[Fractures of the upper ankle]. / Frakturen des oberen Sprunggelenkes.

Upper ankle injuries are the most common reason for presentation in emergency departments. The initial treatment is often left in the hands of young clinical professionals. While the mechanism of injury might appear banal, insufficient diagnosis and treatment can lead to long periods of disability and functional impairment of the joint. Therefore, it is the aim of this work to provide a thorough understanding of the anatomy, biomechanics, mechanism of injury, diagnostic and operative procedures of ankle joint fractures.

[Surgical management of abdominal injury]. / Operative Therapie abdomineller Verletzungen.

PURPOSE: Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury. METHODS: Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine. RESULTS: Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this. DISCUSSION: Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

[Osteomyelitis of the carpus and metacarpus]. / Osteomyelitis der Mittelhand- und Handwurzelregion.

AIM: Because of the low prevalence, there is poor evidence on the effective management of bone and joint infections of the carpus and metacarpus. We therefore studied the outcomes of patients undergoing surgical treatment at our department. METHOD: We conducted a retrospective study on all patients operated on because of osteomyelitis of the carpus and metacarpus between January 1998 and June 2004. Main study endpoint were the infection control rate at end of treatment and at time of follow-up. RESULTS: Of eleven subjects (nine men, two women) with a median age of 43 years (range, 19 to 79 years) serial débridement with temporary wound closure and surgical fixation proved successful in ten cases. We identified causative pathogens in ten cases (S. aureus: n = 3, P. aeruginosa: n = 3, mixed: n = 4) by intraoperative biopsy. Eight subjects received local or free tissue flaps. A 73 year old man died in hospital. Follow-up information was available for eight patients after a median of 19.5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection. CONCLUSION: Adhering to accepted standards of treating osteomyelitis, satisfactory control rates in carpal and metacarpal infection can be achieved while salvaging the hand.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.

BACKGROUND: Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. OBJECTIVES: To assess the efficiency and effectiveness of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CENTRAL, CCMED, publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and congress abstracts were handsearched. Trials were obtained from the Cochrane Injuries Group's trials register. Authors were contacted for further information and individual patient data. PARTICIPANTS: patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. INTERVENTIONS: diagnostic algorithms comprising emergency ultrasonography (US). CONTROLS: diagnostic algorithms without US ultrasound examinations (e.g. primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). OUTCOME MEASURES: mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. STUDIES: randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. MAIN RESULTS: We identified two RCTs with US in the experimental arm and another with US in the control group. We also considered two qRCTs. Overall, trials were of moderate methodological quality. Few authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We were able to pool data from two trials comprising 1037 patients for primary endpoint analysis (i.e. mortality). The relative risk in favour of the no-US arm was 1.4 (95% CI 0.94 to 2.08). Because of a lack of details, the meaning of this observation remains unclear. There was a marginal benefit with US-based pathways in reducing CT scans (random-effects RD -0.46; 95% CI -1.00 to 0.13), offset by trials of higher methodological rigour. No differences were observed in DPL and laparotomy rates. AUTHORS' CONCLUSIONS: There is insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

A likelihood ratio approach to meta-analysis of diagnostic studies.

OBJECTIVE: To develop a clinically and methodologically sound approach to diagnostic meta-analysis. METHODS: Two-step model was used involving four fictitious sets of 10 studies each with varying sensitivity and specificity; this was followed by the application of the method to data from a published systematic review of emergency ultrasound. Multidimensional test characteristics (relating to the detection or exclusion of the condition of interest) were described by likelihood ratio scatterplots and pooled likelihood ratios. Likelihood ratios summarise the ability of a test to revise the prior probability of disease. They can be summarised by established fixed-effects and random-effects methods. RESULTS: Likelihood ratios precisely describe both directions of test performance. By plotting positive against negative likelihood ratios, together with their 95% confidence intervals, a multidimensional forest plot is obtained that can be interpreted in analogy to therapeutic meta-analyses. There are accepted threshold values of positive and negative likelihood ratios (i.e. 10.0 and 0.1) to recommend a test for clinical use. In the matrix space, distinct test characteristics can even be assessed by eyeballing. With regard to data from the real meta-analysis, the suggested high discriminatory power of ultrasound was only partially qualified by likelihood ratios. The positive value confirms the reliability of a positive scan, whereas the negative value questions a normal sonogram. CONCLUSIONS: A full characterisation of test performance requires multidimensional effect measures. Likelihood ratios are recommended descriptors of the two dimensions of diagnostic research evidence and provide a convenient means to visualise and to communicate results as weighted summary estimates of a diagnostic meta-analysis.

[Clinical trials in orthopedic and trauma surgery: randomized or non-randomized?]. / Unfallchirurgische Interventionsstudien: randomisiert oder nicht-randomisiert?

