[Pelvic injuries: low incidence but unsatisfactory outcome].
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External Fixators↗
Biomedical subjects
H Tscherne
Publications and source records attributed to H Tscherne.
[Pelvic fractures: epidemiology, therapy and long-term outcome. Overview of the multicenter study of the Pelvis Study Group].
Pelvic fractures are rare injuries (3-8%) when compared to fractures in other body regions. They are accompanied by high mortality (5-20%), and the survivors suffer from severe pain and pelvic-related handicaps. The German Pelvic Group (German Chapter of the AO-International & German Trauma Society) started a prospective multicenter study, including ten major trauma centers for collecting a high number of data in a short period of time (1991-1993). All pelvic injuries were documented consecutively using a special set of evaluation sheets. The study closed with 1,722 patients. A 2-year follow-up was completed for 486 patients injured in 1991 and 1992 after type B and C injuries, complex pelvic trauma, acetabulum fractures and a random 25% of A-type injuries (overall follow-up rate 73%). The follow-up included special "out-come" criteria. Of the pelvic ring injuries without significant peripelvic soft tissue involvement, 63.6% were A-type fractures, 21.0% B-type injuries and 15.5% C-type injuries. The rate of operative stabilization was 3.9% after A-type injuries, 37.3% after B-type injuries and 54.3% after C-type injuries. In isolated acetabular fractures ORIF was performed in 38.6%. The total lethality was 7.9% with a significant difference between "complex" pelvic trauma (21.3%) and patients without concomitant peripelvic injuries (7.2%). In 0.9% the pelvic injury was reported as the main cause of death. Pain at follow-up was observed in every classification group, the rate of completely "pain-free" patients being 55% after A-type, 41% after B-type and 27% after C-type fractures. Malfunction of micturia was reported by 7.6% of all patients, sexual malfunction by 11.6% of the males ("erectile dysfunction") and 2.2% of the female ("dysparneuria"). Scaled by the recently developed "outcome score", the radiological result showed anatomical healing after 90.8% of the B-type and 74.6% of the C-type injuries. On the other hand, the clinical result was rated as good or excellent in only 70% of the B-type and 54% of the C-type injuries. Although progress in indications and treatment techniques has shown improved radiological results after unstable pelvic ring injuries when compared to earlier studies, the clinical result still remains unsatisfactory. Further analyses and studies must be conducted to identify the prognostic factors for the late sequelae. Whether it is possible influence these factors by additional surgical intervention cannot be answered at present.
Acetabulum↗
[Isolated hip dislocation of traumatic origin].
The final outcome following isolated traumatic dislocation of the hip that is reduced within 6 h is generally believed to be excellent. Forty-nine patients with an isolated dislocation of the hip were treated between 1974 and 1989 at the Department of Traumatology of the Hannover Medical School. The majority of patients were involved in traffic accidents, and 42 had associated injuries. All dislocations primarily treated at our hospital were reduced by closed methods within 3 h, (average 85 min, range 10-180 min), followed by early mobilisation with partial weight-bearing for 2-3 weeks. 42 patients were evaluated after an average follow-up period of 7.7 years. Radiological signs of partial necrosis were seen in two patients. Mild arthrosis was found in seven patients, moderate degeneration in two and heterotopic ossifications in four patients (two Brooker II, one Brooker III, one hip ankylosed). Twenty-nine of 33 MRI examinations were normal. Despite early reduction only 9/12 anterior and 14/30 posterior dislocations revealed excellent and good results according to the Thompson and Epstein classification. According to the present study the important prognostic factors are the direction of dislocation, the overall injury severity and the age at the time of injury.
Adolescent↗
[Morphologic aspects of alloplastic augmentation in replacement of the posterior cruciate ligament. An experimental study on the sheep].
