[Intramedullary nailing today].
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Fracture Fixation, Intramedullary↗
Biomedical subjects
L Schweiberer
Publications and source records attributed to L Schweiberer.
[Intramedullary nailing of lower leg fractures with minimal soft tissue injuries].
The importance of intramedullary nailing (IM) for closed and type I tibial shaft fractures is evaluated on the basis of a review of the recent literature (1991-1996) and the data on 61 patients that underwent a reamed (RTN; n = 31) or an unreamed (UTN; n = 26) procedure. There was no difference between the two groups in age, fracture type or localization. Soft tissue trauma prevailed with 38% type I open fractures in the UTN group (RTN group, 3%). Both groups showed about the same proportion of good and very good results (criteria of Johner and Wruhs; 89% RTN and 88% UTN), which corresponds to the results of other authors (83%-96% RTN; 79%-96% UTN). The rate of nonunions is about the same with 6% (RTN) and 4% (UTN), respectively, and there were no infections. In accordance with the literature, we found earlier osseous reunion after unreamed nailing (RTN = 18 weeks vs UTN = 12 weeks). This corresponds to early, painless, full weight-bearing after an average of 10.3 as opposed to 13.8 weeks in the RTN group. Except for earlier osseous reunion reamed and unreamed TN proved to be equivalent procedures. As a precondition, if more endostium is affected, reaming should be performed after stabilization of the soft tissue damage, and fractures of the metaphysis should be interlocked in two dimensions (using all interlocking possibilities) if treated with the more unstable UTN, along with reduced weight-bearing for at least 6 weeks. The implant should be chosen in compliance with individual demands, taking the higher intramedullary stability of the RTN into consideration and the endostium-preserving insertion of the UTN.
Bone Nails↗
[Intramedullary nailing in callus distraction].
Intramedullary nailing is an established fixation method in fracture treatment as well as in deformity-correction procedures on tubular bones. The interlocking nail has increased the potential for employing the intramedullary nail in the treatment of fractures in metaphysial regions. Recent developments are biased towards the use of small-diameter unreamed nails, preferably made of titanium. Callus distraction, the controlled continuous shifting of corticotomized bone, leads to new bone formation and has been known since the beginning of this century. This method, however, gained wide acceptance and popularity through the work of Ilizarov. This paper describes a fusion of the two methods into a very promising management concept for substantial bone defects resulting from trauma or resection of bone tumors, as well as for the correction of congenital or acquired uni- or bilateral differences in length of the extremities. Various systems such as the combination of callus distraction by external fixation over an intramedullary nail and a fully implantable system are presented.
External Fixators↗
[Lymphangioleiomyomatosis--a rare disease of the lymphatic system].
Lymphangioleiomyomatosis is a rare disease with proliferation of smooth muscle cells within the lymphatics, mediastinal and retroperitoneal lymph nodes and in the lungs. The clinical symptoms are increasing dyspnea, chylous effusion, intestinal obstruction and thoracic or abdominal pain. The authors report the case of a 42-year-old woman who primarily suffered from thoracic pain, dyspnea and chylous effusion. In further examinations we discovered a leftsided retroperitoneal tumor and a tumor in the mesentery. The diagnostic difficulties experienced are described and the necessity of explorative laparotomy for definite diagnosis is demonstrated. Furthermore, the article provides a review of the latest developments in pathology, diagnostics and therapy.
Adult↗
[Intramedullary nailing in multiple trauma].
The indication and best time for intramedullary nailing of long bones in the multiple trauma patient is still controversial. While in the Anglo-American literature primary intramedullary nailing is regarded as the method of choice, differentiated management is preferred in German-speaking countries on account of reports about the pathogenesis of trauma shock. On the one hand, it has been shown that severe thoracic injury greatly influences the course after multiple trauma and, in particular, its combination with femoral fracture represents an increased risk. On the other hand, every surgical intervention represents an additional trauma for the patient. Intramedullary reamed nailing of femur fractures represents considerable trauma, whereas unreamed intramedullary nailing of the femur or intramedullary stabilization of the tibia or humerus causes (in descending order) fewer changes. For early respiratory care (e.g., changing between the prone and supine position), however, primary stabilization of long bones is required. External fixation of the femur appears to be the method of choice for the severely injured patient. Definite fracture healing can be achieved by a change to intramedullary nailing in a secondary operation.
