[Angular and sliding stable internal fixation of proximal humerus fractures using the "Varion" intramedullary nail]. / Winkelstabile Marknagelosteosynthese von proximalen Humerusfrakturen mittels "Varion-Humerusnagel-System"

BACKGROUND: Intramedullary angular and sliding stable interlocking nails are attracting increasing attention in the treatment of fractures of the proximal humerus. This prospective study evaluates the clinical and radiological outcome of the "Varion" nail osteosynthesis system. Additionally we analysed the impact of the postoperative head-shaft angle on the functional outcome. PATIENTS AND METHODS: We examined 61 patients who were treated with a Varion nail and were re-evaluated after an average follow-up period of 7.1 months. We assessed the pre-trauma DASH score and the Constant score of the non-injured side. We also measured the postoperative radiographic head-shaft angle. At the follow-up exam we determined the DASH and Constant scores of the treated extremity and made control radiographs. RESULTS: We were able to re-evaluate 54 patients. The DASH score at follow-up averaged 19.3 and the mean postoperative Constant score reached 67.4 points and thus 81.1 % of the score of the non-injured side. The average pain level was 1.3 on the VAS. A high patient satisfaction was obtained. There was a significant correlation between the complexity of the fracture and the clinical outcome. The best functional result was seen when the postoperative head-shaft angle was between 140 and 151°. There were 7 cases of postoperative complications, in 5 of these cases minor revision surgeries were carried out. CONCLUSION: The "Varion nail" provides safe and effective treatment of even complicated proximal humerus fractures with good clinical and functional results. The optimum angle between head and shaft axis lies between 141 and 150°.

Toxoplasmosis in Pallas' cats (Otocolobus manul) raised in captivity.

Manuls or Pallas' cats (Felis manul, syn. Otocolobus manul) are endangered wild cats from Central Asia kept and bred in many zoos. Despite good breeding success young cats frequently die from acute toxoplasmosis. From 1998 to 2002, a breeding pair in the Schönbrunn Zoo in Vienna, Austria, gave birth to 24 kittens; 58 % of kittens died between the 2nd and the 14th week of life, mostly due to acute toxoplasmosis. The epidemiology of toxoplasmosis in Pallas' cats was examined and a control strategy to protect the kittens from fatal toxoplasmosis was developed. One 12-week-old kitten from a litter of 6 born in 2001 died of generalized toxoplasmosis. This kitten had shed T. gondii oocysts that were bioassayed in mice. Toxoplasma gondii was isolated in tissue culture inoculated with tissues of these mice. The surviving animals were immediately treated with clindamycin for 16 weeks; they acquired a natural infection and seroconverted by the end of this time without clinical signs.

[From quality assurance to quality management. Applying data from quality assurance studies]. / Von der Qualitätssicherung zum Qualitätsmanagement. Umgang mit Erkenntnissen aus Qualitätssicherungsstudien.

The realization of internal and external surgical quality assurance is natural for hospital physicians. External influences on the hospital and a changed understanding of organisation demand a development of classical quality assurance. The primary aim is a patient orientated quality assurance related to the medical benefits and the patient individual needs. The active creation and establishing of functional organisation process and interprofessional and interdisciplinary structures in hospital setting is a requirement of time.

[Treatment of intra-articular calcaneus fractures with a para-articular external fixator]]. / Die Behandlung intraartikulärer Fersenbeinfrakturen mit einem gelenkübergreifenden Fixateur externe.

Operative treatment of the calcaneus is still in discussion. For a better management of soft tissue problems an optimized fixator frame for primary treatment of calcaneus fractures was developed in the Dept. of trauma surgery University of Kiel. A one-plane bilateral construction with one insertion point in the tibia and two in the tuberosity of calcaneus is used. It allows efficient reduction by ligamentotaxis, stable fixation and active motion in ankle joint. We treated 40 patients with 45 calcaneus fractures. In 25 cases the fixator was definite and later plate or screw fixation was performed 20 times. 35 patients with 40 fractures were examined by means of the "Kiel score for calcaneus fractures". Patients who were treated definite reached better longterm-results on average than patients who underwent a secondary open osteosynthesis. Concrete guidelines for the therapy of intraarticular calcaneus fractures are presented.