The treatment of injuries to the posterior cruciate ligament (PCL) remains controversial. Various problems have prevented PCL reconstruction from consistently producing the knee stability desired. Biological graft tissue undergoes a remarkable healing process comprising different phases. The strength of autogenous graft material decreases soon after the operation. During this early healing phase synthetic augmentation could protect the graft tissue from overloading or overstretching, supporting the tissue restoration process. In order to evaluate the morphological effects of the ligament augmentation device (LAD) on a free patellar tendon autograft in PCL reconstruction a comparative study in sheep was conducted. In 24 mature sheep the PCL was replaced with either a patellar tendon autograft alone or a patellar tendon autograft augmented by the LAD. The LAD was fixed at both ends. The animals were not immobilized after the operation. Tibial fixation was released 8 weeks after the operation. The autografts of both groups were histologically evaluated after 2, 6, 16, 26, 52 and 104 weeks. In addition to necrotic and degenerative alterations a pronounced inflammatory reaction could be seen in the LAD-augmented autografts soon after the operation. Compared with the non-augmented autograft, tissue formation and remodeling was delayed in the augmented group. After 1 and 2 years, the morphology of the autograft tissue was similar in the augmented and the non-augmented group and was different from that of a normal PCL. The LAD was surrounded by a chronic inflammatory reaction, and collagen fiber ingrowth into the LAD was not observed. Transmission electron microscopy showed that small-diameter collagen fibrils were predominant in the graft tissue of both groups. Thus, better remodeling of the autograft tissue in the presence of the LAD was not demonstrable in this particular study. The value of synthetic augmentation of biological grafts of PCL reconstruction seems to be questionable at present.
Animals↗
[Screw arthrodesis of the ankle joint. Technique and outcome].
In ankle arthrodeses several clinical and biomechanical studies have shown the superiority of the screw technique over external fixation. As a maximum of stability is a major goal, especially for functional after-treatment or in patients with poor bone stock, the arthrodeses technique at Hannover Medical School is performed with four screws. Two parallel anterior/posterior screws are placed from the tibia to the talus, providing anterior stabilization. One screw posteriomedial has a posterior tension-wiring effect and one screw placed through the fibula to the talus acts against rotational and sagittal translation. From May 1975 to May 1995, 225 ankle arthrodeses with internal or external fixation technique were performed. Complications were found in 47% in the external fixation treatment group (n = 44) and in 10% the patients stabilized with the screw technique (n = 181). Fifty of these 225 patients had a follow-up evaluation after an average of 7.4 years (external fixation, n = 22; screw fixation, n = 28). All patients were examined and scored with three different scoring systems: (1) MHH Score, (2) Clinical Rating System according to Kitaoka et al. (1994) and (3) Outcome Questionnaire for evaluating the overall outcome. The results from the questionnaire were compared to the clinical scores. Retrospective analysis revealed a higher rate of complications for arthrodeses performed by external fixation. The overall results of all three different scoring systems showed a trend in favor of the screw-fixation technique without reaching statistical significance (P > 0.05). The results of the Outcome Questionnaire are statistically as valid as the two clinical scoring systems.
Ankle Joint↗
[Surgical treatment of acute, complete acromioclavicular joint dislocation. Indications, technique and results].
From June 1983 to May 1990, 51 patients were operated on for acute, complete acromioclavicular dislocation (Tossy III). The operative technique includes suturing of the coracoclavicular and acromioclavicular ligaments and stabilization of the clavicle with resorbable, 10-mm coracoclavicular PDS banding. Six patients received primary resection of the lateral end of the clavicle due to significant injury of the AC joint cartilage. Forty-two patients with an average follow-up of 6.1 years were evaluated clinically using the UCLA and Constant-Murley Score, as well as subjective grading. Additional radiological assessment was performed in 36 cases. Excellent or good clinical results were obtained in 97.6%, with 85.7% being free of pain. All patients with primary resection of the lateral end of the clavicle had no pain. The incidence of postoperative complications was low (one deep wound infection with removal of the PDS band, three secondary dislocations). Post-traumatic arthritis developed in 14.7% of the patients. In those cases of acute grade III AC joint dislocations where operative treatment is indicated, this technique provides excellent results with a low complication rate.
