[Innovative 3D imaging]

Intraoperative 2D fluoroscopy is often performed for repositioning and implant control. However, this does not always provide the details needed to reliably detect joint steps or incorrect repositioning. Over the last few years, intraoperative 3D imaging has been established and further developed. Multiple studies demonstrate an advantage and better intraoperative control through 3D imaging. Examples are the upper ankle, the proximal tibia and the distal radius; the rates of intraoperative revisions with digital volume tomography (DVT) are between 20-30%. Technical advancements, such as metal artifact reductions, automated plane setting, automated screw detection, and robotic DVT devices, facilitate intraoperative operation, shorten surgical time, and provide improved image quality. By processing the data sets in the form of an immersive, computer-simulated image in terms of "augmented reality" (AR), increased precision can be achieved intraoperatively while reducing radiation exposure. The implementation of these systems is associated with costs, which are offset by cost savings from avoided revisions. Adequate counter-financing is still lacking at the present time. Intraoperative 3D imaging represents an important tool for intraoperative control. The current data situation makes it necessary to address the routine use of 3D procedures, especially in the joint area. The indications are becoming increasingly broader. Technical innovations such as robotics and AR have significantly improved 3D devices in recent years and offer high potential for integration into the OR.

[Distortion of the cervical spine : Pathophysiology, diagnostics, treatment and assessment]

Distortion or whiplash trauma of the cervical spine is an injury pattern associated with motor vehicle collisions and typically occurs after rear impact collisions, but is not limited to this type of collision and accident. The vast majority of these injuries are low-grade injuries according to the Quebec Task Force (QTF) classification, whereby no objective morphological correlates can be determined in clinical and radiological examinations. The prognosis is predominantly favorable and the condition is self-limiting; however, care must be taken with respect to complex courses with chronic pain and the manifestation of neuropsychiatric complaints. Due to the mechanism of the accident this injury pattern is particularly frequent in accidents associated with third party liability insurance claims. The discrepancy between subjective complaints and the presence of objective findings is a particular challenge for the assessment by the medical expert.

T2 Mapping as a New Method for Quantitative Assessment of Cartilage Damage in Rheumatoid Arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is associated with damage of the articular cartilage and the periarticular bone. While imaging of bone damage has substantially improved in recent years, direct imaging of the articular cartilage of the hand joints in patients with RA is still challenging. The study used T2 mapping of the finger joints to assess cartilage damage in RA.

METHODS

Magnetic resonance imaging (MRI) at 3 Tesla was done in 30 patients with RA, and T2 relaxation times visualizing alteration in the collagen network and hydration of articular cartilage were mapped in 6 cartilage regions of the metacarpophalangeal (MCP) joints 2 and 3. Values were related to autoantibody status [anticitrullinated protein antibodies (ACPA), rheumatoid factor (RF)], disease duration, and disease activity as well as sex and age of the patients.

RESULTS

T2 relaxation times could be reliably measured in the 6 regions of the MCP joints. Significantly higher relaxation times indicating more advanced cartilage alterations were observed in the metacarpal heads of ACPA-positive (p = 0.001-0.010) and RF-positive patients (p = 0.013-0.025) as well as those with longer disease duration (> 3 yrs; p = 0.028-0.043). Current disease activity, sex, and age did not influence T2 relaxation times.

CONCLUSION

These data show that cartilage damage can be localized and quantified in the hand joints of patients with RA by T2 mapping. Further, ACPA and RF positivity as well as disease duration appear to be the crucial factors influencing cartilage damage.

Early Changes of the Cortical Micro-Channel System in the Bare Area of the Joints of Patients With Rheumatoid Arthritis

OBJECTIVE

To characterize the specific structural properties of the erosion-prone bare area of the human joint, and to search for early microstructural changes in this region during rheumatoid arthritis (RA).

METHODS

In the initial part of the study, human cadaveric hand joints were examined for exact localization of the bare area of the metacarpal heads, followed by detection of cortical micro-channels (CoMiCs) in this region by high-resolution peripheral quantitative computed tomography (HR-pQCT) and, after anatomic dissection, validation of the presence of CoMiCs by micro-computed tomography (micro-CT). In the second part of the study, the number and distribution of CoMiCs were analyzed in 107 RA patients compared to 105 healthy individuals of similar age and sex distribution.