Optimized preoperative planning of calcaneal fractures using spiral computed tomography.

The aim of this study was the evaluation of spiral-CT examinations in preoperative planning of calcaneal fractures supported by 3D reconstructions after electronic disarticulation. We examined 45 patients with 47 calcaneal fractures with diagnostic spiral-CT examinations in a prospective study. In addition to the conventional axial slices and sagittal reconstructions, 3D reconstructions prior to and after electronic disarticulation were performed and rated by orthopaedic surgeons and radiologists. The following diagnostic criteria were rated: involvement of articular facets, number of fragments and hindfoot deformities. Axial slices were considered to be the gold standard, because not all patients underwent surgical treatment. Axial slices showed involvement of 90 articular facets (100 %). Three-dimensional reformations after electronic disarticulation depicted 82 fractures (82 of 90, 91 %), sagittal reconstructions 63 fractures (63 of 90, 70 %). Three-dimensional reconstructions without electronic disarticulation showed five fractures (5 of 90, 5.5 %). The number of fragments was demonstrated best on sagittal reconstructions (two, three or four fragments); five fragments were diagnosed best on axial slices, and 3D reconstruction without electronic disarticulation showed only a very small number of fragments, due to overlaying bones. Hindfoot deformities (lateralisation, varus deformation, shortening) were demonstrated best on axial slices, except in terms of showing height reduction, which was demonstrated better on sagittal and 3D reconstructions. Three-dimensional reconstructions after electronic disarticulation support a clear understanding of the 3D position of the fragments and of their displacement in comparison with 3D reconstruction without electronic disarticulation, which is essential for an effective surgical reduction. Due to the potential manipulation of surface-oriented 3D reconstructions, regardless of whether electronic disarticulation is used, this imaging technique should not be considered in an isolated framework. Three-dimensional images without electronic disarticulation are superfluous in any case.

Microarchitecture and innervation of the human latissimus dorsi muscle.

Re-investigation of the adult human latissimus dorsi muscle (HLD) by microdissection of acetylcholinesterase (AChE)-stained material revealed a complicated microstructure of this muscle. Motor endplates distribute over the entire muscle; numerous AChE-stained myomyonal and myotendinous junctions are interspersed. After teasing muscle fascicles from selected representative areas, the following results were obtained. Most of the single muscle fibers constituting the fascicles are shorter than the length of the fascicles. They are linked together by myomyonal junctions or by myotendinous intersections end-to-end, end-to-side, or via muscular crossbridges side-to-side, thus forming chains and nets of varying appearance and length. Additionally, many fiber furcations were found. These observations throw light on the microarchitectural basis of local mass changes of the triangular HLD occurring during its convergence from its wide lumbar and thoracic attachment line to its narrow tendon attached to the humeral crista tuberculi minoris. The microstructural observations also explain why motor endplates spread over the whole muscle, instead of being restricted to a single central endplate-band, as is found in the majority of other muscles. To clarify postnatal development, the topography of endplates in adult muscles was compared with fetal and infantile muscles. Primarily, the endplate bands were clearly demarcated; their width then broadened, and they gradually scattered into groups of single endplates. Simultaneous with these developmental changes, a corresponding branching of the thoracodorsal nerve occurs.

Suspected dermatophilosis in an adult orangutan (Pongo pygmaeus pygmaeus).

An adult female Bornean orangutan (Pongo pygmaeus pygmaeus) had a pruritic, vesicular skin disease, particularly of the extremities, trunk, and face. Over a 2-yr course, symptoms resolved only transiently after corticosteroid treatment. Antibiotic treatment and withdrawal of all corticosteroids resulted in complete recovery of the animal and return to normal activity patterns. On the basis of the dermal histopathologic lesions, Dermatophilus congolensis was suspected as the causative organism, although subsequent cultivation was not attempted because of the stress additional procedures would have caused to the orangutan.

[The CT of calcaneal fractures: 3-D reconstructions with electronic disarticulation]. / CT von Kalkaneusfrakturen: 3-D-Rekonstruktionen mit elektronischer Desartikulation.

