[LISS versus condylar plate]

Up to the seventies the surgical treatment of supra- and bicondylar femoral fractures was difficult and showed a lot of complications. In most studies a conservative treatment was recommended. In the least 30 years the clinical outcome after surgical treatment improved. This was a result of the development of new implants and improved surgical techniques. However, today the primary surgical treatment is the therapy of choice. We reviewed from 1986 to 2001 n = 121 distal femoral fractures which were in 32 cases treated with a Condylar Blade Plate and in 10 cases with a less invasive stabilisation system (LISS). The final results after condylar blade plating were rated using the system that was described by Neer. The averaged follow up time was 9 years. Low postoperative infection rates and in 75% excellent and satisfactory results combined with low cost are the reference for the evaluation of the LISS results. While in our owen series according to the literature there were no significant better functional results for the LISS group than for the Condylar Blade Plate group there were only few autologous bone grafts necessary. Due to the angle-stable self-drilling and self-cutting screws and the Internal-Fixater Principle the LISS has some mechanical and biological edge on the condylar blade plate.

[Conservative treatment of metacarpal fracture]

Conservative treatment of meatacarpale fracture is recommended if there are no joint displacement, rotation failures, displacement over 30 degrees ad axim and shortening over 5 mm. Operative procedures should be done in open fractures and serial of fractures of metacarpale bones. Early functionally treatment should be done in stable, not displaced fractures. Cast can be used only for a short time in full extended position of fingers and flexion in metacarpo-phalangeal joint in 60-90 degrees. Twin-tapes after reduction of edema allowed free range of motion by fixed rotation. Closed reduction of displaced fractures of fifth metacarpal bone (boxer's fracture) isn't successful. Cases with displacement over 30 degrees may be operatively treated by intramedullary stabilization.

[Stabilizing intramedullary pediatric shaft fractures]

Intramedullary stabilisation (Prévot-nailing) of shaft fractures in childhood allows full weight bearing without cast. Early fracture healing is seen by respecting soft tissue around fracture and by using distal or proximal approaches. Good indications of femoral shaft osteosynthesis are recommended in oblique and transverse fractures. Intramedullary stabilization seems to be a good alternative method instead of casting calf-shaft fractures. An unstable fracture of forearm may be treated intramedullary to avoid often observed displacement ad axim and rotation. Humoral fractures primary have to be treated conservatively. Only in displaced fractures or in cases with additional injuries an intramedullary procedure with free range of motion is recommended.

[Tossy III injuries of the acromioclavicular joint. In what circumstances is surgery still justified? Personal results and literature review]

In Germany AC-joint-dislocations type Tossy III are treated in most of the cases operatively. Over two times of period we treated AC-joint-dislocations type Tossy III with biodegradable PDS-cords. 54 patients were operated between 1989 and 1997 and followed up after 39 months. 87.5% of patients are satisfied with results and have 10.2 points at Taftscore. In this period we couldn't differentiated the results by Rockwood classification. 12 patients with Rockwood V were operated between 1998 and 2002 and followed up after 14 months. Excellent and good results were seen in 92% of cases. At Taftscore we seen 10.7 points. 3 patients with Rockwood III were treated conservative with 10.3 points and 3 patients were operated with 10.7 points at Taftscore. AC-joint dislocations should be classified to Rockwood. No differences were seen between operation and conservative treatment in Rockwood III in literature. We recommend operation with PDS cords with good results in Rockwood V.

[Candida infection in hip alloarthroplasty]

A 46-year-old polytoxicomanic patient underwent a total hip replacement for necrosis of the femoral head. The patient suffered additionally from chronic pancreatitis with insulin-dependent diabetes and polyneuropathy. Three weeks later he developed a deep wound infection followed by surgical revision. The infection persisted despite further revision operations and systemically and locally applied antibiotics. After removal of the prosthesis,microbiology revealed Staphylococcus aureus, enterococcus,and Candida parapsilosis. Five additional revision operations, application of suction-irrigation drainage, and systemically administered antibiotics could not stop the infectious process. The patient was transferred to our institution 3 months after primary surgery. The joint defect was filled with a PMMA Palacos spacer. This time biopsies were only positive for Candida albicans. After 12 days of antifungal therapy with fluconazole,microbiological biopsies were sterile. The spacer was removed and femoral extension applied. After 4 weeks of further antifungal therapy, a revision prosthesis was implanted. Until now no signs of infection have appeared.