Acromioclavicular Joint↗
Epidemiology of pelvic ring injuries.
3260 patients with pelvic and acetabular fractures were assessed using a standardized documentation form by collating the data on 1905 patients treated at the Department of Traumatology of the Hannover Medical School together with those patients treated between 1991 and 1993 in the German Multicentre Study Group (Pelvis) of the German Trauma Society and the German Section of the AO International. 2551 patients had pelvic ring injuries. 61.7% of the patients were multiply injured. 12.2% were suffering a complex pelvic trauma defined as a pelvic injury with concomitant soft tissue injury. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury). There were concomitant acetabular fractures in 15.7%. The most frequent single lesions affecting the pelvic girdle were fractures of the ischiopubic bones (transpubic instability), injuries involving the sacroiliac joint (transiliosacral instability), and sacral fractures (transsacral instability). The overall rate of operative stabilizations was 21.6%. Type B injuries were stabilized in 28.9% and type C injuries in 46.7%. The overall mortality rate was 13.4%, depending significantly on the associated extrapelvic trauma. In complex pelvic injuries, the mortality rate was 31.1% whereas for pelvic fractures without concomitant soft tissue injury the rate was only 10.8%.
Accidents, Traffic↗
[Intramedullary nailing of open fractures].
The goal of treatment of open fractures is to prevent infection, promote fracture healing, and restore normal limb alignment and function. The initial treatment of these fractures includes: debridement, soft tissue coverage, antibiotic therapy, and fracture stabilization. Four different techniques for intramedullary nailing for the fixation of open fractures have been employed: (1) unreamed, unlocked nails (i.e., Ender and Lottes, which have low infection rates, but are mechanically insufficient); (2) reamed unlocked nailing (which relies on overreaming to provide stability through bone-nail surface contact, but is associated with high infection rates); (3) reamed locked nailing (which may rely on limited reaming because of the interlocking screws); and (4) unreamed nailing (which always relies on interlocking screws and is associated with function better than and infection rates similar to those with external fixation, but has an increased incidence of screw breakage). In contrast to the biological problems in the tibia, those problems encountered in the femur are more predominantly mechanical in origin. For humeral shaft fractures, shoulder problems associated with the antegrade approach are frequent, and bypassing the rotator cuff with a retrograde approach appears advantageous.
Anti-Bacterial Agents↗
[The posterior cruciate ligament: step child in research and the clinic].
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Biomechanical Phenomena↗
[Rupture of the posterior cruciate ligament: status of current treatment].
The posterior cruciate ligament acts as a complex system and is formed by the anterolateral an posteromedial bundle an the meniscofemoral ligaments. The main function of the ligament is stabilization of the tibia against posterior subluxation in flexion of the knee. Isolated PCL deficiency is compensated by increased quadriceps action in many patients for years, although natural history studies demonstrate retropatellar and medial osteoarthritis after 5-15 years in a not yet defined percentage. Osseous avulsion of the PCL from the tibia have a good prognosis when treated by open reduction and stable fixation. Ruptures of the ligament should not be treated by suture repair, since this technique has failed to restore posterior knee stability in most studies. Augmented repair and reconstruction of the ligament tend to improve the objective results, although the clinical data are not yet conclusive. Complex posterior instability should be treated by acute ligament reconstruction, since the results of conservative treatment are inferior and operative treatment in chronic complex posterior instability is extremely difficult. Potential osseous abnormalities (varus morphotype) and posterolateral rotatory instability must be addressed in these cases. PCL reconstruction with a patellar tendon graft can be performed with a two tunnel technique or with a Femur tunnel and a direct tibial graft fixation via a posterior approach. The results reported in the literature do not support the use of augmentation devices in PCL surgery.