PURPOSE: To evaluate the clinical value of 3-D-reformations with and without electronic disarticulation of calcaneal fractures compared to axial CT and sagittal reformations. MATERIAL AND METHODS: 25 patients with intra-articular calcaneal fractures underwent diagnostic CT-examinations. Axial slices, sagittal and 3-D-reformations with and without electronic disarticulation were performed. The sagittal and both types of 3-D-reformations were compared to the axial slices with regard to the diagnostic criteria: involvement of articular facets, number of fragments, and traumatic changes of the hindfoot. RESULTS: The best proof of involvement of articular facets is found in axial slices and 3-D-reconstructions after disarticulation followed by sagittal reconstructions. Usually on 3-D-reconstructions without disarticulation articular facets cannot be identified because of overlapping bones. The number of fragments is clearly demonstrated by axial slices and sagittal reconstructions followed by 3-D-reconstructions after disarticulation. Traumatic changes of the hindfoot can be diagnosed in all four forms of visualisation. CONCLUSION: The decisive diagnosis for treatment planning is made based on the axial slices supported by sagittal reformations. In unclarified cases 3-D-reformations after electronic disarticulation may provide further information. 3-D-reformations without disarticulation are useless.

Brain cooling in humans--anatomical considerations.

Vascular arrangements allowing a bulky transfer of venous blood from the skin of the head and from nasal and paranasal mucous membranes to the dura matter provide an excellent anatomical basis for the convection process of cooling, caused by evaporation of sweat or mucus. The dura mater, with its extraordinarily high vascularization controlled by a potent vasomotor apparatus, may transmit temperature changes to the cerebrospinal fluid (CSF) compartment. Temperature gradients of the CSF may in turn influence the temperature of brain parenchyma (1) directly, along the extensive contact area between the cerebrocortical surface and the CSF-compartment, or (2) indirectly, via brain arteries that extend over long distances and arborize within the subarachnoid space before entering the pial vascular network and brain parenchyma. Numerous subarachnoid and pial arterial branches exposed to the CSF have diameters in the range of the vessels of the retia mirabilia of animals in which selective brain cooling has been clearly established experimentally. It is also shown that the arrangements of venous plexuses within the vertebral canal provide anatomical preconditions for a cooling of the spinal cord via the CSF. The possibility of spinal cord and spinal ganglia cooling by temperature convection via venous blood--cooled in the venous networks of the skin of the back--flowing through numerous anastomoses to the external and internal vertebral plexuses and, finally, into the vascular bed of the spinal dura is discussed on the basis of anatomical facts.

Hoof horn abnormalities in Lipizzaner horses and the effect of dietary biotin on macroscopic aspects of hoof horn quality.

This study involved a macroscopic evaluation of hoof quality in 152 Lipizzaner horses (130 from Austria and 22 from other countries) and a controlled double blind trial of the effects of biotin on hoof horn growth and quality over 19 months in 42 stallions from the Spanish Riding School (SRS) in Vienna. Using a grading system that incorporated evaluation of horn wall, white line, sole and frog, the macroscopic study revealed the following: 90% of the Austrian Lipizzaners had soft white lines and crumbling, fissured horn at the bearing border of the walls; 39% of the stallions of the SRS, > 4-years-old, had medium to severe hoof horn changes. Daily administration of 20 mg biotin to a test group of horses (n = 26) and a placebo to a control group (n = 16) showed that after 9 months the test group had significantly improved compared to the beginning of the trial and the placebo group (P < 0.01). In the test group, further improvement was observed during the following 5 months and, subsequently, the same good level of hoof condition was maintained over 3 further years of observation. Growth rate of the horn wall was equal in the biotin and placebo group, being 7 mm/28 days, giving a wall renewal period of 11 months. Mean plasma biotin level of untreated horses was 350 ng/l; plasma levels of biotin supplemented horses were > 1000 ng/l. It was concluded that continuous dietary supplementation with biotin at a daily dose of 20 mg is indicated to improve and maintain hoof horn quality in horses with less than optimum quality hoof.

Histological and physical assessment of poor hoof horn quality in Lipizzaner horses and a therapeutic trial with biotin and a placebo.

