[Non-occlusive Mesenteric Ischemia caused by Diabetic Ketoacidosis - Pneumatosis intestinalis and Portal Venous Gas as an Indication of Mesenteric Ischemia]. / Nicht-okklusive Mesenterialischämie bei diabetischem Koma.

HISTORY: A 67-year-old woman was found lying naked on the bathroom floor for at least the last 12 hours. She had a medical history of insulin-dependent diabetes mellitus type 2 and a resection of the cecal pole. EXAMINATIONS: The patient was hypotonic (60/40 mmHg), hypothermic (29 °C) and hyperglycemic. The bowel sounds were sparse. There was a severe metabolic acidosis (pH 6.7). A Urinalysis showed a high concentration of ketone bodies. An abdominal ultrasonography revealed air reflexes in the liver parenchyma. A computer tomography was used to diagnose an acute mesenteric ischemia (AMI) with pneumatosis intestinalis and portal venous gas. TREATMENT: In an exploratory laparotomy the finding of necrotic bowl made it necessary to resect 160 cm of the small intestine as well as the remaining ileum and right hemikolon during a second surgery on the following day. Histopathologically there was no evidence for an occlusive genesis in the resected specimen. CONCLUSION: The clinic of the AMI is manifold - with fatal consequences in case of delayed diagnosis. Serum parameters are often overestimated. In this case report a diabetic coma was responsible for the AMI. The diagnosis was based on sonographic imaging followed by computed tomography, so that the life-saving operation could be performed. Therefore, sonography should be considered as a mandatory examination of critically ill patients.

Mono- versus polyaxial locking plates in distal femur fractures: a prospective randomized multicentre clinical trial.

PURPOSE: Treatment of complex fractures of the distal femur utilizing monoaxial locking plates (e.g. Less Invasive Stabilisation System, LISS®, Synthes) is considered to be superior to conventional plating systems. Due to the limitation that the thread forces the screw into pre-determined positions, modifications have been made to allow screw positioning within a range of 30° (Non Contact Bridging, NCB®-DF, Zimmer). For the first time, this multicenter prospective randomized clinical trial (RCT) investigates the outcome of LISS® vs. NCB®-DF treatment following complex fractures of the distal femur. METHODS: Since June 2008, 27 patients with a fracture of the distal femur (AO ASIF 33-A-C and periprosthetic fractures) were enrolled in this study by four university trauma centres in southern Germany. Clinical (e.g. range of motion, Oxford knee score, Tegner score) and radiological (e.g. axis deviation, secondary loss of realignment) follow-ups were conducted one and six weeks, as well as three, six, and 12 months after the operation. RESULTS: This study comprises data of 27 patients (8 male, 19 female; 15 NCB®-DF, 12 LISS®). Polyaxial osteosynthesis using the NCB® system tended to result in better functional knee scores and a higher range of motion. Interestingly, fracture union tended to be more rapid using the polyaxial plating system. CONCLUSIONS: We present the analysis of a multicenter prospective RCT to compare the monoaxial LISS® vs. the polyaxial NCB®-DF treatment following complex fractures of the distal femur. NCB®-DF treatment tended to result in better functional and radiological outcomes than LISS® treatment. LEVEL OF EVIDENCE: Level I.