[Risk factors for the development of pneumonia in multiple injured patients. Results of a prospective clinical trial]

Pneumonia is the most common infectious complication in multiple trauma patients. In a prospective clinical cohort study, 266 multiply injured patients were examined for the development of pneumonia. Various risk factors were tested in uni- and multivariate analyses. Three different definitions of pneumonia were used in order to examine how results depended on definition. The incidence of pneumonia was 41%, but varied with definition (30-50%). Injuries to the thorax, head,and abdomen were associated with a significantly increased risk of pneumonia (adjusted relative risk: 1.77, 1.97,and 1.52, respectively).Furthermore, increasing age led to a higher risk of pneumonia. Although the primary analysis revealed a higher pneumonia risk in male patients (adjusted relative risk: 2.23; 95% CI: 1.43-3.05), this result could not be consistently reproduced when using other definitions of pneumonia. Trunk and head injuries and age are proven risk factors for developing posttraumatic pneumonia. The association between male gender and an increased rate of infectious complications remained questionable.

[Categories for evaluating surgical procedures by expert medical witnesses]

An analytical procedure is presented that helps to determine the causes of surgical malpractice. A first evaluation scale of six levels is applied to the assessment of the indications for surgery and the method used as well as a second scale for the technical realisation of the treatment. For the indication and method categories A-F are used.A: method of choice; B: a time-tested method but second choice; C: exceptional method, rarely practised; D: historical method no longer in use; E: incorrect method/simple mistake; F: blatant mistake in the assessment of indication or choice of method, not understandable. To evaluate the technical realisation of treatment a scale from 1 to 6 is applied. 1: excellent realisation; 2: successful, but minor drawbacks; 3: atypical but acceptable result; 4: technically failed but no harm to the patient; 5: insufficient realisation; 6: faulty, grossly failed. Three cases are given as examples. In these cases the use of the proposed categories and scaling leads to differentiated assessments.

[Reconstruction of shoulder-girdle symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage]

The aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1+/-0.9 years in group 1 and 2.9+/-0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly ( P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78+/-23 in group 1 and 97+/-4 in group 2 ( P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

[New biodegradable polylactide implants (Polypin-C) in therapy for radial head fractures]

Dislocated radial head fractures of the type Mason II are usually treated with screws and buttress plates. The implants are generally removed at a later date. Biodegradable implants can be applied successfully for the reduction of small radial head fractures subject to shearing forces and slight loads. The implants are completely absorbed once the fracture has healed, making a second operation for the removal of the implant unnecessary. The Polypin C-Pin is made of poly(L, DL-lactide) mixed with 10% beta-tricalcium phosphate to ensure controlled, slow degradation with no significant side effects. This new Polypin C fixation pin was clinically tested on 35 patients with radial head fractures (CCF 21B2.1 and 21B2.2) from 31.10.1996 until 1.4.2002. A total of 34 of the patients (97.1%) underwent a clinical and conventional radiological follow-up examination after an average of 38.2 months. In 29 cases a CT was also carried out. Between 18 and 24 months, two cases of grade 1 osteolysis were observed around the pin head. No trace of osteolysis was observed at the final examination in either case. According to the Broberg score, an average of 96 out of a possible 100 points were attained at the final examination (31 excellent, 2 good, 1 unsatisfactory). After a period of 24 months, the pins were no longer visible on a conventional x-ray. A CT evaluation showed a density similar to that of spongioid bone in the original pin cavities after 3 years. These excellent clinical results prove that the Polypin C is a good method to treat dislocated radial head fractures.

Large angle elastic alpha scattering on a N=Z nucleus above A=40

Scattering of alpha particles from 44Ti, the lightest unstable alpha-particle nucleus above A=40, has been measured at backward angles. The "anomalous" order-of-magnitude enhancement that is characteristic of 40Ca and other light alpha-particle nuclei is not observed. Instead, the backward yield is similar to that observed for other nuclei heavier than 40Ca, and is well described with average optical model parameters.

