scapula have improved the operative treatment in those cases. However, in principle only dislocated and instable extra-articular scapula fractures should be addressed operatively.