RESULTS

Investigation by HR-pQCT combined with adaptive thresholding allowed the detection of CoMiCs in the bare area of human cadaveric joints. The existence of CoMiCs in the bare area was additionally validated by micro-CT. In healthy individuals, the number of CoMiCs increased with age. RA patients showed significantly more CoMiCs compared to healthy individuals (mean ± SD 112.9 ± 54.7/joint versus 75.2 ± 41.9/joint; P < 0.001), with 20-49-year-old RA patients exhibiting similar numbers of CoMiCs as observed in healthy individuals older than age 65 years. Importantly, CoMiCs were already found in RA patients very early in their disease course, with enrichment in the erosion-prone radial side of the joint.

CONCLUSION

CoMiCs represent a new form of structural change in the joints of patients with RA. Although the number of CoMiCs increases with age, RA patients develop CoMiCs much earlier in life, and such changes can even occur at the onset of the disease. CoMiCs therefore represent an interesting new opportunity to assess structural changes in RA.

Age- and Sex-Dependent Changes of Intra-articular Cortical and Trabecular Bone Structure and the Effects of Rheumatoid Arthritis

The objective of this cross-sectional study was to define normal sex- and age-dependent values of intra-articular bone mass and microstructures in the metacarpal heads of healthy individuals by high-resolution peripheral quantitative computed tomography (HR-pQCT) and test the effect of rheumatoid arthritis (RA) on these parameters. Human cadaveric metacarpal heads were used to exactly define intra-articular bone. Healthy individuals of different sex and age categories and RA patients with similar age and sex distribution received HR-pQCT scans of the second metacarpal head and the radius. Total, cortical, and trabecular bone densities as well as microstructural parameters were compared between 1) the different ages and sexes in healthy individuals; 2) between metacarpal heads and the radius; and 3) between healthy individuals and RA patients. The cadaveric study allowed exact definition of the intra-articular (intracapsular) bone margins. These data were applied in measuring intra-articular and radial bone parameters in 214 women and men (108 healthy individuals, 106 RA patients). Correlations between intra-articular and radial bone parameters were good (r = 0.51 to 0.62, p < 0.001). In contrast to radial bone, intra-articular bone remained stable until age 60 years (between 297 and 312 mg HA/cm³ ) but decreased significantly (p < 0.001) in women thereafter (237.5 ± 44.3) with loss of both cortical and trabecular bone. Similarly, RA patients showed significant (p < 0.001) loss of intra-articular total (263.0 ± 44.8), trabecular (171.2 ± 35.6), and cortical bone (610.2 ± 62.0) compared with sex- and age-adjusted controls. Standard sex- and age-dependent values for physiological intra-articular bone were defined. Postmenopausal state and RA led to significant decrease of intra-articular bone. © 2016 American Society for Bone and Mineral Research.

Anti–citrullinated protein antibody positivity correlates with cartilage damage and proteoglycan levels in patients with rheumatoid arthritis in the hand joints

Objective: To investigate the factors associated with cartilage proteoglycan content in patients with rheumatoid arthritis (RA) Methods: 32 RA patients received high-field 3 Tesla Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) for determining cartilage proteoglycan content. Measurements were performed in three individual cartilage regions (medial, central, lateral) of the metacarpophalangeal joints 2 and 3. dGEMRIC values were then related to disease duration, disease activity, anti-citrullinated protein antibody (ACPA) status, rheumatoid factor status and C-reactive protein level. Results: dGEMRIC values were not significantly different between the MCP2 and MCP3 joint. Inter-class correlations were high (>0.92) for all three (medial, central and lateral) cartilage compartments. dGEMRIC values were significantly lower in RA patients with longer disease duration (≥3 years) and those with ACPA positivity than those with a short disease duration (<3 years)(p=0.034) or negative ACPA (p=0.0002), respectively. In contrast, no association between cartilage proteoglycan content and disease activity, C-reactive protein level and rheumatoid factor status was found. Conclusion: Decreased cartilage proteoglycan content in RA patients is associated with disease duration and ACPA positivity but not with the actual disease activity, CRP level or rheumatoid factor status. These data suggest that the cumulative burden of inflammation as well as ACPA are the determinants for cartilage damage in RA.

