The classic. Review article: Traffic accidents. 1966.

This Classic Article is a translation of the original work by Prof. Harald Tscherne, Der Straßenunfall [Traffic Accidents]. An accompanying biographical sketch of Prof. Tscherne is available at DOI 10.1007/s11999-013-3011-x . An online version of the original German article is available as supplemental material. The Classic Article is reproduced with permission from Brüder Hollinek & Co. GesmbH, Purkersdorf, Austria. The original article was published in Wien Med Wochenschr. 1966;116:105-108. (Translated by Dr. Roman Pfeifer.).

Posttraumatic multiple organ failure--a report on clinical and autopsy findings.

In a retrospective analysis, clinical data and histological specimens were obtained from patients (n = 59) who died of severe injury. Three groups with comparable injury severity were differentiated according to the time of death. In group A (death, within 24 h) (n = 15) despite multiple injuries, patients almost always died from brain injury. Pulmonary failure was the leading cause of death in group B (death, days 2-7) (n = 16). The majority of group C patients (death, > 7 days) (n = 28) died of multiple organ failure. Organ weights at autopsy were all pathologically high but did not show an association with the amount of intravenous volume infused during intensive care. Organ histology revealed signs of interstitial edema and infiltration of polymorphonuclear leukocytes in group B patients especially in the lung, and in all groups to a lower degree in liver and kidney. The distribution of interstitial edema and cell necrosis appeared to be organ-specific. Our data confirm the presence of a generalized inflammatory reaction in patients with severe trauma. The pattern of organ failure, in addition to known pathogenetic changes (mediators, endotoxemia, etc.), appears to be influenced by organ structure and perfusion.

Multiple organ failure (MOF) after severe trauma--a sheep model.

OBJECTIVE: To perform a reproducible long-term (10 days) large animal model of multiple systems organ failure without necessity of a continuous stimulus. DESIGN: Adult female merino sheep submitted to a 5-day stimulation period followed by a 5-day observation period. Day 1: Hemorrhagic shock was combined with a traumatic surgical insult (reamed intramedullary femoral nailing), followed by serial administrations every 12 h for 5 days of a combination of endotoxin and zymosan activated plasma. Organ function was followed for 5 further days. RESULTS: Cardiac index increased significantly during the study (day 1: 491 +/- 8 mm Hg; day 10: 427 +/- 20, p < 0.05). Liver function was impaired and bilirubin levels increased significantly (day 1: 2.9 +/- 0.3 micromol/l; day 10: 7.2 +/- 0.9; p < 0.05). Creatinine clearance decreased initially (day 1: 54 +/- 7 ml/min), increased to a peak on day 2 (104 +/- 27), and then deteriorated again (day 10: 53 +/- 18). CONCLUSION: This new large animal model of trauma-induced MOF is reproducible and may be suitable for the study of new therapeutic approaches to therapy.

Reticuloendothelial system activity and organ failure in patients with multiple injuries.

HYPOTHESIS: Reticuloendothelial system function is altered in patients with multiple trauma and organ failure. DESIGN: Prospective cohort study. SETTING: Surgical intensive care unit at a level I trauma center. PATIENTS: Patients with multiple blunt trauma and injury severity scores greater than 20, with no referrals. INTERVENTIONS: Every second day reticuloendothelial system (RES) clearance capacity and liver blood flow were determined by administering labeled human albumin. Liver function was measured by enzymatic decay of indocyanine green, and levels of plasma tumor necrosis factor alpha were evaluated. RESULTS: In nonsurviving patients with blunt trauma, RES function was altered and was associated with organ dysfunction and infectious complications. Of 61 patients, 42 survived and 19 did not. Sixteen patients (84%) died of multiple organ failure. Significantly elevated RES activity (colloid clearance rate) was present between day 5 and day 13 after trauma in nonsurvivors (0.86+/-0.16 [mean +/- SD] on day 7, P = .003) compared with survivors (0.48+/-0.08 on day 7) and 20 healthy volunteers (0.47+/-0.06); RES activity then decreased to subnormal levels in nonsurvivors. Tumor necrosis factor alpha plasma levels were elevated early after injury only in nonsurvivors (on day 1: nonsurvivors, 1.2+/-0.4 ng/mL [mean +/- SD]; survivors, 0.5+/-0.2 ng/mL; P = .02). Indocyanine green half-life values increased late after trauma, indicating late organ failure (on day 19: nonsurvivors, 111+/-29 minutes [mean +/- SD]; survivors, 12+/-4 minutes; P<.001). CONCLUSIONS: Early after trauma, nonsurviving patients demonstrated increased proinflammatory cytokine levels, followed by a state of pathological hyperactivation of the reticuloendothelial system prior to death. These results indicate that the stationary host defense system is involved in the mechanisms causing organ failure after severe trauma.

