[The upper ankle joint--a "permanent runner"].
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Ankle Injuries↗
Biomedical subjects
G Muhr
Publications and source records attributed to G Muhr.
[Stable ankle joint fractures. Indication for surgical or conservative management?].
In German literature, ankle joint fractures are mostly classified in three groups according to Weber. In cases of the type A, the fracture line runs below, in cases of type B at height of the syndesmotic ligaments. C-type fractures are typically seen above this region. However, this practical and simple classification allows no inferences at accompanying injuries which in turn influence the functional outcome. We observed isolated fractures of the lateral malleolus in more than 60% of all type B-fractures, as soon as in the majority the type A-fractures. Since isolated medial ankle fractures occur very rarely, careful exclusion of further injuries is advisable here. In order to differentiate stable ones from unstable type B ankle injuries, we carry out a manual stress test, if there is less than 2 mm fracture dislocation and a congruent ankle mortise. In this manner we could find that stable lateral ankle fractures are characterized with a combination of an intact dorsal syndesmotic and medial ligament. Stable type B and undisplaced type A fractures were treated conservatively with an ankle brace (Aircast?). Unstable ankle injuries were treated by ORIF. Conservative treatment for undisplaced medial malleolar fractures is recommended, if x-rays showed less than 2 mm dislocation which allows a tibio-talare impingement. Biomechanical investigations could prove a significant increase in ankle joint stability, when an axial load of 300 N was applied to various horizontal loads. The talus does not follow automatically a displaced fibular fracture. The dorsal syndesmotic and the medial deltoid ligaments control ankle joint stability.
Ankle Injuries↗
[Surgical management of posttraumatic mal-alignments and arthroses in the ankle].
Joint incongruency, malalignement as well as degenerative changes of the ankle joint may result in disabling pain with a significant decrease in function and mobility. The clinical symptoms may affect all aspects of life. Primary osteoarthritis of the ankle joint is uncommon, and posttraumatic conditions with significant changes in joint mechanics are usually the primary source of joint degeneration with the resultant clinical symptoms. Apart from pain relief and restoration of joint mobility, prevention of joint degeneration or progression of arthrosis should be the main goal in treating such conditions. Arthrodesis of the ankle still is the method of choice for severe osteoarthritis of the ankle, however several surgical treatment options are available to deal with mild to moderate joint degeneration. Restoration of the anatomy and joint alignement in posttraumatic deformities as well as ligament reconstruction in chronic instability are measurements to prevent development or progression of osteoarthritis. Joint debridement is useful in primary anterior joint pathology, in advanced osteoarthritis at least temporary pain relief can be achieved. In severe osteoarthritis arthrodesis of the ankle is the method of choice for long-term pain relief and restoration of mobility.
Ankle Injuries↗
Surgical excision of heterotopic bone after hip surgery followed by oral indomethacin application: is there a clinical benefit for the patient?
The clinical effect of surgical excision of heterotopic bone after hip surgery in combination with an oral indomethacin application was analysed in 21 patients in a retrospective study. Indomethacin (3 x 50 mg) was administered after the first postoperative day for a period of 6 weeks. To avoid gastrointestinal side-effects, a mucoprotectivum (sucralfat, 3 x 1 g) was also applied. One year after surgery, 19 patients (90.4%) had excellent relief of pain, the average improvement of flexion was 40 degrees, of abduction 13 degrees, of internal rotation 8 degrees and of external rotation 14 degrees. Only one patient (4.8%) suffered a recurrence of heterotopic bone formation, and in one patient (4.8%) we observed gastrointestinal side-effects. Thus, we recommend surgical excision of heterotopic bone followed by oral indomethacin therapy as a convenient and reliable strategy to prevent new heterotopic bone formation after hip surgery.
Adolescent↗
Ipsilateral fractures of the pelvis and the femur--floating hip? A retrospective analysis of 42 cases.