3D-isotropic high-resolution morphological imaging and quantitative T2 mapping as biomarkers for gender related differences after matrix-associated autologous chondrocyte transplantation (MACT)

The aim of this study was to determine in vivo high-resolution morphological and biochemical gender related differences in cartilage repair tissue (MACT). Forty patients were examined clinically and by MR scans at 3T-MRI (coronal 3D True-FISP sequence for morphologic assessment and multi-echo spin-echo T2-mapping for biochemical assessment of healthy cartilage and MACT cartilage). Mean T2 values in repair tissue in the deep zone showed significantly shorter T2 times in females (p = 0.009, female 43.5 ± 9.8 vs. male 48.2 ± 7.7 ms). The superficial zone showed higher T2 values than the deep zone in both the groups (female 48.5 ± 9.8, males 52.6 ± 11.0 ms) without significant difference between female and male patients. Native control cartilage showed no statistically significant differences for T2 between females and males. The subdivisions "structure of the repair tissue" and "subchondral bone" of the MOCART score showed statistically significant differences between females and males (p = 0.026 and p = 0.007) as well as the Lysholm score (p = 0.03). Our investigations revealed differences between female and male patients after MACT of the knee in clinical outcome and advanced morphological and biochemical MRI. The presented imaging biomarkers can depict subtle changes after cartilage regeneration procedures and might help to understand gender related differences after cartilage repair procedures.

Osteitis and synovitis, but not bone erosion, is associated with proteoglycan loss and microstructure damage in the cartilage of patients with rheumatoid arthritis

OBJECTIVES

To investigate the relation between anatomic changes of the synovium, the bone, the bone marrow and the cartilage to biochemical properties of the cartilage in patients with rheumatoid arthritis (RA).

METHODS

33 patients with RA received 3-T MRI scans of the metacarpophalangeal joints. Two independent methods, (A) the delayed gadolinium enhanced MRI of the cartilage (dGEMRIC, T2-mapping), which was used to assess the biochemical properties of the cartilage; (B) synovitis, osteitis and bone erosions were quantified according to the RA MRI scoring (RAMRIS) method and cartilage thickness (CT), interbone joint space (IBJS, distance between proximal and distal bone surface) and intercartilage joint space (ICJS, distance between proximal and distal cartilage surface) were measured.

RESULTS

Biochemical changes of the cartilage, corresponding to low dGEMRIC and high T2 values, were more likely to be seen in joints with decreased IBJS and ICJS as well as decreased CT. For instance, dGEMRIC was directly correlated to the IBJS (p=0.001) and ICJS (p=0.001), whereas T2 mapping was inversely correlated to IBJS and ICJS (both p=0.017). Moreover, the degree of osteitis, and to some extent synovitis, was correlated to biochemical cartilage changes as measured by dGEMRIC (p=0.003) or the T2 mapping (p=0.013). By contrast, bone erosions did not correlate to the degree of biochemical cartilage changes.

DISCUSSION

These data support the concept that synovitis and osteitis may be two main triggers for cartilage damage. Thus, the actual inflammatory state of a joint, but not so much the degree of bone erosion, appears to influence cartilage properties in RA.

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients

Background

Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.

Objective

To compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients.

Methods

A multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher’s exact tests, Mann–Whitney U-tests and adjusted analysis of variance (ANOVA).

Results

Forty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17–86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up.

Conclusions

Our findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

[Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation]

BACKGROUND

This study was initiated to evaluate early results of a locked screw plate for unilateral fixation of bicondylar fractures of the tibial plateau. Emphasis was laid on malreduction, secondary loss of reduction, union rate, and infection.

MATERIAL AND METHODS

A case series of patients with AO/ASIF 41-C type fractures treated with the less invasive stabilization system for the proximal lateral tibia (LISS PLT) were prospectively followed up until 11-13 months after surgery. Malreduction and malalignment were defined as an intra-articular step-off of 2 mm or more or as a malalignment in the frontal or sagittal plane of more than 5 degrees.

RESULTS

Sixty-eight patients with 69 fractures were involved. Fourteen fractures were open. Primary bone grafting was performed in 13 patients. Significant malreduction was seen in 16 patients. Sixty-two (91%) patients returned for follow-up. All but one fracture healed eventually. The number of infections was low (4 superficial, 1 deep). Nine patients had a significant loss of reduction. Of 54 patients outcome scores were good to excellent in 47 patients on the Lysholm score (average 87.2) and in 44 patients on the Rasmussen score (average 26.7).