Deformation of femoral nails with intramedullary insertion.

Current methods of distal interlocking of intramedullary femoral nails are dependent on image intensification. However, radiation exposure to the patient, the operating room staff, and the surgeon remains a concern. Proximally mounted, radiation-free aiming systems for distal interlocking of femoral nails have reportedly failed because of nail deformation with insertion. To better understand this deformation, a three-dimensional magnetic motion tracking system was used to determine the position of the distal interlocking hole following nail insertion. The amount and direction of deformation of commercially available small-diameter implants (unslotted 9-mm nails inserted without reaming) and large-diameter implants (slotted 13-mm nails inserted with reaming) from a single manufacturer were analyzed. Measurements of deformation (three translations and three angles), based on the center of the distal transverse locking hole, were performed on 10 paired intact human cadaveric femora before and after insertion. The technique produced the following results for the small and large-diameter nails, respectively: lateral translations of 18.1+/-10.0 mm (mean+/-SD, range: 47.8 mm) and 21.5+/-7.9 mm (range: 26.4 mm), dorsal translations of -3.1+/-4.3 mm (range: 15.2 mm) and 0.4+/-9.8 mm (range: 30.1 mm), and rotation about the longitudinal axes of -0.1+/-0.2 degrees (range: 0.7 degrees) and 10.0+/-3.1 degrees (range: 7.8 degrees). This technique is useful for measuring insertion-related femoral nail deformation. The data for the nails tested suggest that a simple aiming arm, mounted on the proximal end of the femoral nail alone, will not sufficiently provide accurate distal aiming.

The role of supplemental lag-screw fixation for open fractures of the tibial shaft treated with external fixation.

Ninety-nine open fractures of the tibial shaft were treated with unilateral external fixation with or without supplemental lag-screw fixation. We compared the results in forty-four fractures in which only external fixation was used (control group) with those in fifty-five fractures that were stabilized with lag-screws and external fixation, and we found no statistically significant differences between the two groups with respect to the time to full weight-bearing, the time to union, or the rates of delayed union, osteomyelitis, malunion, superficial or deep pin-track infection, or loosening of the pins. The limbs in which the fracture was treated with external fixation and supplemental lag-screws had more than twice the rate of refracture of the control limbs (11 compared with 5 per cent), and the percentage of fractures having supplemental lag-screw fixation that needed bone-grafting to achieve union was more than twice that in the group treated with external fixation alone. We concluded that the routine use of supplemental lag-screw fixation is not indicated in patients who have an open fracture of the tibial shaft that has been stabilized with external fixation.

Scapulothoracic dissociation.

Scapulothoracic dissociation is a rare entity that consists of disruption of the scapulothoracic articulation. The mechanism of injury is probably traction caused by a blunt force to the shoulder girdle. This lesion is characterized by massive soft-tissue swelling of the shoulder; lateral displacement of the scapula, measured radiographically; an injury to bone (an acromioclavicular separation, a displaced fracture of the clavicle, or a sternoclavicular disruption); a severe neurovascular injury; and a variety of upper and lower-extremity fractures. We treated fifteen patients who had this lesion, most of whom had several associated injuries. Three patients died: two from exsanguination and one from a cardiac arrest. In most patients, the damaged artery was repaired and the brachial plexus was explored. All of the twelve patients who had a complete brachial-plexus injury were left with a flail upper extremity. Most patients refused amputation.

The relationship of mechanical properties to morphology in patellar tendon autografts after posterior cruciate ligament replacement in sheep.

