From Correspondenzblatt to BJS - a century of Swiss surgical publishing.
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General Surgery↗
Biomedical subjects
A Leutenegger
Publications and source records attributed to A Leutenegger.
[Editorial on the last issue of Swiss Surgery].
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Consumer Behavior↗
[How often do surgical residents operate in a category A non-university post-graduate teaching hospital?].
INTRODUCTION: After introduction of the new postgraduate training program for general surgery the completion of the operation list still represents the most important step. Based on our number of operations we examined whether residents would carry out the requested interventions at our non-university teaching hospital (category A). METHOD: For eight tracer operations we retrospectively counted the number of cases of the non private patients from 1998-2002 and took account of the postgraduate education status of the operator. In this period the team consisted of 51 residents (71 education years), of whom 18 candidates for general surgery who carried out the interventions (35 education years, inclusive rotation in ICU, emergency room and special surgical disciplines). RESULTS: Regarding all tracer operations, the amount of interventions per year and candidate which are necessary to accomplish the goal for the first four years of education are reached: appendectomy 8.9, laparoscopic cholecystectomy 7.3, open inguinal hernia repair 9.4, varicose veins operation 12.1, open colon sigmoideum resection 3.2, hip and malleolar fracture 6.9, hemithyreoidectomy 5. CONCLUSION: Completion of the operation list as the major training goal was reached at our institution. Following our structured education program the demands regarding postgraduate education will be met also in future. Further studies however, must examine the impact of the new resident's work contracts dictating a reduction of the weekly working hours.
Clinical Competence↗
[Distal radius fractures--retrospective quality control after conservative and operative therapy].
BACKGROUND: The distal radius fracture is the most frequent fracture in the adult patient. The wide spectrum of different types of fracture and the coexisting factors make the choice for the optimal treatment difficult. As an interne quality control we retrospectively evaluated all patients with distal radius fractures treated in 1995 at our institution. METHODS: The study included 69 adult patients with 71 distal radius fractures. After on average 26 months 58 patients with 59 fractures were clinically and radiologically evaluated. The patients were asked to give supplementary information about their follow-up treatment as well as any remaining physical difficulties and limitations in the daily life. All x-rays of the broken radius were carefully analysed and compared with the opposite side. The final results were evaluated according to the "Demerit Point System". RESULTS: Patients were treated with five different therapeutical methods. 76.3% of the patients showed a very good/good final result. In 56.7% of the cases secondary fracture dislocation occurred; the dislocation-rate of fractures treated with percutaneous k-wires was 93.3%! A clear correlation between secondary displacement and final results was found. CONCLUSION: A main factor for an optimal outcome is the anatomic restoration of length and axis of the distal radius as well as of joint congruency, also moderate angular deformities are well tolerated. Our collective showed an unexpected high rate of secondary displacement, especially in the k-wire group. The reasons for this unsatisfactory event are manifold: too optimistic indication, insufficient follow-up examination in the first four to six weeks, inconsequent change to a more stable fixation method in case of a secondary dislocation. The results of this retrospective evaluation had a major impact on our concept of treatment. The dorso-radial double-plate technique combined with bone graft will be more used in the future especially in younger patients. The new standardised concept is the base of a present prospective study.
Adolescent↗
[Secondary hyperparathyroidism: pathophysiology and therapy--follow-up analysis of patients of the Chur dialysis department].
Between 1982 and 1998 12 chronic dialysis patients treated at the dialysis unit of Kantonsspital Chur were operated for secondary hyperparathyroidism (HPT). In 10 patients total parathyroidectomy with autotransplantation of parathyroid tissue was performed. Two patients had subtotal parathyroidectomy. Patient data were retrospectively analyzed in regard to indication, operation techniques, pharmacological therapy and possible recurrence or persistence of HPT. Four patients had normal PTH levels upon follow up. The parathyroid function was judged "equivocal" in three patients, the average PTH being to high (1), normal (1) and too low (1). One patient showed moderate hyperparathyroidism. Two patients developed recurrence of HPT one of which was sufficiently severe to necessitate reoperation at the autotransplantation site. In the first two operated patients the data are missing. Compared with other studies the rate of recurrence is higher in our series. Intraoperative ultrasound and improving diagnosis of the frozen sections could possibly favorably influence outcome.