CONCLUSION

We concluded that unilateral locked screw plating is a good alternative in the treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

Prevalence of Dental Fluorosis in German Schoolchildren in Areas with Different Preventive Programmes

In a retrospective study in two different regions of Germany, 1,041 fifteen-year-old pupils were examined for dental fluorosis. The adolescents had taken part in different caries prevention programmes. There were 746 subjects in the study group and 295 subjects in the control group. For each participant, specific aspects of early development, diet and fluoride exposure in group prevention programmes and at home were determined by means of questionnaires. The Thylstrup-Fejerskov index was used to classify the fluorosis scores on the buccal surfaces of teeth 11, 12, 13, 14, 15 and 16 after compressed air drying of the teeth. Binary logistic stepwise regression analyses were conducted to identify associations between fluorosis and potential influence factors. A distinction was made between early and late developing tooth parts. The significance level was set at alpha = 0.05. Fluorosis prevalence in the regions studied was 7.1 and 11.3%, respectively. The difference was not statistically significant (p = 0.052; chi square). Binary logistic stepwise regression analysis revealed that 'early start of toothbrushing' was a statistically significant predictor of dental fluorosis in the early-mineralizing enamel (OR = 1.99, p = 0.027). For the late-mineralizing enamel no single independent variable was identified as a significant predictor of dental fluorosis.

[Intramedullary nailing of humeral shaft fractures--initial experiences with an unreamed humerus nail]]

Interlocking intramedullary nailing has become the preferred method of internal fixation for diaphyseal fractures of the lower extremity. In shaft fractures of the humerus however open reduction and internal fixation with plates and screws is still considered the gold standard for operative treatment. The unreamed humerus nail (UHN) is a new implant for interlocking intramedullary nailing, which allows for stable fixation of humerus shaft fractures and immediate functional after treatment. The UHN could thus become an equal alternative to plate osteosynthesis. From this point of view we analyzed retrospectively 19 shaft fractures of the humerus, which have been treated at our institution with an UHN. Infections and iatrogenic nerve lesions did not occur. One patient with a rotational malalignment of 45 degrees underwent a secondary procedure. In two out of ten fresh fractures the bone healing failed and resulted in a non-union. In all cases of pathological fractures a good palliation could be achieved. With exception of two patients the range of motion of the shoulder and elbow was symmetric. We conclude that the UHN is a real alternative to plate osteosynthesis. Compared with most series of plate osteosynthesis published in the literature the risk for iatrogenic lesions of the radial nerve appears to be lower. Even in this small series we found however a rather high rate of non-unions.

[Inferior epigastric artery. An atypical source of bleeding in pelvic fracture]

The most common mechanism of pelvic fractures after blunt trauma is lateral compression of the pelvis. Most of these fractures are of slight severity but it is possible, that a life-threatening hemorrhage can appear. The inferior epigastric artery is an atypical bleeding site but it has to be considered in the search of the origin of the hemorrhage. Diagnostic tools are ultrasound, computed tomography and angiography. After external fixation of the pelvis and persistent haemodynamic active bleeding is the percutaneous transcatheter embolization (PTE) in our opinion the treatment of choice. The introduced case is confirm with this statement.

Early psychological reactions to life-threatening injuries

OBJECTIVE

To assess the prevalence of posttraumatic stress symptoms and coping patterns in severely injured accident victims; to study correlations between injury severity and psychosocial variables and the presence of posttraumatic stress symptoms; and to analyze intensive care unit (ICU) personnel's global clinical appraisals in relation to patient characteristics.

DESIGN

A study of critically ill accident victims assessed within one month of the trauma.

SETTING

ICU of the traumatology department at the University Hospital, Zurich.

PATIENTS

121 consecutive patients with accidental injuries (mean Injury Severity Score, 21.8; mean Glasgow Coma Scale score, 14.4) admitted to the ICU between January 1996 and June 1997, aged 18-68 yrs. Patients with severe head injuries, attempted suicides, and victims of physical assault were excluded.

MEASUREMENTS

Extensive clinical interview, Impact of Event Scale, Clinician-Administered Posttraumatic Stress Disorder Scale, social support, life events, biographical protective and risk factors, Sense of Coherence questionnaire, Freiburg Questionnaire of Coping with Illness.