In a sheep model the posterior cruciate ligament (PCL) was replaced by a patellar tendon autograft (PTAG) using the central one-third of the ipsilateral patellar tendon (PT). The sheep were sacrificed at 16, 26, 52 and 104 weeks postoperation. The PTAG, and, as controls, the contralateral PCL and PT were harvested. These were examined using biomechanical testing as well as light and transmission electron microscopy, including immunohistological techniques. The material properties (maximum stress, elastic modulus) were compared to the morphological features. The cellular distribution, the distribution of glycosaminoglycans (GAGs), the collagen fibril diameter and the occurrence of Type III collagen were studied. Prior to transplantation, the PTAG was shown to be superior in maximum stress (57.2 +/- 5.5 MPa vs 41.3 +/- 1.9 MPa) and elastic modulus (368.8 +/- 49.3 MPa vs 172.3 +/- 14.6 MPa) to the PCL. The early decline in material properties of the PTAG (maximum stress 22% and elastic modulus 42% of the control) after free grafting paralleled a cell- and capillary-rich PTAG tissue with remnants of necrosis and a poorly organized extracellular matrix. Two years after implantation, with progressive alignment of the tissue matrix, maximum stress and elastic modulus acquired approximately 60 and 70% of the control, respectively. However, there was also an evidence of degenerative changes characterized by acellular areas, loss of the normal bundling pattern of collagen fibers and abnormal accumulation of GAGs. Ultrastructurally, there was a predominant shift to thin collagen fibrils in the PTAG compared to PCL and PT, both consisting of thick and thin collagen fibrils. Thin fibrils were demonstrated to be, in part, split thick fibrils as well as newly formed fibrils. Most of these thin fibrils revealed a positive reaction with antibodies to Type III collagen.

The deformation of small diameter solid tibial nails with unreamed intramedullary insertion.

'Radiation-independent' aiming systems for the placement of interlocking screws in intramedullary tibial nails have failed because of insertional related nail deformation. Prior to the development of these distal aiming systems, the variable position of the nails' interlocking holes after insertion must be known. In this study, the amount and direction of implant deformation of solid stainless-steel tibial nails (diameters of 8 and 9 mm, n = 20) were analyzed. Measurement of implant deflection (three translations, three angles) in the center of distal transverse locking hole was performed with a three-dimensional-magnetic motion tracker system after nail insertion in paired human cadaver tibiae. The results showed combined mean lateral translation of the 8 and 9 mm nails (n = 20) of -4.5 +/- 3.5 mm (range: 14.3 mm) and dorsal translation -7.8 +/- 5.8 mm (range: 19.2 mm). The combined mean rotational deformation about the longitudinal axis of the nail was 0.3 +/- 0.7 degree (range: 2.4 degrees). The authors conclude that a simple aiming arm, mounted on the proximal nail end alone, is not sufficient to provide accurate distal aiming.

A new kinematic model of pro- and supination of the human forearm.

We introduce a new kinematic model describing the motion of the human forearm bones, ulna and radius, during forearm rotation. During this motion between the two forearm extrem-positions, referred to as supination (palm up) and pronation (palm down), effects occur, that cannot be explained by the the established kinematic model of R. Fick from 1904. Especially, the motion of the ulna is not properly reproduced by Fick's model. During forearm rotation an evasive motion of the ulna is observed by various authors, using magnetic resonance imaging MRI) technology. Our new kinematic model also simulates this evasive motion. Furthermore, the model is enlarged to include angulations of the forearm bones. Using these results the influence of forearm fractures on the range of forearm motion can be predicted. This knowledge can be used by surgeons to choose the optimal therapy in re-establishing free forearm mobility.

Anterior plating in thoracolumbar spine injuries. Indication, technique, and results.

The selection of surgical approach for patients suffering from acute thoracolumbar spinal trauma is presently imbued with great controversy. The surgical method chosen depends on the type of fracture, anatomic and biomechanical factors, and the habits and experience of the surgeon involved. Due to new techniques for the posterior approach and the use of internal fixators, the indications for the anterior approach must be reassessed. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. Additional indications are seen in patients with vertebral body fractures with complete comminution and dislocation, noncorrectable burst fractures, and late misalignments. After removal of vertebral body and intervertebral disc fragments, autogenous bone should preferably be used for interposition. Different plates can be used for instrumentation. While anterior plates most often offer complete stability for the thoracic spine and a dorsal plating in this region can turn out to be quite difficult, in the lumbar spine, especially with destruction of additional posterior structures, one must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators. So far, we have gained experience from treating 39 patients with anterior decompression and stabilization. One of 19 patients with Frankel Grades A and B and 50% of the remaining 20 patients had improved one Frankel grade. Only a few of the patients with incomplete neurologic symptoms had back pain. All except for one returned to work. According to radiologic examinations, the average loss of correction amounted to 7%.

[The value of bone scintigraphy in thigh pain following cementless hip prosthesis]. / Aussagefähigkeit der Skelettszintigraphie bei Oberschenkelschmerz nach zementlosem Hüftgelenkersatz.