[Treatment of metacarpal fractures]

Conservative treatment of metacarpal fractures is recommended if there is no joint displacement, malrotation, displacement of over 30 degrees ad axim and shortening of over 5 mm. Surgery should be performed in open fractures and serial fractures of metacarpal bone. Early functional treatment should be carried out in stable, not displaced fractures. A cast can be used for a short period in full extended position of fingers and flexion in metacarpo-phalangeal joint in 60 - 90 degrees. Twin-tape fixation allows functional treatment after soft-tissue swelling has disappeared. Closed reduction of displaced fractures of the fifth metacarpal bone (boxer's fracture) is not successful. Cases with displacement of over 30 degrees may be treated surgically by intramedullary stabilisation.

Unexpected behavior of heavy-ion fusion cross sections at extreme sub-barrier energies

The excitation function for fusion evaporation in the (60)Ni+ (89)Y system was measured over a range in cross section covering 6 orders of magnitude. The cross section exhibits an abrupt decrease at extreme sub-barrier energies. This behavior, which is also present in a few other systems found in the literature, cannot be reproduced with present models, including those based on a coupled-channels approach. Possible causes are discussed, including a dependence on the intrinsic structure of the participants.

[Technique of intramedullary osteosynthesis of the clavicle with elastic titanium nails]

This prospective controlled clinical trial was performed to assess fracture healing and clinical outcome after intramedullary nailing of midclavicular fractures. Within 3.5 years elastic-stable intramedullary nailing was performed in 62 patients with 65 midclavicular fractures. Surgery was performed in supine position. The ventral cortex of the proximal clavicle was opened using a 2.5 mm drill. The nail was advanced laterally under fluoroscopic control. If closed reduction failed, an additional incision was made to enable direct manipulation of the fragments. There were no infections, no implant displacements or refractures. Postoperatively, the mean subjective pain was significantly lower, and the range of motion improved. We observed one nonunion. The mean Constant-score 6 months after hardware removal was 96.9 +/- 3.3 points. Intramedullary fixation of midclavicular fractures with an elastic titanium nail is a safe minimally invasive surgical technique, producing excellent functional and cosmetic results.

Pneumonia in multiple injured patients: a prospective controlled trial on early prediction using clinical and immunological parameters

OBJECTIVE AND DESIGN

In a prospective trial 266 multiple injured patients were included to evaluate clinical risk factors and immune parameters related to pneumonia.

METHODS

Clinical and humoral parameters were assessed and multivariate analysis performed.

RESULTS

The multivariate analysis (odds ratio with 95% confidence interval (CI)) revealed male gender (3.65), traumatic brain injury (TBI) (2.52), thorax trauma (AIS(thorax) > or = 3) (2.05), antibiotic prophylaxis (1.30), injury severity score (ISS) (1.03 per ISS point) and the age (1.02 per year) as risk factors for pneumonia. The main pathogens were Acinetobacter Baumannii (40%) and Staphylococcus aureus (25%). A tendency towards higher Procalcitonin (PCT) and Interleukin (IL)-6 levels two days after trauma was observed for pneumonia patients.

CONCLUSION

The immune parameters (PCT, IL-6, IL-10, soluble tumor necrosis factor p-55 and p-75) could not confirm the diagnosis of pneumonia earlier than the clinical parameters.

[CT morphometry for calcaneal fractures and comparison of the Zwipp and Sanders classifications]

AIM

The aim of the study is to correlate the CT-morphological changes of fractured calcaneus and the classifications of Zwipp and Sanders with the clinical outcome.

METHOD

In a retrospective clinical study, the preoperative CT scans of 75 calcaneal fractures were analysed. The morphometry of the fractures was determined by measuring height, length diameter and calcaneo-cuboidal angle in comparison to the intact contralateral side. At a mean of 38 months after trauma 44 patients were clinically followed-up. The data of CT image morphometry were correlated with the severity of fracture classified by Zwipp or Sanders as well as with the functional outcome.

RESULTS

There was a good correlation between the fracture classifications and the morphometric data. Both fracture classifying systems have a predictive impact for functional outcome. The more exacting and accurate Zwipp classification considers the most important cofactors like involvement of the calcaneo-cuboidal joint, soft tissue damage, additional fractures etc. The Sanders classification is easier to use during clinical routine.

CONCLUSION

The Zwipp classification includes more relevant cofactors (fracture of the calcaneo-cuboidal-joint, soft tissue swelling, etc.) and presents a higher correlation to the choice of therapy. Both classification systems present a prognostic impact concerning the clinical outcome.