RESULTS

13.7 (SD, 6.8) days after the accident, 5 patients (4.1 %) met all criteria for posttraumatic stress disorder with the exception of the time criterion. A further 24 patients (19.9%) had subsyndromal posttraumatic stress disorder. Posttraumatic psychiatric symptomatology did not correlate with objective injury criteria, but rather with pretrauma variables (female gender, biographical risk and protective factors, life events), the patients' subjective appraisal of the severity and threat of the accident, their general attitude toward life ("sense of coherence"), and their current coping strategies. Surgeons' and nurses' global clinical appraisals did not correlate with injury severity or with the patients' coping strategies.

CONCLUSIONS

Trauma surgeons and ICU personnel should pay special attention to the strains and stressors their patients have been exposed to when recording case histories and to the level of their patients' psychosocial adaptation before the trauma.

Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures

OBJECTIVE

To evaluate whether the implantation of the modular trochanter stabilizing plate (TSP) in addition to the dynamic hip screw (DHS) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures.

DESIGN

Prospective clinical study.

SETTING

The study was conducted at the trauma unit of the Surgical Department of the University of Basel, Switzerland.

PATIENTS

Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP super-imposed on the regular DHS at our institution between July 1991 and July 1993. Five patients died before the first follow-up, one patient was lost to follow-up, and another patient refused follow-up. Thus, thirty-nine patients were followed for at least twelve months (mean 14 months, range 12 to 20 months).

INTERVENTION

The fractures treated were classified according to the OTA classification, which is based on the AO classification. Seventeen were 31-A2.2, seven were 31-A2.3, and fourteen were 31-A3.3 fractures.

RESULTS

Lateralization of the greater trochanter was successfully prevented in all fractures. Limited fracture impaction was found in 90 percent (n = 35) of the patients with telescoping of 9.5 millimeters (range 0 to 30 millimeters), resulting in mean limb shortening of 5.37 millimeters (range 0 to 14.9 millimeters). Four patients suffered limb shortening exceeding fifteen millimeters (range 15.6 to 21.3 millimeters). Functional results were excellent and good in 87 percent of patients and fair in 13 percent according to the Salvati-Wilson score. All fractures had healed six months after the operation. Three complications required a secondary procedure: one from not inserting a second screw parallel to the gliding hip screw to prevent rotation of the head-neck fragment ("antirotation screw"), one because of deep infection, and one because of a refracture after premature implant removal.

CONCLUSION

In unstable pertrochanteric fractures with small or missing lateral cortical buttress, the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment. Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90 percent of these patients.

The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation

The unstable shoulder girdle--a combination of a scapular neck fracture with a clavicular fracture, acromioclavicular dislocation, or sternoclavicular dislocation--represents a rare and often underestimated injury. Sufficient treatment to permit early function is necessary to avoid a frozen shoulder as well as to treat concomitant thoracic injuries. This is possible only by open reduction and internal fixation. In most cases this can be achieved by a sole osteosynthesis of the clavicular injury. We retrospectively analyzed 12 cases and classified the results according to the Constant Score. This analysis showed excellent functional results in nearly all cases.

[Intestinal drug transport: a surgical problem?]

The case of a 35-year-old man is reported, who presented himself in the emergency room with anxiety and hallucinations. He then passed a small oval pack consisting of a dark paste wrapped in cellophane with his stool. This led to the suspicion of a "body packer syndrome" with cocaine intoxication. The plain abdominal X-ray revealed multiple oval structure scattered over the entire gastrointestinal tract. Cocaine metabolites in the urine confirmed the diagnosis. During the following whole-bowel irrigation the patient had a grand mal seizure. In order to accelerate the retrieval of this threatening load, surgical evacuation was immediately executed. 78 packs containing 650 grams cocaine were removed through a gastrotomy and a coecotomy, respectively. Two of these packs were leaking. Following an uneventful postoperative course the patient was discharged from the hospital 11 days later. According to the literature the recommended treatment for cocaine body packers is whole bowel irrigation. Operative treatment is mandatory in cases of small bowel obstruction or drug intoxication due to leaking packs.

[Treatment of displaced and comminuted multifragment fractures of the head of the radius: is resection a therapeutic option?]

The treatment of displaced comminuted fractures of the radial head type III of the Mason classification is still controversial. The restoration of anatomy including additional lesions with a stable fixation is a prerequisite of early mobilisation. Removal of the radial head, in case of severe comminution, and complete separation of the fragments from the radial neck remain the exception. Insertion of a prosthesis as a spacer is only recommended if there is a remaining instability of the elbow after resection of the radial head. With this treatment modality we have 22/29 good to very good results evaluated by the Morrey score after a follow-up period of 8 years (4-11 years).