Persisting postoperative pain of the thigh is a common problem of cementless hip endoprostheses occurring in about 15-20% of the patients. We performed a comparative study including patients with (n = 40) and without (n = 45) pain of the thigh. 85 cementless porous-coated anatomic (PCA) hip endoprostheses in 74 patients were examined. All patients underwent clinical examination including a standardized questionnaire, x-ray, and 3-phase bone scintigraphy. Slight or moderate 99mTc-MDP uptake in the area of the greater and lesser trochanter as well as at the tip was a common finding in PCA prostheses in patients without pain and was not a sign of loosening of the hip. Radiologically, there was no difference between patients with and without pain. However, persisting pain of the thigh in patients with PCA prosthesis corresponded with an increased uptake at the tip and the medial and lateral femur, not being a sign of loosening even in this group. The special biomechanical conditions of cementless prostheses causing inhomogeneous intraosseous stress distribution are supposed to be the reason for that.

Isolated traumatic dislocation of the hip. Long-term results in 50 patients.

From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries.

Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament: a prospective, longitudinal study.

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined. Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 +/- 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.

Recurrent rotational deformity of the femur after static locking of intramedullary nails: case reports.

Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Reamed, locked intramedullary nailing may be performed, but concern about cortical blood supply and potential pulmonary dysfunction from reaming have led many surgeons to limit this and use smaller diameter nails. Slotted nails are commonly used but are less stiff in torsion than the newer unslotted nails, particularly at the lower diameters. We report two cases of recurrent femoral rotational deformity after using statically interlocked slotted intramedullary nails to correct existing femoral rotational deformities. These patients show that small diameter statically interlocked femoral nails with diminished bone-nail contact must be stiff enough in rotation to avoid potential recurrence.

Biomechanical study of nine different tibia locking nails.

We compared different nail types within the Bone/Implant-Complex to look for differences in stiffness for axial load, bending and torsion of the System. We simulated comminuted mid shaft fractures by a 2-cm defect osteotomy in paired human cadaver tibiae. We fixed tibiae with one of nine different interlocking nails [AO Unreamed Tibial Nail 9 mm (UTN9), AO Unreamed Tibial Nail 8 mm (UTN8), Russell & Taylor Delta Tibial Nail 9 mm (RTD), Russell & Taylor Reconstruction Tibial Nail 11 mm (RTR), Brooker & Wills Tibial Nail 11 mm (B&W), Grosse & Kempf Tibial Nail 11 mm (G&K), AO Universal Tibial Nail 11 mm (AOU), Klemm & Schellmann Tibial Nail 11 mm (K&S), and Börner & Mattheck Tibial Nail 11 mm (B-M)] according to the manufacturer's recommendations. In torque testing the unslotted nails (UTN9, UTN8, RTD, RTR, B&W) showed significantly higher stiffness compared to the slotted nails (G&K, AOU, K&S, B-M). Compared to intact bone, both groups of nails were significantly less stiff. In axial load testing large diameter nails interlocked by large diameter interlocking bolts (G&K, K&S, B-M) showed significantly higher stiffness. For A-P bending no significant differences between implants were found, but isolated bones showed significantly higher A-P bending stiffness. In varus-valgus bending large diameter nails (RTR, G&K, K&S, B-M) showed significantly higher bending stiffness compared to low diameter (UTN8, B&W) implants.

A review of the therapeutic concept and results of operative treatment in acute and chronic lesions of the cervical spine: the Hannover experience.

A therapeutic concept for the treatment of acute and chronic cervical spine lesions is presented. Unstable fractures and dislocations of the cervical spine should be reduced as soon as possible. Most frequently, we employ the anterior approach using the Smith and Robinson technique (37) with the addition of an H-shaped plate. The posterior approach is mainly indicated for the release of irreducible locked facets. Unstable odontoid fractures, especially those in group II of Anderson and d'Alonzo (3), are stabilized by screw osteosynthesis. Between 1971 and 1989, 306 patients with cervical spine lesions were treated surgically. In these cases, there were 205 acute injuries and 52 chronic instabilities. Forty-nine patients had tumors or metastases. Ninety-two patients with acute injuries (group I) and 24 with chronic lesions (group II) were reexamined. Out of 53 group I patients, the neurologic symptoms improved in 45 cases (85%), and in 30 of these (mainly with radicular compression syndromes) a complete recovery was noted. Seventy-two percent of the patients were symptom-free. Seventy-four percent of the acute and 58% of the chronic lesions showed a good or very good result having little or no limitation of motion and minimal or no pain. Irrespective of neurologic deficits, 89% of the acute traumatized patients were able to work after 5 months. The rate of pseudarthrosis was 2%. The risks of an anterior interbody arthrodesis are small when using a careful and standardized operative technique. It allows an early functional treatment and shortens the rehabilitation time.