Follow-Up Studies↗
[Femur head dislocation fractures. Long-term outcome of conservative and surgical therapy].
From 1974 to 1989, we treated 32 patients with a femoral head fracture: 28 were associated with a traumatic posterosuperior dislocation of the hip (6 Pipkin type I, 7 type II, 4 type III and 11 type IV), 1 with a posteroinferior and 3 with an anterior displacement of the femoral head. Twenty-four patients had been involved in a traffic accident, 23 had associated injuries, and the average polytrauma score (PTS) was 21. All dislocations primarily treated at our hospital were reduced by closed methods within 4 h (mean 105 min). Eleven patients received no further operative treatment, 21 were treated by open reduction and screw fixation of the fragment of the head (n = 7), fixation of the acetabular fracture (n = 3) or removal of the fragments of the head (n = 10). Four Pipkin type III fractures received primary total hip replacement. Twenty-six of the surviving 29 patients were reviewed after an average follow-up of 5 years (2-11). Radiological signs of mild arthrosis were seen in 4, moderate degeneration in 2. Partial avascular necrosis was found in 4, subchondral collapse in 1 and heterotopic ossification in 8 patients. According to the Thompson and Epstein criteria 15 of 26 patients presented fair to poor results.
Adolescent↗
Care of the polytraumatised patient.
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Acute Disease↗
[Distal femoral fractures. Transarticular reconstruction, percutaneous plate osteosynthesis and retrograde nailing].
Techniques for operative treatment of supra- and intercondylar fractures have changed in recent years. Some of these changes have come about in reduction techniques and implant selection. Operative approach concepts, which had remained unchanged for several decades, have been critically evaluated and modified, leading to a minimally invasive osteosynthesis (MIO) with transarticular joint reconstruction, closed plate positioning techniques or retrograde intramedullary nailing. These techniques result in better operative visualization and management of intraarticular comminution, safer fracture healing and better functional outcome. New strategies and techniques for the avoidance of axial malalignment, rotational deformities and leg length discrepancies are described.
Bone Plates↗
[Complex injury of the elbow joint].
High-velocity trauma now often results in complex injuries to the upper extremity, and especially the elbow joint. These can lead to both an enormous reduction in the range of motion of the shoulder, elbow and wrist joints, in severe cases with complete loss of upper extremity function. A complex injury is defined as a fracture and/or dislocation of the elbow in association with (1) a serial injury of the upper extremity, (2) a severe soft tissue trauma, or (3) concomitant injury to vessels or nerves. Serial fractures, in particular can lead to enormous problems with treatment and are often associated with special complications. A standardized operative approach therefore seems essential. An analysis of our patient populations was made to compare the frequency of different injury types, develop specific treatment regimens, and document the clinical course. We made a retrospective analysis of patients admitted to our facility between 1981 and 1992, with particular reference to cause of accident, severity of injury (ISS), type of fracture of the upper extremity (according to the AO classification), extent of soft tissue trauma and whether closed or open, and the concomitant injuries (vascular, compartment and nerve lesions). Type and sequence of therapy and any complications were noted, and the clinical course up to consolidation was recorded. The functional result (i.e., ROM, neurology) was observed at primary discharge and 12 weeks, 6 months and 2 years later. In the time period mentioned 224 complex injuries of the elbow region were noted. Often MVAs were the cause of the complex trauma (39% car/30% motorcycle). The average injury severity was scored as 32 (ISS) in these, mostly polytraumatized, patients (68%). The most frequent fracture combination at the elbow region was combined with C2/C3 fractures of the distal humerus (57%) and proximal ulna (43%). A very commonly seen complex injury was the Monteggia equivalent, with fracture dislocation of the proximal ulna. Most (82%) of the injuries at the elbow region were open, and open lesions were similarly frequently seen at the forearm shaft. The most frequent concomitant injuries was were to the nerves (63.5%) and the plexus. A compartment syndrome developed in 23.8%. This complication was frequently seen in multiple trauma patients after primary resuscitation (extensive volume therapy) and in serial fractures with more than three associated lesions. In 67% of these complex injuries a definitive operation was performed as primary treatment (in the first 24 h after injury). Debridement of open fractures and fasciotomy in compartment syndrome of the forearm are standard techniques in the initial care. In serial fractures all concomitant (humerus, forearm, wrist, etc.) fractures were operated on primarily. This primary treatment included ORIF of humeral and forearm fractures in 76%. In patients with multiple injuries (ISS > 30) primary treatment was not possible in 37%, and in these cases transfixation of the elbow joint was performed. Other indications for transfixation were severe comminution of the elbow joint, impossibility of achieving complete stability after ORIF, extensive soft tissue injuries, with healing dependent on short-term immobilization, and finally status following extensive ligamentous reconstruction. The most frequent permanent disturbance was a persisting nerve lesion in our patients. A significantly reduced range of motion (30% deficit flexion/extension) was mostly seen at the elbow (17%), most frequently associated with serial fractures (> 3 associated injuries) and with severe semicircular soft tissue trauma. The most severe injury in combined trauma of the upper extremity is a serial fracture in the elbow region. Such fractures are often associated with vascular and nerve lesions. Even with primary fracture stabilization and early soft tissue management these often end with significant functional deficits.(ABSTRACT TRUNCATED)
Elbow Joint↗
Outcome after pelvic ring injuries.
Open reduction and internal fixation of unstable pelvic ring fractures provides the best stability of fixation as well as the best late clinical results. Whereas several studies have supported this both in biomechanical studies and clinical trials, there is still controversy about the long-term outcome of these injuries. A series of 58 patients who had received surgical stabilization of Tile B- and C-type fractures between 1985 and 1990 were followed up for an average of 28 months. The follow-up included a detailed clinical and radiological examination, an evaluation of the patient's general social status and a detailed neurological and urological screening. The data were summarized in a new scoring system rating radiological, clinical and social results independently. Patients suffering B-type fractures showed 79% good and excellent results. Despite the fact that after C-type fractures 50% healed anatomically and 30% healed with a 5 mm or less residual posterior displacement, only 27% of the patients were rated good or excellent. Further studies must be conducted for closer evaluation of risk factors influencing the results after anatomical reconstruction of the pelvic ring.
Female↗
[Perioperative hygiene in trauma surgery].
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Cross Infection↗
[Perioperative hygiene in trauma surgery].
Wound infection is the most significant nosocomial infection in trauma surgery. The acceptance of hygiene measures in the operational sector is generally high with a good educational level of personnel involved. In spite of this, inappropriate hygienic behavior can be observed repeatedly. The cause of this lies, in part, in a mental state of mind and is therefore not accessible to routine discussion. Several routinely relevant psychological aspects of hygiene behavior and motivation are shown. In addition, hygienic measures in the operating theater as they apply to the patient, the personnel and the surgical procedure are discussed. The authors opinion is stated.
Cross Infection↗
[Minimally invasive osteosynthesis of fractures of the tibial head].
The role of closed reduction techniques in tibial plateau fractures was evaluated retrospectively in a group of 33 patients. The patients had mainly B fractures (AO classification) and were treated by the arthroscopic reduction technique (n = 10) or by reduction under fluoroscopic control (n = 23) and transcutaneous screw fixation. The 21 patients with an average follow-up of 34 months (minimum 1 year) were reviewed. Using clinical and radiological criteria, 19 results were considered excellent to good. One patient with a residual deformity was revised with a total knee and 1 patient with an anatomical result had arthritic pain in the knee operated on. Arthroscopic reduction had no advantages over reduction under fluoroscopic control in this study. The specific value of the technically demanding endoscopic procedure should be questioned, as percutaneous reduction under fluoroscopic control may achieve comparable results in the majority of these cases.
Adolescent↗