Female↗
[Fractures of acetabulum and pelvic ring--epidemiology and clinical outcome].
From 1980 to 1995 inclusive we conducted a study on pelvic ring and acetabular fractures in Kantonspital Chur (KSC). 118 patients were studied and of these 51 had pelvic ring fractures and 67 acetabular fractures. Most of the patients with pelvic ring fractures had additional severe injuries and almost two thirds of them were polytraumatised and very shocked. One third of the acetabular patients were polytraumatised and about one fifth shocked. The length of the hospital stay was also noteworthy--an average of 47 days for the pelvic ring fractures and 30 days for the acetabular fractures. These injuries mainly affected patients in the active working age group (20-60 years of age). 56 of these had acetabular fractures and 39 had pelvic ring fractures. From 51 patients (76%) treated with acetabular fractures and 45 with pelvic ring fractures (88%) (i.e. of total 96 (81%)) we have summarised our results. About two thirds of the patients were followed up at one year and the AO documentation form completed. The remainder were sent a questionnaire. The results showed that 84% of the acetabular fracture group and 83% of the pelvic ring fractures had a good or excellent final result. Radiological complications noted in the acetabular fracture group were early signs of degenerative disease (18), a slight pelvic tilt (8), heterotopic ossification (7), early evidence of femoral head necrosis (3) and 1 definite pseudoarthrosis. Additionally 7 patients had significant motor or sensory loss. By comparison, those with pelvic ring fractures showed less in the way of radiological complications. 17 patients were seen to have a slight tilt, 9 showed initial signs of arthrosis and there was 1 pseudoarthrosis. Of the 5 patients in this group with neurological damage, 3 had difficulty in achieving an erection and 2 had urological problems. One patient who had a pelvic ring fracture had to have a caesarean section for a subsequent pregnancy.
Acetabulum↗
[Migration of Kirschner wires after surgical stabilization of injuries in the area of the shoulder--4 case reports].
Internal fixation is recommended for displaced and unstable fractures of the lateral clavicle and fractures involving the proximal humerus. Kirschner wires, although recommended in the orthopedic literature bear the risk of wire breakage and migration. 4 cases with serious and potentially hazardous complications are presented. All reported complications occurred years after the operative treatment without clinical symptoms. Regular postoperative follow-ups and early hardware removal after fracture healing is recommended.
Adult↗
New techniques in indirect reduction of long bone fractures.
The most important and demanding part of operative fracture treatment concerns the reduction and correct alignment of the fracture fragments, which must be gentle to the bone and surrounding soft parts to preserve the essential blood supply to all tissues. The so called indirect reduction techniques apply the principles of nonoperative fracture care (ligamentotaxis) in combination with surgical tools and a number of techniques, where by the exposure of the most critical fracture focus can be minimized. New implant designs, low contact plates, cannulated screws, unreamed nails, pinless and hybrid external fixators, are helpful adjuncts: however, the surgical technique remains of paramount importance. The essence of careful handling of the soft and hard tissues has been stressed time and again. With the introduction of biological or minimally invasive surgery, the techniques of indirect reduction have had a renaissance. A few examples are described.
Bone Screws↗
[Submucous lipoma of the colon--report of 2 cases].
Gastrointestinal lipomas are benign but rare lesions, mainly located in the colon. Depending on their size they are responsible for obstructive bowel symptoms. Diagnostic tools are either the endoscopy or computer tomography. It is recommended to investigate the entire large bowel as other pathologies are often found. Any lipoma found should be removed. Two cases with symptomatic lipoma are presented. In both cases the lipoma was removed by open surgery.
Aged↗
[The floating joint injury of the lower and upper extremity--epidemiology, therapy and results in 40 extremities].