[Stable joint-bridging extension of malleolar dislocations and pilon fractures with the AO pinless external fixator]

The pinless external fixator, introduced into clinical practice for open tibial fractures, suggested itself for use as a traction substitute because of its pinless frame. The aim of this feasibility study was to replace the conventional calcaneal pin traction by a joint-bridging pinless fixator, inserted under local anesthesia. 10 patients with 6 malleolar dislocation fractures, 3 pilon tibial and 1 open distal tibial fracture were immobilised by a joint-bridging pinless fixator during 10.4 days (5-16 days) till swelling had subsided and definitive fracture treatment, consisting of plate fixation, took place. The implantation of the joint-bridging pinless fixator in local anaesthesia was well tolerated by all patients. This traction substitute offered good patient comfort and easy care. Although the provided stability was less than a conventional fixator, all patients were able to lift up their fractured extremity without pain.

[Quality of emergency admission (resuscitation, REA) and first aid in multiple trauma]

Undue delay between hospital admission and the beginning or urgent operative procedures is considered as a major mortality risk for polytraumatized patients in any trauma center. As part of a quality control study at our institution (Kantonsspital, University of Basel), the time spent for early resuscitation and diagnostic procedures was therefore prospectively recorded in 20 patients (mean age 38 years) with a mean ISS of 26.9 (range: 13 to 43). Time spent in the resuscitation room averaged 31.4 min (range: 10 to 50 min). Conventional radiographic diagnostic procedures took 34.7 more min (range: 20 to 60 min). An additional CT scan was performed in 15 patients requiring 19.5 min per region (head/thorax/abdomen/spine). Four patients underwent angiography necessitating 28 more min (mean). Time elapsed between admission and arrival of the patient in the OR or the ICU respectively accounted for an average of 89 min (range 22 to 200 min). For comparable injury severities this interval was shorter during the day than during the night (77 and 103 min respectively). Diagnoses established during this period were both accurate and comprehensive, as detectable from the low rate of missed diagnosis (three minor fractures). Although our results match favorably with figures reported in the literature we feel that further improvements could be achieved by performing the conventional radiographic procedures simultaneously with the early resuscitation in the resuscitation room. At present time, for reasons of X-ray protection, this is not possible in our institution.

[Quality control and cost-benefit analysis in surgical fracture treatment]

In recent years quality assurance is gaining increasing importance in all parts of medicine. In this article, different quality control measures in the field of operative fracture treatment are reviewed and illustrated. As in most other therapeutic specialties, the most commonly used measures are sporadic quality control studies. The Documentation Center of the association for the study of internal fixation [AO] offers in addition to all its contributing clinics an extraordinary measure for a continuous control of their treatment results. So far only a few instances of cost-benefit analysis have been published. Besides direct comparison of costs of different treatment options, improved quality of life may be calculated as well, using the method of Quality-Adjusted Life Years [QALY].

[Proximal femoral fractures: trochanteric area (classification 31 A1-A3)]

The increasing incidence of trochanteric fractures renders their treatment a challenging task concerning both medical and increasingly socio-economical questions as well. The majority of these fractures occurs in elderly patients compromised by various preexisting medical problems. The primary goal of treatment therefore has to be early mobilisation to avoid secondary complications. This can only be achieved by operative treatment. Regarding the perioperative management an antibiotic as well as an antithrombotic prophylaxis is advisable. Recent data also suggest to add an enteral nutritional supplement during the postoperative period. The social reintegration depends however primarily upon the rapid restoration of the walking capacity. In this concern the Dynamic Hip Screw (DHS) is an optimal implant for ORIF, since it allows early full weight-bearing and shows a lower complication rate than static implants (e.g. the condylar blade plate).

[The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures]

The DHS-implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4-part fractures rotation of the head and neck fragment around the lag screw and significant impaction might lead to lateralisation of the greater trochanter and therefore to marked shortening. To prevent these effects we treated 17 patients with 4-part fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of telescoping, with less shortening even with immediate full weight bearing.