[A condylar plate in distal femoral fractures]

Up to the seventies, the surgical treatment of supra- and bicondylar femoral fractures was difficult and was accompanied by a lot of complications. In most studies conservative treatment was recommended. In the last 30 years the clinical outcome after surgical treatment has improved. This was a result of the development of new implants and improved surgical techniques. Today, the primary surgical treatment is the therapy of choice. We reviewed from 1986 to 2000 105 distal femoral fractures which in 32 cases were treated with a condylar blade plate. The final results were rated using the system that was described by Neer. The averaged follow up time was 9 years. Low postoperative infection rates and in 75% excellent and satisfactory results combined with low cost are the state of art which has to be the reference for new methods and new implants in the future.

[Linezolid--a new antibiotic for treatment of methicillin resistant Staphylococcus aureus infections in trauma surgery? Report of 2 cases]

PROBLEM

Infections with Methicillin-resistant Staphylococcus aureus are reported increasingly in intensive care unit and ward, that means not only a dangerous disease but also a considerable expenditure factor.

METHODS

In trauma surgery we could observe the Linezolid treatment of 2 patients with a MRSA infection. After treatment with Vancomycin and further evidence of MRSA the application of Linezolid was continued during 3 weeks accompanied by further microbiologic investigations.

RESULTS

In a 73 year old man with humerus shaft fracture the MRSA osteomyelitis was eradicated with Linezolid (600 mg/day per os over 3 weeks) after radical débridement and reosteosynthesis. The MRSA pneumonia in a 14 year old girl was treated successfully by Linezolid (600 mg/day i.v. over 3 weeks) and pneumotherapy. Follow up excluded further MRSA infection.

CONCLUSIONS

Linezolid represents an efficient new reserve antibiotic. In case of pneumonia, severe skin and soft tissue infections good results can be expected. The treatment of osteomyelitis has been reported only in single cases.

[Unusual removal of a Küntscher nail after 35 years]

A 68 year old patient with persistent feeling of sickness and increasing pain in the left forearm was seen. A complex both bone fracture of the distal forearm shaft had been stabilized with Küntscher nails in radius and ulna 35 years ago. The loose ulna nail had been removed after ten weeks. Reosteosynthesis twelve months later with a Küntscher nail and cerclages had led to osteomyelitis and persistent bone defect, possibly caused by galvanic reaction between the different alloyies. A lymphocyte transformation test with nickel sulphate confirmed an allergic reaction and supported the indication to late implant removal. After exposure of the nail's end by a short approach a sufficient take over of power to the implant was reached by a coupling pole. Extraction was stopped after two centimetres by a blockage of the nail. Widening the entry of nail and drilling its whole notch by means of a Kirschner wire using the radiolucent ruler and by the repeated extraction and reinsertion led finally to the complete removal of the nail. Whereas local pain is disappeared three month after removal presenting bland local findings the general condition is improved slowly. Already Küntscher described the blockage of his nail after a short distance extraction. In addition to a number of not always successful means of extraction this method is described for the first time.

[Treatment errors of metacarpal fractures. An analysis of expert testimony of the "Committee for Medical Malpractice" of the North Rhine Physician's Council]

A large number of publications notwithstanding, there are no clear guidelines regarding the treatment of metacarpal fractures. Some authors believe that even severely dislocated fractures should not be surgically fixated. This paper analyzes the forensic problem on the basis of court rulings in Germany. Seventeen evaluations of metacarpal fractures conducted by the commission on medical malpractice of the physicians' council in North Rhein were analyzed and common mistakes were listed. The average age of the eight male and nine female patients was 41.9 years. The fifth metacarpal bone (MB) was affected eight times, the fourth MB four times, and the first MB twice. The second MB and third MB were affected once each. Surgery was performed in nine cases, while the conservative approach was taken eight times. An independent expert determined medical malpractice in 13 cases (76%). In 10 of these 13 cases, the symptoms the patients exhibited were linked to medical malpractice. In the 13 cases of medical malpractice there were 5 cases with technically insufficient osteosynthesis, 4 cases of uncorrected dislocation, 2 false diagnoses, and 2 false immobilizations. An independent expert identified a link to the symptoms in three of the four cases of uncorrected dislocation. These were an anatomically nonreduced fracture with joint involvement, a fracture with a dislocation of 50 degrees, and a fracture with rotation dislocation. Cases where fractures healed with severe dislocation or immobilization in a wrong position or for a too long a period are common but avoidable mistakes in the treatment of metacarpal fractures.