This paper represents the second part of a study searching for factors which could be responsible for an inferior hoof horn quality of the Lipizzaner horses of the Viennese Spanish Riding School (SRS) noticed in the late 1980s. It includes an evaluation of a treatment with biotin and 42 Lipizzaner horses were tested in a double blind study. The following parameters were evaluated: 1) the histology of the hoof horn in samples from the bearing border 2) the tensile strength of the coronary horn in bearing border samples and 3) the influence of biotin upon the histological changes and the tensile strength after application of 20 mg/day of biotin during 38 months. The histological alterations of bearing border specimens were assessed by use of a grading system (Grade 0 = unchanged; Grade 1 = slight changes; Grade 2 = moderate changes; Grade 3 = severe changes). Initially more than two thirds of the horses showed moderate to severe changes: microcracks visible in the transition from the middle to the inner zone of the coronary horn; separation of the sole from the coronary horn in the region within the white zone. The tensile strength of the coronary horn, with a mean of 39 N/mm2, was 13 N/mm2 lower compared with the unchanged hooves of 10 Warmblood horses, which were investigated by Küng (1991). After 19 months of biotin treatment, the horn quality showed a small but significant improvement. This could be shown by comparing the histological tissue structure before and after treatment, as well as treated animals vs. a placebo group.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphological indications for considerable diffuse reabsorption of cerebrospinal fluid in spinal meninges particularly in the areas of meningeal funnels. An electronmicroscopical study including tracing experiments in rats.

Transmission and scanning electron microscopical observations in the rat indicate a considerable capacity of the spinal meninges to reabsorb cerebrospinal fluid. The density of blood vessels and lymphatics in the duramater is extremely high, particularly in the areas of meningeal funnels and spinal nerve root sleeves. Arterioles with closely related unmyelinated nerve fibres, many fenestrated capillaries and venules predetermine these areas as sites where absorption processes could take place. At certain sites of the meningeal angle region, the arachnoid membrane, mostly multilayered, is reduced to only three or four layers. Intercellular discontinuities and cytoplasmic fenestrations occurring in the arachnoid lining cell layer result in direct communications between the subarachnoid space and cisterns of the arachnoid "reticular layer". These cisterns are partly fluid-filled, partly occupied by a net of collagen fibre bundles. Some cisterns harbour macrophages that often project filiform processes through the lining cell layer into the subarachnoid space, contacting cerebrospinal fluid. Desmosomes and gap junctions are present in all layers of the arachnoid. However, tight junctions and the continuous electrondense intercellular gap, known to occur normally within the "arachnoid barrier layer", were not seen in many sites of the meningeal angle region. Numerous arachnoid cells display a high degree of vesiculation. Cationized ferritin, introduced in vivo into the rat subarachnoid space, passes inter- and intracellularly from the cerebrospinal fluid compartment through the arachnoid membrane, reaching dural blood vessels and lymphatics. Tracer could be visualized both in the cytoplasm of the endothelium and on the luminal surface of the cells. Tracer also passed through pial cell layers into pial vessels, through leptomeningeal sheaths into vessels crossing the subarachnoid space, into the connective tissue compartment and into vessels of spinal dorsal root ganglia. In the angle region, a particularly large number of macrophages can be found on the surface of leptomeninges, within the arachnoid reticular layers, and in close relation to dural and epidural capillaries, venules and lymphatics. Their possible role in the process of cerebrospinal fluid reabsorption is discussed.

[Analysis of 55 post-traumatic pseudarthroses after tibial fracture]. / Analyse von 55 posttraumatischen Pseudarthrosen nach Unterschenkelfraktur.

In a retrospective analysis of 1,300 lower leg fractures, treated by operative stabilization in the years from 1980 to 1992, we examined disturbances of bone healing. In 55 patients (4.2%) faults in indication and completion of internal or external stabilization, infections with consecutive instability (43.6%), and bone defects (63.6%) led to prevention of bone healing. Conservation of blood supply and medial cortical support should be ensured.

[Pelvic fractures in the Kiel trauma surgery clinic. A one-year evaluation]. / Beckenfrakturen in der unfallchirurgischen Klinik Kiel. Eine Ein-Jahres-Bilanz.