[The dynamic hip screw support plate for management of unstable proximal femoral fractures]

The DHS-Implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4 part-fractures rotation of the head and neck fragment around the lag screw and a significant impaction might lead to a lateralisation of the greater trochanter and therefore to an important shortening. To prevent these effects we treated 17 patients with 4 part-fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant the lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of the telescoping, with less shortening even with immediate full weight bearing.

[Initial experiences with the unreamed tibial nail]

During a one-year period starting January 1991, 17 tibial shaft fractures have been treated with the new AO unreamed tibial nail in a prospective study. Fractures were classified according to the AO classification: 10 type A, 6 type B, one type C. 7 fractures were closed. Out of those 3 showed marked soft tissue contusions and 2 required a fasciotomy because of a concomitant compartment syndrome. The open fractures were classified according to the Gustilo classification: 3 grade I, 5 grade II, 1 grade III B and 1 grade III C injury. There were 5 polytraumatised patients (ISS 27-34). The nailing procedure was preformed on the day of admission in 11 cases and in a delayed fashion (2-14 days after the accident) in 6 cases. There were no specific technical problems encountered intraoperatively. The only perioperative complication consisted of 1 case of fat embolism syndrome. 1 fracture required secondary plate osteosynthesis because of a unacceptable valgus deformity 6 weeks postoperatively. There was 1 too long nail implanted at the initial surgery, which then had to be changed during the rehabilitation period because of pain in the region of the knee. In 3 cases the interlocking bolts broke and 3 other cases required secondary dynamisation. There was a complete follow-up in all cases of at least 6 months. There were no infections. All fractures are healed. Full weight bearing was allowed at a mean of 10 weeks for closed fractures and 14 weeks for open fractures, respectively. All but one fracture (valgus 8 degrees) healed in a correct axial alignment without shortening.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cocaine poisoning from transport of the drug in the gastrointestinal tract (the body-packer syndrome)]

Three days after arriving in Switzerland from Bolivia a 35-year-old man presented at a casualty department. He was anxious, agitated and hallucinating, and he expressed delusional ideas of being poisoned. As a general physical examination was without abnormal findings he was thought to suffer from a psychiatric disorder. It was only when he had evacuated in stool a long oval foreign body, packed in plastic sheeting and filled with a dark paste, that cocaine poisoning due to cocaine transport in the gastrointestinal tract (body packer syndrome) was suspected. Plain X-ray of the abdomen revealed numerous regular structures of poor X-ray contrast and the urine contained cocaine metabolites, confirming the tentative diagnosis. As the patient's state of consciousness deteriorated and he had a grand mal seizure, an emergency laparotomy was performed. 78 packages (two of them had opened) were removed by gastro- and caecotomy. Total cocaine weight was 650 g. He was discharged from hospital after 11 days, free of symptoms.

Stable temporary traction substitute with the Pinless external fixator

The stable traction substitute with a JBPF seems a very promising indication for pinless clamps, offering good patient comfort and easy care. The implantation of a JBPF is possible under the same conditions as for conventional calcaneal traction. Although the stability provided is less than for conventional external fixators, it is sufficient for a temporary traction device. The JBPF does not affect secondary ORIF.

A simple teaching model for mucoperiosteal flaps and suturing techniques

A simple static model is described to teach students oral surgical procedures and to enable them to practise the design, incision and suturing of muco-periosteal flaps.

Cyclosporin A and osteonecrosis of the femoral head

A vascular osteonecrosis has occurred in 5 to 40 per cent of patients who have undergone transplantation of a kidney and generally has been considered to be a complication of the use of corticosteroids. Currently cyclosporin A is in general use for its immunosuppressive property, so that a lower dose of corticosteroids is needed. We analyzed the cases of a series of our patients who underwent transplantation of a kidney in order to find out if our present regimen, using cyclosporin A, influenced the prevalence of osteonecrosis of the femoral head. Of a total of 270 patients, osteonecrosis of the femoral head developed in fifteen of 174 who received conventional immunosuppressive therapy and in only one of ninety-six who received cyclosporin A (p less than 0.05). During the first two months after transplantation, the mean dose of prednisone was approximately 2.5 milligrams per kilogram of body weight per day in the group that received conventional immunosuppressive therapy and approximately 1.1 milligrams per kilogram of body weight per day in the group that received cyclosporin A (p less than 0.001). We concluded that the pathogenesis of the osteonecrosis in patients who underwent transplantation of a kidney was probably related to the higher doses of corticosteroids that were administered.