Compartment syndrome of the foot

The hindfoot compartment syndrome occurs in 10% of cases after calcaneal fracture. We analyzed the pathological anatomical reasons for this syndrome using the 10 feet from cadavers plastinated and cut into 4-mm thick sequential sections. CT scans of patients with calcaneal fractures were then compared with the anatomical findings. The key component of this compartment syndrome is the quadratus plantae muscle. The sustentacular calcaneal fragment causes bleeding from the bone or the medial calcaneal arteries into this compartment. The medial and lateral plantar nerves and vessels are then compressed between the quadratus plantae muscle and the short flexor digitorum muscle. Relieving pressure by surgical decompression of the quadratus plantae compartment via a medial or plantar approach is the recommended treatment.

[Diagnosis of intra-articular fracture of the head of the tibia. A prospective comparative study]

Complete visualization of the joint surface is essential for correct assessment of tibial head fractures. Conventional tomography, computed tomography (CT), and magnetic resonance imaging (MRI) are compared in this prospective study. We examined 27 patients (19 suffering from B fractures and 8 from C fractures) from 1 January 1995 to 11 November 1998. Conventional tomography underestimated the fractures in 3 of the 19 cases of B fractures. Computed tomography underestimated two of these cases. MRI could not exactly depict the essential structures in three of the eight cases of C fractures because of edema and effusions. MRI identified complete cruciate ligament rupture in 6 of the 27 cases (18%) and 10 meniscal ruptures in 9 cases (33%: 6 medial meniscus, 4 lateral meniscus). Complete ruptures of the lateral collateral ligament were detected in five cases and medial collateral ligament ruptures in two cases. According to this, 63% of the patients suffered from relevant accompanying soft tissue injuries. The rate of soft tissue injuries increased up to 92% including the partial collateral ligament ruptures. Local hospital conditions permitting, X-ray-loaded conventional tomography should no longer be used in tibial head fractures. X-ray-free MRI is most efficient in cases of B fractures, which can in most cases be treated with a minimum of invasive techniques. Computed tomography is to be used in cases of C fractures that are regularly managed by open surgery accompanied by direct visualization of the inside of the knee joint.

[Spinal injuries in jockeys. 2 case reports and review of the literature]

Two cases of severe spinal cord injuries to professional horse-racing jockeys are presented. There is only one comprehensive study conducted to ascertain the nature and incidence of injuries in the literature. The pathomechanism and surgical therapy of vertebral trauma in jockeys was analysed.

The injury of the calcaneocuboid ligaments

The selective rupture of the calcaneocuboid ligament is extremely rare and frequently misdiagnosed. This study tries to clarify the mechanism, classification and treatment of this entity. The necessity of radiographs with varus stress and in certain cases of computer tomography (CT) and magnetic resonance imaging (MRI), beside the routine antero-posterior and lateral views, is emphasized. Thirteen cases out of five-hundred-twenty-one sprain injuries of the ankle are described, classified and the therapy discussed: If on varus stress radiographs, there is a calcaneocuboid angle <10 degrees without a bony flake (type 1) strapping for six weeks is indicated. A calcaneocuboid angle >10 degrees with or without a small bony flake of the ligament insertion (type 2) should primarily be treated with a shoe cast for 6 weeks; if there are persistent symptoms a secondary peroneus brevis tendon graft is recommended. A calcaneocuboid angle >10 degrees with a big flake (type 3) should be treated by open reduction and refixation of the ligament. Complex injuries (type 4) are characterised by cuboid compression fracture and ligament rupture.

The 44Ti(alpha,p) reaction and its implication on the 44Ti yield in supernovae

Cross sections for the 44Ti(alpha,p)47V reaction which significantly affects the yield of 44Ti in supernovae were measured in the energy range 5.7 MeV</=E(c.m.)</=9 MeV, using a beam of radioactive 44Ti. The cross sections and the deduced astrophysical reaction rates are larger than the results from theoretical calculations by about a factor of 2. The implications of this increase in the reaction rate for the search of supernovae using space-based gamma detectors are discussed.