48 injuries to the pelvis were treated from January 1991 through December 1991. We found 45 fractures of the pelvic ring with associated acetabular fractures in 15 cases and three isolated acetabular lesions. 19 injuries were caused by car accidents, 18 fractures resulted from a fall, especially in older patients. Isolated fractures of the pelvis occurred in 18 cases. The average total severity of the injuries was 19.7 points according to the Hannover Polytrauma Score (PTS). Every fracture was classified using the Tile-classification. There were 15 (33%) Tile A lesions, 18 (40%) Tile B fractures and twelve (27%) type C pelvic ring injuries. In 18 cases surgery was the method of treatment. Seven out of 18 injuries to the acetabulum were treated with open reduction and internal fixation. In ten patients the unstable pelvic ring was fixed by means of an external fixator. To do so, a pair of 6 mm diameter pins were placed on both sides in the supraacetabular region of the iliac bone directed towards the sacroiliac joints. We used a triangular form of external fixation. An open reduction and internal fixation (ORIF) was necessary in five cases, one injury required a combination of external and internal procedures. There were 14 cases in which we found sacral fractures as an additional dorsal lesion. Nine of 14 sacral fractures were recognized only by CT examination. In eleven cases the conventional radiographs showed simple anterior pelvic ring fractures while the CT examination revealed an additional lesion of the sacroiliac joint in nine of these cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Plaster-free, early functional after-care of surgically managed Achilles tendon rupture]. / Die gipsfreie, frühfunktionelle Nachbehandlung der operativ versorgten Achillessehnenruptur.

The widely used treatment of Achilles tendon rupture by operation and postoperative plaster is more and more controversially discussed. The disadvantages of plasters with thrombosis and joint stiffness and recent results about tendon healing makes it worth while to illucinate an immediate functional physiotherapy. Our study consists of two groups of patients who were operated for tendon rupture. Postoperative one group (n = 24) was treated with a plaster for six weeks. The second group (n = 17) was immediately treated by physiotherapy without any immobilisation. After a mean time interval of 19.8 months the joint movement and tendon flexibility was evaluated. Furthermore soft tissue ultrasound was performed to measure the tendon tissue density and gliding movement. Our data showed that 1. Early functional treatment resulted in minor problems (35%) than immobilisation (46%). 2. Plaster-free treated patients had higher tendon density values (grade II 41%, grade III 47%, grade IV 12%), which depicts a higher tensile strength than the comparable group (grade II 29%, grade III 58%, grade IV 13%). 3. Plaster-free treated patients showed significant lesser adhesion formation to the Achilles tendon (grade I 29%, grade II 53%, grade III 18%) than immobilisation (grade I 4%, grade II 59%, grade III 37%).

Cellular components of the immune barrier in the spinal meninges and dorsal root ganglia of the normal rat: immunohistochemical (MHC class II) and electron-microscopic observations.

This report deals with the distribution, morphology and specific topical relationships of bone-marrow-derived cells (free cells) in the spinal meninges and dorsal root ganglia of the normal rat. The morphology of these cells has been studied by transmission and scanning electron microscopy. Cells expressing the major histocompatibility complex (MHC) class II gene product have been recognized by immunofluorescence. At the level of the transmission electron microscope, free cells are found in all layers of the meninges. Many of them display characteristic ultrastructural features of macrophages, whereas others show a highly vacuolated cytoplasm and are endowed with many processes. These elements lack a conspicuous lysosomal system and might represent dendritic cells. Scanning electron microscopy has revealed that free cells contact the cerebrospinal fluid via abundant cytoplasmic processes that cross the cell layers of the pia mater and of the arachnoid. Cells expressing the MHC class II antigen are also found in all layers of the meninges. They are particularly abundant in the layers immediately adjacent to the subarachnoid space, in the neighbourhood of dural vessels, along the spinal roots and in the dural funnels. In addition to the meninges, strong immunoreactivity for MHC class II antigen is observed in the dorsal root ganglia. The ultrastructural and immunohistochemical findings of this study suggest the existence of a well-developed system of immunological surveillance of the subarachnoid space and of the dorsal root ganglia.

[Stabilizing the pelvic ring with the external fixator. Biomechanical studies and clinical experiences]. / Stabilisierung des Beckenrings mit Fixateur externe. Biomechanische Untersuchungen und klinische Erfahrungen.