A consecutive series of 40 patients, who sustained 42 ipsilateral pelvic and femoral fractures, is reported. There were eight (26.6%) traumatic neurological deficits and three open femoral fractures. Two multiply injured patients died in the postraumatic period because of the severity of their injuries. No associated vascular injuries could be identified. All but two fractures of the femur, 8 of the 15 fractures of the pelvic ring and 17 of the 30 fractures of the acetabulum were treated by internal fixation. In 26 patients internal fixation was performed on both fracture components (in 17 patients this was done under the same period of anaesthesia). Postoperatively, a deep venous thrombosis in three patients, one deep wound infection and five (18.5%) iatrogenic neurological deficits had to be notified. In this series we could not identify any specific associated injuries and complications as known for the floating knee or the floating elbow. The term floating hip is inprecise and misleading, and its use is not recommended. The treatment of this fracture-combination follows the guidelines established for the individual lesions.
Acetabulum↗
Management of odontoid fractures in the elderly.
Odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years of age they form the majority of spinal fractures. In a retrospective analysis of 23 geriatric (> 70 years) patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years of age. Whereas in the younger patients high-energy trauma accounted for the majority of the fractures, low-energy falls were the underlying cause in 90% of the odontoid fractures in the elderly. In contrast to the younger age group, in elderly patients predominantly type II fractures (95%) were identified. Anterior and posterior displacement were recorded with equal frequency on the first postinjury radiograph in the younger age group, whereas in geriatric patients displacement was mainly posterior. The number of associated injuries was significantly higher in younger patients. There was no difference in the occurrence of neurological deficits (13%) between the two age groups, and neurological compromise was mainly related to posterior dislocation of the odontoid in both groups. The overall complication rate was significantly higher in elderly patients (52.2% vs 32.7%), with an associated in-hospital mortality of 34.8%. Loss of reduction and non-union after non-operative treatment, a complicated postoperative course and complications due to associated injuries accounted primarily for this high complication rate. Elderly patients with a fracture of the odontoid are a high-risk group with a high morbidity and mortality rate. An aggressive diagnostic approach to detect unstable fractures and application of a halo device or early primary internal stabilisation of these fractures is recommended.
Adolescent↗
Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases.
OBJECTIVE: To analyze the results of 45 patients after ankle arthrodesis in the presence of joint infection. METHODS: Arthrodesis was performed with two compression screws and an anterior plate in 29 patients and with two compression screws only in 16 patients. In all patients, additional stabilization with external fixation was used. In 29 patients, isolated fusion of the ankle joint was performed; in 13 patients, the ankle and subtalar joints were fused, and in 3 patients, isolated arthrodesis of the subtalar joint was performed. RESULTS: In 39 of 45 patients (86.6%), solid fusion was obtained. Nonunions occurred in 6 patients (13.4%). A below-knee amputation was necessary for one patient. Full weight-bearing was achieved after 21.6 weeks on average. Thirty-two patients returned to work after 35.5 weeks on average. Five of the six patients with failed ankle fusion needed special shoes; in one patient, a below-knee amputation was performed. A total of 33.3% of failed ankle fusions were associated with systemic disorders such as diabetes mellitus, and other concomitant diseases compromising local arterial blood supply and proprioception. CONCLUSION: Our results prove that limb salvage is possible even in complex ankle and subtalar pathology by thorough fusion by using a number of different techniques.
Adult↗
[Hierarchy in surgery. An antiquated system?].
Medical responsibility and hospital management, competency for resident's training and decision making in therapy are better performed in a system of hierarchy than other kinds of organisation of a surgical department. If all the duties and responsibilities are concentrated to a head of the department, it is also necessary to give him the adequate instruments for leadership, to stay alive.
Curriculum↗
[Surgical, conservative and functional fracture treatment].
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Casts, Surgical↗
[Where is the truth? Logic and suggestions in publications].