Bone Plates↗
[Perspectives in callus distraction].
Callus distraction is an enrichment of the surgical orthopaedic way of reconstructing bone defects, but it is also an effective method of lengthening limbs. The biological facts correspond to our knowledge about fracture healing. Concerning apparatures, further development is needed. In certain cases the ring fixator is the method of choice, but in most indications it is not necessary. Every effort should be made to adapt modern technologies, including fully implantable systems, to the "biological method" of callus distraction, whenever possible.
Bone Lengthening↗
[Injuries of the talus and calcaneus].
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Ankle Injuries↗
Platelets of patients with peripheral arterial disease demonstrate a hypersensitive response to heparin.
We sought to verify earlier reports of increased platelet reactivity in patients with peripheral arterial disease (PAD) during perioperative heparin administration, and to test the hypothesis of platelet hypersensitivity to heparin in these patients. Before and after incubation of platelet rich plasma with unfractionated (UH), low molecular weight heparin (LMWH), and a low molecular weight heparinoid, real-time quantitative assessment of platelet function was performed by stagnation point flow adhesio-aggregometry (SPAA) in 21 patients with PAD and 14 healthy volunteers. With SPAA the occurrence of spontaneous aggregation is pathological. In the 15 patients requiring operation, platelet function and count were measured at regular intervals. To detect heparin dependent antibodies, the heparin induced platelet activation assay (HIPA) was performed preoperatively and after 10 days of heparin therapy. Mean baseline platelet adhesion in patients was double that observed in controls (p < 0.001). Spontaneous aggregation was seen in 9 (43%) patients and no controls (p < 0.001). In controls heparinoid reduced, whereas UH and LMWH slightly increased adhesion. Spontaneous aggregation was observed once with UH. Platelets from patients showed significantly enhanced adhesiveness and aggregability (p < 0.05) with UH and LMWH when compared to controls. Effects with the heparinoid were less pronounced and nonsignificant. In patients requiring operation, postoperative increases in platelet function and reductions in count were significant (p < 0.001). Ten (67%) experienced a fall in platelet count of > 50%. Preoperatively the HIPA assay showed no evidence of antibodies, whereas after heparin administration antibodies were verified in 4 (32%) patients and could not be ruled out in 6 (40%). Three developed postoperative thrombosis, in one case fatal. A hypersensitive in vitro and in vivo platelet response to heparin was verified in patients with PAD and a large number developed the immunological type of heparin-associated thrombocytopenia. Our findings suggest that a thrombin antagonist which does not interact with platelets may give the best perioperative protection in these patients.
Adult↗
[No room for neurotraumatologic tourism].
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Brain Injuries↗
[Preclinical diagnosis and management in severe craniocerebral trauma].
Both prehospital and hospital management of patients with severe head injury has clearly improved in the last decades. There is a greater knowledge of how secondary brain injury is caused and how it can be prevented. Intracranial mechanisms (e.g. haematoma and elevated intracranial pressure and systemic mechanism (e.g. shock and hypoxaemia) are two of the major causes of secondary brain injury. Adequate prehospital evaluation and treatment determine the later outcome for the patient. The Glasgow Coma Scale has become the standard score for assessing the level of consciousness. Early prehospital treatment must prevent secondary brain damage through adequate oxygenation (intubation, ventilation) and a sufficient cerebral perfusion pressure (treatment of shock). The neck of the patient should be positioned straight and the upper part of the body should be elevated to about 30 degrees. The prophylactic use of steroids, mannitol or high dose barbiturates is not indicated. Aggressive hyperventilation (pCO2 < 30 mmHg), especially during the first few days after severe brain injury, should be avoided.