Experimental studies were performed on anatomic pelvis specimens. In different series of experiments the positioning of the screws and the assembly of the external fixator were changed. We tried fixing the external fixator to the screws at varying distances from the body surface. For stabilisation of the fractured pelvic girdle a self-constructed "bow fixator", fixed to supra-acetabular screws with proximal compression and distal traction showed the best results. Homogeneous distribution of the pressure could be achieved on the unstable dorsal pelvic ring structures. In clinical routine we used the triangular external fixator, which in the experimental situation yielded results close to those of the bow fixator. External fixation of the pelvic girdle has been performed 128 times since 1977, in January 1991 a prospective study was started. For Tile type B injuries the external fixator itself represents an effective, minimally invasive system, but type C fractures often require an additional internal fixation of the dorsal lesion.

5'-nucleotidase in spinal meningeal compartments in the rat. An immuno and enzyme histochemical study.

The distribution of 5'-nucleotidase (5'-Nu) is reported in spinal meninges of the rat on the basis of an immunohistochemical and enzyme histochemical investigation. Strong immunoreactivity was found in the arachnoid membrane and in the sheaths of the spinal roots as well as in septa subdividing the roots. Also the superficial layer of the ligamentum denticulatum showed enzyme staining. No immunoreactivity could be detected in the pia mater or along the spinal nerve roots outside the subarachnoid space. Within the arachnoid mater the immunoreactivity was concentrated in the basal zone of the arachnoid membrane, thus appearing as a narrow fluorescent band near the border of the dura. An accentuation of immunoreactivity could be observed in areas where small dural blood vessels approach the subarachnoid space. It is well known that adenine nucleotides released from neural and glial cells of the central nervous system finally reach the cerebrospinal fluid. We presume that 5'-Nu in the arachnoid membrane and spinal root sheaths is responsible for the conversion of adenine nucleotides into adenosine and that this conversion is associated with the reabsorption process of cerebrospinal fluid which most probably also takes place in spinal meninges. Adenosine, the product of 5'-nucleotidase, could play a role in the reabsorption process by its vasodilatatory effect on dural and epidural vessels.

[Patterns of injuries: a guideline for evaluation of multiple injuries?]. / Verletzungsmuster--Leitlinie bei der Beurteilung des Mehrfachverletzten?

By means of 468 patients with polytrauma the pattern of injuries were analysed. Separated into body regions the combinations of injuries to skeleton/thorax and skeleton/thorax/abdomen were found most often. A high lethality was evaluated for the combination of skeletal and abdominal injuries. 362 patients of the examined collective survived, 106 patients died. Among the deceased patients with head-injuries intracranial bleeding could be seen much more than in the group of survivors. Patients who died had also more ruptures of liver and other gastrointestinal injuries. Concerning the skeletal patterns of injuries they surprisingly had more fractures of shoulder, forearm and lower leg than the survivor-group. The statistic demonstrates clearly that in pattern of head or abdominal injuries the single diagnosis determines the rate of lethality. This correlation could not be seen in skeletal injuries. The pattern of injuries cannot be used as a guideline for the assessment of therapy of the severe trauma patient.

Conduction velocities of pyramidal tract fibres and lumbar motor nerve roots: normal values.

Measurements of spinal cord and individual lumbar nerve root lengths were performed in 20 dissected cadavers. These data were correlated with the pyramidal tract and motor root conduction times obtained in 53 healthy subjects using motor evoked potentials. The distance between motor cortex and the level of the anterior horn cells ranged from 50.2 +/- 3.0 cm (mean +/- standard deviation) for the L1 segment to 54.4 +/- 3.6 cm for the L5 segment. The length of the motor roots from their exit from the myelon to their exit from the intervertebral foramen ranged from 10.3 +/- 1.7 cm in the L1 root to 17.5 +/- 1.9 cm in the L5 root. The central motor conduction velocity calculated for the distance motor cortex - anterior horn cells of the L5 segment was 50.1 +/- 4.5 m/s. The proximal peripheral conduction velocity of the motor nerve root between its exit from the spinal cord and its exit from the intervertebral foramen was 75.9 +/- 29.0 m/s. The overall conduction velocities between motor cortex and exit of the nerve roots from the intervertebral foramen were 57.4 +/- 6.3 m/s for the L4 fibers to the quadriceps femoris and 57.3 +/- 6.1 m/s for the L5 fibers to the anterior tibial muscle.