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Diffusion of Innovation↗
[Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate?].
In a prospective study, 53 fractures of the distal fifth of the tibia were stabilized by unreamed nailing. Additional involvement of the ankle joint occurred in 18 patients. 50 patients returned for follow-up. In 30 patients tibia and fibula were fractured at the same (distal) level; in 20 patients the fracture of the fibula was located more proximally. In 12 patients the fractures extended into the tibial pilon. Severe soft tissue damage was seen in 24 fractures (18 open, 6 closed). Ninety percent of all fractures healed uneventfully without further surgical intervention after unreamed nailing. In two patients the unreamed nail had to be exchanged for a reamed tibial nail. Bone grafting and secondary dynamization of the nail by removal of a proximal interlocking bolt were performed in one case each. Thirty-one fractures healed in anatomical position. Valgus or varsus angulation of less than 5 degrees occurred in 18 patients. One fracture healed with rotatory angulation of 15 degrees. The highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.
Adult↗
[Corrective arthrodesis in isolated post-traumatic malalignment of the subtalar joint].
Between 1990 and 1995, 27 patients with posttraumatic disorders of the subtalar joint were treated by correcting fusion. Preoperatively 24 patients (88.89%) suffered from pain; 15 (55.56%) had a walking range below 100 m. Seven patients were unable to work in their original profession. After an average period of 13.85 months postoperatively the patients were examined again. At this time 18 (66.67%) had no or minimal pain; 19 (70.37%) had no claudication. According to the score of Angus and Skuginna, in 81.48% of patients the result of the correcting arthrodesis was successful; according to Kitaoka's clinical rating system for ankle-hindfoot, midfoot, hallux and lesser toes, the average postoperative score was 75.8 points.
Adult↗
[Functional outcome of surgical therapy of talus fractures].
Forty-five patients with fractures of the talus were treated operatively at the Department of Surgery in Bergmannsheil Hospital between 1989 and 1995. Of these, 21 patients were operated on the day of the accident. The Marti/Weber classification system was used: 9 fractures were type I, 12 type II, 18 type III and 6 type IV. Twenty-five neck-fractures were classified according to Hawkins (type I-6, type II-10, type III-6, type IV-3). The mean time of follow-up was 37.3 months (minimum of 12 months). One patient needed a primary and 2 other patients a secondary arthrodesis of the ankle and subtalar joint; 2 others required arthrodesis of the talonavicular joint. Eleven patients showed no complaints at follow-up. Twenty-five reported complaints only during strenuous exercise, 5 others during walking and 3 patients reported initial pain when walking. The mean time of therapy was 22.5 weeks. As a consequence of trauma, 7 patients changed their jobs. The most important prerequisites for successful surgery are early reduction and stable osteosynthesis. Residual complaints are frequently seen. The rate of avascular necrosis (8% in fractures of the neck of the talus) and the necessity for arthrodesis was significantly diminished.
Adolescent↗
[Nonbacterial osteomyelitis of the clavicle].
Osteomyelitis can be subdivided into a bacterial exogenic (post-traumatic/postoperative), bacterial endogenic (hematogenous) and an abacterial type, including the rare group containing primary chronic sclerosing osteomyelitis, which is typically localized in the clavicle. In a review of the literature, the criteria for the various types of chronic sclerosing osteomyelitis are analyzed. Out of a group of 17 patients with osteomyelitis of the clavicle treated between 1978 and 1996, three cases of primary chronic sclerosing osteomyelitis are demonstrated. In the differential diagnosis, primary chronic sclerosing osteomyelitis of the clavicle has to be taken into consideration despite its rareness. After establishing a diagnosis by biopsy, in contrast to the other forms, drug therapy will be the treatment of choice and not an operation.
Adolescent↗
[Os odontoideum. Etiology, clinical aspects, therapy].