Therapeutic concept and results of operative treatment in acute trauma of the thoracic and lumbar spine: the Hannover experience.

A therapeutic concept for the treatment of acute thoracolumbar spinal injury includes an early closed reduction as the first step. In cases with a surgical indication in the lower thoracic area as well as in the lumbar spine, the posterior approach is preferred. Following decompression of the spinal cord, a transpedicular lifting of the upper endplate is done and the fractured vertebra is filled with corticocancellous bone chips. Stabilization is achieved with an internal fixator usually over two motion segments only. Subsequently, autologous corticocancellous bone is added between lamina and between the transverse processes. In the thoracic spine proper, the anterior approach is more advantageous. Following spondylectomy (removal of the vertebral body whole or in part), an intercorporal spine arthrodesis is performed utilizing a solid bone graft and plates. Seventy-six patients with 78 fractures and subluxations of the thoracolumbar spine were reexamined for an average of 3 years and 4 months after their operation. Of the patients with an incomplete cord injury (Frankel B-D) 60% improved at least one Frankel grade and an additional nine patients improved within their group. Clinical deterioration did not occur. Irrespective of the localization, the radiologically determined loss of correction following an anterior approach was an average of 7 degrees whereas the settling after posterior approach averaged 9 degrees. The sagittal index of the affected vertebra improved from 0.59 preoperatively to 0.80 postoperatively. All spinal arthrodeses healed with osseous reorganization. Twelve postoperative computer tomographies were analyzed (11 after a posterior decompression), and showed a decrease of the spinal canal compromise from 65% preoperatively to 11% following surgery.

Use of an injectable calcium phosphate bone cement in the treatment of tibial plateau fractures: a prospective study of twenty-six cases with twenty-month mean follow-up.

OBJECTIVE: To evaluate the potential benefit of a new injectable mineral bone cement (Norian SRS, Cupertino, CA, USA) for the treatment of tibial plateau fractures OTA types 41.B2-B3 and C3. DESIGN: Prospective study with established protocol. SETTING: University hospital; university teaching hospital. PATIENTS: Twenty-six patients gave informed consent to participate in this study and were available for follow-up examinations. All patients had sustained intraarticular tibial plateau fracture types OTA B2-B3 and C3. All cases were followed with a mean follow-up time of 19.7 months (6 to 36 months, median eighteen months). INTERVENTION: Twenty-five cases were treated with open reduction, osteosynthesis with screws or plate, and injection of Norian SRS in the subchondral bone defect. One case had closed reduction, screw osteosynthesis, and percutaneous cement injection. MAIN OUTCOME MEASUREMENTS: Radiographs in two planes were evaluated prospectively at six, twelve, and twenty-six weeks postoperatively and at last follow-up using Rasmussen's radiologic score. Clinical parameters were measured at the same time intervals using Lysholm's and Tegner's knee scores. RESULTS: Two cases required early wound revisions because of sterile drainage. Two cases developed partial loss of reduction of the fracture between four and eight weeks after surgery, requiring revision surgery in one case (total complication rate 15.3 percent). No other patients had complications, and all other fractures healed without any displacement. The high mechanical strength of the cement allowed early weight bearing after a mean postoperative period of 4.5 weeks (1 to 6 weeks). CONCLUSIONS: An injectable mineral bone cement with high initial mechanical strength was used to fill bone defects in unstable tibial plateau fractures with good success. This material offers new perspectives in the treatment of tibial plateau fractures.

Fatal pulmonary embolization after reaming of the femoral medullary cavity in sclerosing osteomyelitis: a case report.

Reaming of the medullary may be used in cases of sclerosing osteomyelitis (type Garré), refractory to other methods. We report a case of fatal intraoperative complication related to this procedure. An otherwise healthy young patient died during reaming using a machine-driven reamer of the femoral medullary canal due to pulmonary bone embolism. The technique and the indication for this procedure as well as the intraoperative monitoring options are discussed.