Brain Damage, Chronic↗
[Severe craniocerebral trauma].
In medical services where acute accident patients are encountered, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the Department of Surgery at the University Hospital in Munich, we have been performing neurotraumatological treatment since 1983. We had 162 patients with severe head and brain injuries, 95 intracerebral contusional bleeding, 8 depression fractures, and 3 hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 68 patients and osteoclastic trepanation in 65. Further interventions were elevation of the 8 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurosurgical surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1 cured; 2 slightly; 3 severely handicapped; 4 vegetative state; 5 expired). The Traumatic Coma Data Bank (1991) recorded the outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.
Adolescent↗
[Is maximum management of polytrauma patients financially assured?].
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Adult↗
[Diagnostic problems in acute appendicitis and indications for laparoscopic appendectomy].
A retrospective study analyzing the outcome of 400 appendectomies for acute appendicitis in two different hospitals revealed a negative appendectomy rate of over 25%. As a consequence we altered the operative strategy by employing diagnostic laparoscopy in combination with laparoscopic appendectomy in all uncertain cases while still carrying out a conventional appendectomy when there was diagnostic certainty. Preliminary results show that laparoscopic appendectomy is a safe procedure and that the new concept reduces the negative appendectomy rate.
Acute Disease↗
[Endosonography of tumors of the upper gastrointestinal tract: is routine use justified?].
Major indications of endoscopic ultrasound (EUS) are staging of carcinomas of the oesophagus, stomach, and pancreas, lymphomas of the stomach and the diagnosis of submucosal tumors. Based on a meta-analysis, the accuracy of EUS is 84% in the T-stage of oesophagus carcinoma (1154 patients) and 77% (1035) in the N-stage, and of stomach carcinoma 80% (2699) and 70% (1207), respectively. Drawbacks of EUS: tumor stenosis which cannot be passed by the endoscope; the inability to distinguish between benign and malignant stomach ulcera and the diagnosis of lymph nodes.
Endosonography↗
Increased platelet and coagulatory activity in peripheral atherosclerosis flow mediated platelet function is a sensitive and specific disease indicator.
The importance of flow in both athero- and thrombogenesis is well established. In peripheral arterial disease (PAD) atherosclerosis is disseminated, thrombosis risk high and systemic hemostatic derangement believed contributory. We studied platelet and coagulatory activity in PAD patients, thereby evaluating the clinical efficacy of Stagnation Point Flow Adhesio-Aggregometry (SPAA). SPAA provides real-time quantitative assessment of platelet adhesion and aggregation under convective, low-shear flow conditions. 62 nondiabetic PAD patients and 66 healthy volunteers were examined, whereby SPAA and conventional aggregometry were performed and circulating fibrinogen, fibrin monomer (FM), the fibrin degradation product D-Dimer and thrombin-antithrombin-complex (TAT) assessed. Conventional aggregometry detected no differences between patients and controls. SPAA-measured platelet function (p < 0.001), fibrinogen (p < 0.001), FM (p < 0.001), TAT (p < 0.02) and D-Dimer (p < 0.001) were significantly increased in patients and not effected by aspirin therapy. Respective sensitivity and specificity in detecting PAD was as follows: SPAA (96%/95%), fibrinogen (36%/92%), FM (46%/88%), TAT (40%/73%), D-Dimer (75%/80%). Increased platelet and coagulatory activity was verified in PAD, whereby flow-mediated platelet adhesion and aggregation proved the most sensitive and specific parameter. These findings indicate the usefulness of SPAA for delineating platelet-related disease mechanisms and evaluating therapeutic strategies to prevent platelet activation.
Antithrombin III↗
Sterilization of partially demineralized bone matrix: the effects of different sterilization techniques on osteogenetic properties.