The etiology of os odontoideum is still controversial. In most patients, it is found by accident because of neurological symptoms and/or painful range of motion of the cervical spine. Upon recognition of the os odontoideum, it is unknown whether or not immediate surgery is beneficial. This is in contrast to an "unstable" os odontoideum, which could result in atlantoaxial instability or compression of the myelon. In this study, we present the results of our treatment of four patients with an unstable os odontoideum. In all four cases, a C1-2 fusion was performed (3 x Magerl/Seemann, 1 GallieBrooks). Postoperatively, we found a complete regression of neurological symptoms in three patients and one was significantly improved. The range of motion of the cervical spine was free of pain in all patients. As a result, we strongly support immediate surgical treatment of an unstable os odontoideum in order to prevent severe and life-threatening neurological complications.
Adult↗
[CPAP-augmented spontaneous respiration in thoracic trauma. An alternative to intubation].
Intubation and Positive End Expiratory Pressure Ventilation (PEEP) is a well established therapeutic strategy for impaired lung function, particularly following blunt chest trauma. Complications of this regime are however also well known and pose the question why non-invasive forms of respiratory assistance such as Continuous Positive Airway Pressure (CPAP) have only gained minor popularity. In a prospective study, 30 patients who had suffered blunt chest trauma were treated with CPAP administered by mask. The regime consisted of continuous administration of CPAP by a face-mask, with gradually increasing periods of spontaneous breathing. Initially a FiO2 of 0.33 (range 0, 28-0, 33) proved necessary. The initial CPAP level was 7 mbar (range 5-8) with an (Assisted Spontaneous Breathing) ASB of 15 mbar (range 13-8). FiO2 and CPAP/ASB levels were subsequently gradually reduced until no longer necessary. In all patients intubation and ventilation was avoided by this regimen. The treatment was well accepted by all patients and common ventilation associated complications such as pneumonia did not occur. In comparison with the former standard method of treatment the average ICU stay was dramatically reduced, principally due to not having to gradually wean patients from ventilation and sedation. Other positive benefits include normal communication and feeding with active early mobilisation leading to faster recovery, both physical and psychological. We conclude that non-invasive respiratory techniques should be used more frequently and recommend further studies are undertaken to define the indications.
Adult↗
[Intramedullary boring in infected intramedullary nail osteosyntheses of the tibia and femur].
UNLABELLED: The infection after intramedullary nailing is a severe complication, which is hard to eradicate. The results of reaming the intramedullary canal after removal of the infected nail were evaluated in our investigation. From 1984 to 1991 fifty-five patients with infected intramedullary nails of the lower extremity were included in this trial. Twenty-one patients had an infection of the femur. Thirty-four patients had a primary infection of the nail, twenty-one patients had multiple operations with periods of infection prior to nailing. All patients had signs of a chronic osteitis and sinus formation. At the time of the follow-up the success of the procedure was evaluated regarding recurrence of infection, range of motion of the extremity and patient comfort. The mean time of observation was 10.1 +/- 4.9 years. All patients with initially infected intramedullary nails had no recurrence of the infection, compared to 62% of those with multiple operations prior to nailing. At the time of the follow up all fractures had healed. 85% of the patients performed full weight bearing. 32 patients (91%) had good or excellent ROM of the adjacent joints. CONCLUSION: Intramedullary reaming after infected nails is a successful procedure and results in infect healing in the majority of patients.
Adult↗
[Subdural abscess as a complication of halo fixator].
Complications associated with the application of a halo device are not infrequent; however, osteomyelitis of the skull with a consecutive subdural abscess is a rare but severe complication. We present the case of a patient with a subdural abscess as a result of a local pin-track infection of the halo device, in whom pathological behavior was the primary clinical finding. The possible complications associated with the halo device are discussed with emphasis on associated head injuries and preexisting neurological diseases, as well as indications for the halo, clinical symptoms of pin-track infections, necessary diagnostic measurements and the appropriate treatment.
Cervical Vertebrae↗