GOAL: Floating Joint Injuries (FJI) are resulting from high energy traumas and are often combined with additional neuro/vascular damage. The high incidence of severe open or closed soft tissue injuries is complicating the initial management and requires a broad surgical know-how also in minimal-invasive fixation techniques. In a retrospective analysis of our cases treated between 1980 and 1995, we try to find out some important therapeutical feedback for the future. MATERIAL AND METHODS: Of the 37 patients, 33 had a FJI of the lower (2 bilateral) and 7 patients of the upper extremity. 90% were road traffic injuries, 75% showed an open fracture situation and 25% an associated neuro-vascular injury. All fractures were stabilised within the first hours, femur, humerus and forearm in one step, the tibia in 33% in two steps (initial external fixator ...). 80% of the FJI have been reexamined after 1-2 y. RESULTS: Local complication: Femur: 4/33 (1 infection, 2 refractures, 1 non-union). Tibia: 11/33 (5 infections, 4 delayed/non-unions, 2 malalignements). Humerus: 0/7. Forearm: 1/7 (1 malalignement). 1-2 y-results: Very good-good: Femur: 26/27 (96%). Tibia: 23/27 (85%). Humerus: 4/5. Forearm: 3/5. DISCUSSION: FJI should be stabilised as soon as possible in a way allowing for early functional aftercare of the affected joint. Most complications are observed in the proximal tibia fracture because of the thin and therefore often severely (open or closed) injured soft tissue cover. Despite a staged procedure, there exists a high complication rate, which probably can be reduced in the future by the single-step use of the hybrid external fixateur.
Adolescent↗
[The trauma patient: open hospital choice?].
Victims of trauma have usually no choice regarding the physician or hospital they are admitted to. In order to deliver the best possible trauma care it is crucial that trauma victims first receive competent on site primary care before being admitted directly to a hospital that is sufficiently equipped and qualified to take care of their injuries. Recent literature suggests that individual outcomes, but also per-case costs of trauma patients clearly improve, when prehospital care, triage and admission to specially designed trauma centres are coordinated within regional trauma systems. This provides supporting evidence for the recent proposals by the Swiss Medical Association (FMH) in 1996 who formulated 12 statements regarding rescue services in Switzerland. In order to optimise rescue and trauma care there is an urgent need for restructuring existing systems nation-wide. Trauma patients may thus to some degree lose their freedom in choosing their preferred physician or hospital.
Cost-Benefit Analysis↗
[Elbow fractures in elderly patients].
Are the well established methods for operative treatment of fractures about the elbow and their results also applicable to elderly people with osteoporosis? In a retrospective study 23 of 32 patients with 33 operatively stabilized fractures of the distal humerus and the proximal radius and ulna, could be reviewed and personally questioned. The fracture type, the complications and the range of motion of the elbow were analysed and classified. Over 75% of the cases presented with a good to excellent range of motion with no increase of complications. 80% of the patients were satisfied with their result after surgical treatment of the fracture. Fractures of the elbow in elderly people with osteoporosis may be sucessfuly treated by ORIF. It appears important to start early with postoperative physiotherapy. Thereby good functional results can be expected without an increase of complications.
Activities of Daily Living↗
[Blunt abdominal trauma with lesion of the abdominal aorta--a case report].
A 58-year old lady, involved in a head-on motor vehicle crash suffered a severe intestinal injury associated with an intimal flap lesion of the distal abdominal aorta. Thrombotic occlusion of the aortic bifurcation with clinical evidence of lower extremity ischemia was noted. The management of blunt injury to the abdominal aorta is discussed with special regard to placing prosthetic material in a potentially infected field.
Abdominal Injuries↗
Ten-year follow-up after operative treatment for intra-articular fractures of the calcaneus.
Our first 16 patients with intra-articular calcaneal fractures that were managed by open reduction and internal fixation were originally reviewed on average 3 years after operation. We looked at the same patients again on average more than 10 years after surgery using the same evaluation system by the same physician. Seventy-five percent of the patients showed an excellent or good functional result. In no case was there an indication for a secondary arthrodesis. In spite of the fact that radiologically most patients showed a slowly progressing posttraumatic subtalar osteoarthritis, the subjective results (pain, capacity to work, and/or sports) at 10 years were clearly better than 3 years after surgery. These results may allow the conclusion that radiologic findings are only of limited value in the assessment of long-term results after operative treatment of calcaneal fractures. From a functional point of view and on the long-term follow-up most patients with intra-articular fractures of the calcaneus seem to profit from open reduction and internal fixation.
Adolescent↗
Severe skiing injuries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality.