Transplantation of allogenic bone requires the thorough examination of donors as well as the careful processing and storage of samples in order to minimize potential infection. Other problems associated with allogenic transplants such as low osteoinductive properties and immunological reactions led to the development of partially demineralized bone matrix (PDBM). This highly osteogenic bone extract is largely free of antigens and easy to produce. However, in order to exclude the potential risk of infection, PDBM should be sterilized prior to implantation. It was the purpose of this study to investigate the influence of various sterilization techniques on the osteoinductive properties of PDBM. Seventy-six drill defects with a diameter of 0.6 cm in the tibia of 11 Merino sheep were filled with PDBM as well as autogenic or allogenic cancellous bone. Prior to implantation the PDBM was sterilized using autoclavation, gamma irradiation, ethylene oxide, or ethanol. Twelve empty drill holes served as controls. The extent of new bone formation was ascertained by histological, fluorescent-optical, and microradiographical examinations 3 and 6 weeks postoperatively. Furthermore, the amount of newly formed bone was measured quantitatively. Apart from autoclaved PDBM, all matrix grafts showed excellent new bone formation after sterilization, exceeding the results of allogenic cancellous bone.
Animals↗
Perioperative management in thoracic surgery.
The quality of perioperative treatment for patients undergoing thoracic surgery is of the utmost importance for postoperative morbidity and mortality. Hence, it was the purpose of this study to examine various aspects of our own procedure. The clinical course following 812 successive thoracotomies in 792 patients over a period of 3 years was documented and analysed. The overall complication rate was found to be 19.7%, with a mortality of 3.8% over a 30-day period. Secretostasis, atelectasis and pneumonia were the most common complications. Owing to the predeposition of autologous blood, the percentage of patients requiring allogeneic blood transfusion was reduced from 27% to 9%. There was no evidence suggesting an increase in the complication rate or a longer stay in hospital. Perioperative antibiotic prophylaxis has reduced postoperative wound infection significantly. Similar reductions in the FEV1 are recorded following thoracic surgery, irrespective of the amount of lung tissue resected. This observation indicates that the remaining lung tissue is severely compromised throughout the postoperative period and that the surgical trauma alone is a major factor influencing postoperative pulmonary function for at least 2 weeks.
Adolescent↗
Prevention of experimental endotoxin shock by a monocyte activator.
In patients with polytrauma or major surgery, severe bacterial infections leading to septic shock and multiorgan failure are still a major cause of death. Prevention of septic shock in patients at risk would be an alternative to treatment of patients with overt septic shock. We therefore conducted a trial with the monocyte activator muramyl tripeptide phosphatidylethanolamine (MTP-PE) in an experimental pig model. Liposome encapsulated MTP-PE (50 micrograms/kg of body weight) or liposomes alone were given intravenously at 72 or 24 h before endotoxemia was induced by lipopolysaccharide (LPS), simultaneously with the induction of endotoxin shock, or 1 h thereafter. Pretreatment with MTP-PE at 72 and 24 h before endotoxemia was induced resulted in a reduction of endotoxin shock-induced mortality from 81.8% (9 of 11 animals) in the control group to 8.3% (1 of 12 animals) of the MTP-PE-pretreated animals (P < 0.001). The administration of MTP-PE 24 h before the induction of endotoxin shock was more effective (P < 0.01) than administration of MTP-PE 72 h before endotoxemia was induced (P = 0.05). The pretreated animals did not develop fever or cardiovascular complications, and pulmonary function was significantly improved. Furthermore, the alpha-form of the soluble CD14 LPS receptor in pig serum showed a marked decrease in LPS-treated animals, and this decrease was reduced by MTP-PE pretreatment at 24 h before endotoxemia was induced. When MTP-PE was given simultaneously with the induction of septic shock or 1 h thereafter, it did not influence either mortality or morbidity. In conclusion, pretreatment of pigs with MTP-PE improves several parameters of endotoxin shock and it reduces mortality. Patients with high risk of developing septic complications might benefit from a pretreatment with this monocyte-activating substance.
Acetylmuramyl-Alanyl-Isoglutamine↗