All ski accident patients requiring an inhospital treatment at our institute from 1984 to 1992 (n = 2,053) were analyzed retrospectively. The incidence, pattern, and severity of the injuries, as well as the 30-day mortality comparing two time slots (1984 to 1988 and 1989 to 1992) were analyzed for the 361 cases classified as "serious" injuries according to the following definitions and groupings: group 1, multiple trauma (Injury Severity Score > or = 18) and patients with multiple fractures (n = 179; group 2, abdominal or thoracic single trauma (Abbreviated Injury Scale (AIS) score > or = 2, n = 58); and group 3, isolated head injuries (AIS score > or = 2, n = 124). Serious injuries were observed in 19% in the first period compared to 16% in the second period (not significant). Two hundred thirty-eight of 361 patients injured themselves by just falling, while 117 collided with some sort of obstacle like other skiers (45), trees or rocks (27), posts, pylons, barriers (20), and moving objects (25) such as piste machines, ski lifts, automobiles, and in one case a helicopter. Six skiers were caught on the ski run by an avalanche. Comparing the two time periods, trauma circumstances did not change significantly. The number of most severe head injuries (AIS score > or = 4) increased from 11.6 to 19.3% (p < 0.05). The overall mortality increased from 2 to 7% (p < 0.05). Group 2 had the best prognosis with no mortality, while group 3 was rated worst with 8%. Skiing remains a major source of serious trauma in winter resort areas.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Preoperative measures in emergencies].
AIM: To define the minimally necessary preoperative evaluation and preparation of an emergency patient of a surgical ward. DISCUSSION: While the preoperative evaluation and preparation of a patient for elective surgery aiming at minimizing any risk may take some time, the emergency patient has to be managed intensively and rapidly in order to save life, limb or organ function. Resuscitation of vital functions is best done in collaboration with the anaesthesists and ICU team and has absolute priority. Following this careful clinical examination and the personal history--if obtainable--are more important for decision making than most laboratory data or technical investigations. However, any informations on coagulopathy and metabolic disorders appear essential, as they should be corrected before surgery. Ultrasound is today the most important technical tool to evaluate the abdominal and thoracic cavity, while x-rays are essential for the detection and documentation of any skeletal lesions. CT-scan is indispensable for the examination of the central nervous system. All findings must be carefully recorded allowing for the scoring of any injury or illness which appears important for prognostic considerations as well as for follow-up and quality control. CONCLUSION: The management of any emergency case is demanding and needs experienced physicians. A schematic procedure adapted to the local possibilities and facilities is helpful for an effective and often life-saving team work between the resuscitation team and surgeons.
Diagnostic Tests, Routine↗
Osteosynthesis of 245 tibial shaft fractures: early and late complications.
A consecutive series of 245 fresh fractures of the tibial shaft, including 60 open fractures underwent operation in a 5 year period (1980-1984). Two hundred and forty-two (98.8 per cent) of these fractures were followed-up for an average of 79 months (6.5 years). Early and late complications as well as complications after implant removal were taken into account for closed and open fractures. In the 185 closed fractures, infection was observed in 1.7 per cent and delayed union in 6.8 per cent. More than 94 per cent of the closed fractures had an excellent or good late result. In open fractures (60 cases) infection was seen in 6.8 per cent, and plate fatigue with delayed union was seen in 10.3 per cent. However an excellent or good functional result was obtained in 93 per cent of the open fractures. After implant removal refractures occurred in 1.3 per cent and other minor complications in 0.9 per cent.
Adolescent↗
[Integration and resorption of calcium phosphate ceramics in defect filling of fractures of the tibial head. Radiologic long-term results].
Calciumphosphate ceramics are considered as a substitute for cancellous bone grafts. 16 patients with traumatic impressions of the tibial plateau were treated according to the AO-principles and subchondral bone defects were filled with hydroxyapatite (10x) or tricalciumphosphate (6x). Clinical and radiological follow-up after 3 to 10 1/2 years was uneventful with primary bone healing and excellent results in all cases. No adverse reactions of the completely integrated ceramics have been observed. Hydroxyapatite, even after 10 years, showed no proof of biodegradation, whereas tricalciumphosphate showed slow dissolution and replacement by new host bone formations in the later follow-up after 2 to 6 years.
Calcium Phosphates↗