Drawing inferences on a causal relationship between a particular intervention and the observed outcome requires to conduct a clinical experiment which controls for study conditions and systematic errors (bias). This is best to be achieved by randomization in which known and unknown biological risk factors are distributed equally among treatment arms. Trauma and orthopedic surgery,however, occupies an exceptional position in clinical medicine. Random allocation of subjects is often considered difficult because of the tight time frame between patient presentation and the urgent need for surgical treatment, and the dependence of operative results upon technical skills. Evidence of a true treatment effect does not only depend on design issues (i.e., randomized or non-randomized treatment assignment), but on both the prior probability of efficacy and the observed effect size as well. Even though our knowledge of the efficacy of osteosynthesis comparing with, let's say, plaster immobilization or (fictive) placebo therapy is hardly supported by randomized trials, the biologically plausible principle of stable operative fixation of fracture fragments has established itself as the scientific basis to propagate surgical rather than other treatment options. Thus, the efficacy of a medical intervention can be well demonstrated without randomization. Regarding the ultimate goals of stabilization, pain removal, and mobilization,osteosynthesis of a pertrochanteric fracture fits these principles in terms of an all-or-none effect (so called level Ic evidence): without the intervention, effects will not be observed. On the other hand, endpoints such as healing and infection rates or duration of rehabilitation may be severely influenced by confounding factors (e.g., concomitant diseases, age, or gender). Under these circumstances,the goal of quantifying treatment effects of different interventions (i.e., interlocking nails, plates, K-wires) and of discriminating these effects from bias might be solved more reliably by a randomized than by a non-randomized trial.Obviously,the need for randomization relies on the choice of the main endpoint of interest.The postulated overestimation of treatment effects by nonrandomized trials has been proven only for methodologically weak investigations. In contrast, high quality studies led to comparable findings regardless of randomization. In conclusion, there are thinkable alternative designs to randomized trials in trauma surgery, accounting for selected clinical questions and objectives. It must be emphasized that these designs will require a similarly rigorous planning (i.e., study protocols, ethics, sample size considerations) and analysis of the results.

[Emergency ultrasound for blunt abdominal trauma--meta-analysis update 2003]. / Sonographische Diagnostik im Schockraum bei stumpfem Bauchtrauma--Metaanalyse Update 2003.

Emergency ultrasound has established itself as a key procedure of primary diagnostic work-up for blunt abdominal and multiple trauma. However, in a systematic review published in 2001 ultrasonography turned out to provide an unexpectedly low sensitivity. We conducted an update of this analysis to investigate if test characteristics will be maintained including recent studies. Prospective trials published between January 1957 and January 2003 were identified using the Medline/Oldmedline, Embase and Cochrane Controlled Trials Register databases. The searching strategy comprised a manual search as well as a search along the world-wide web. Qualitative rating was carried out by two investigators using criteria proposed by the Centre for Evidence-Based Medicine, Oxford. We investigated a composite endpoint (i. e., free fluid and/or organ laceration) as well as the single criteria organ injury and free intraabdominal fluid collections. After calculation of two-by-two-tables, Summary Receiver Operating Characteristics (SROC) and Q* values were determined together with their 95% confidence intervals. The Q* value was proposed as the point of intersection where sensitivity equals specificity. In addition, a random effects model was employed to compute common positive and negative likelihood ratios (LR). By assessing the title and/or abstract, 349 of 957 papers contained potentially valid information for the purpose of this review. A total of 67 studies were deemed eligible, nine of which had to be excluded from meta-analysis because of dual publication. This left 58 trials allocating 16,361 subjects for statistical analysis. Despite a trend towards improved study designs observed during the past decade, the included trials were of average methodological quality. Two-thirds of all investigations fulfilled two or less of the six possible quality criteria. The diagnostic reference standard was applied independently in only 40% of all protocols. With regard to the composite endpoint and the sonographic depiction of free fluid, the Q* value was estimated at 0.91, whereas Q* equaled 0.90 for the detection of organ injury. Q* values subsequently decreased with improving study quality and fell clearly below 0.80 in methodologically proper studies. Accounting for a negative LR of 0.23 (composite endpoint) and an assumed prevalence of 35% of intraabdominal injury, a post-test probability of 11% will remain in case of a negative sonogram. In pediatric trauma, ultrasound showed even worse test characteristics (negative LR = 0.43). Thus, in case of a 35% prevalence, the post-test probability has to estimated at 19%. Emergency ultrasound provides high specificity but insufficient sensitivity to reliably rule out intraabdominal injury.

Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma.

BACKGROUND: How precise and reliable is ultrasonography as a primary tool for injury assessment in blunt abdominal trauma? METHODS: A systematic review and meta-analysis were conducted of prospective clinical trials of ultrasonography for blunt abdominal trauma. Publications were retrieved by structured searching among databases, review articles and major text books. Authors and experts in the field were contacted for original and unpublished data. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using weighted and robust regression models, with Q* denoting the shoulder of the curve. Post-test probabilities were calculated as a function of pooled likelihood ratios (LRs). RESULTS: Thirty of 123 trials enrolling 9047 patients were eligible for final analysis. With respect to targeting organ lesions, ultrasonography showed a summary Q* value of 0.91 (inverse variance weights, 95 per cent confidence interval (c.i.) 0.76-1.07); negative predictive values ranged from 0.72 to 0.99. A similar SROC slope was calculated for screening for free fluid (Q* = 0.89 (95 per cent c.i. 0.73-1.05)). Ultrasonography detects the presence of organ lesions, but fails to exclude abdominal injuries (random effects negative LR 0.23 (95 per cent c.i. 0.18-0.28)). Given a pretest probability of 50 per cent for blunt abdominal injury, a post-test probability of nearly 25 per cent remains in the case of a negative sonogram. CONCLUSION: Despite its high specificity, ultrasonography has an unexpectedly low sensitivity for the detection of both free fluid and organ lesions. In clinically suspected abdominal trauma, another assessment (e.g. helical computed tomography) must be performed regardless of the initial ultrasonographic findings.

Discriminatory power of 3.5 MHz convex and 7.5 MHz linear ultrasound probes for the imaging of traumatic splenic lesions: a feasibility study.

BACKGROUND: Ultrasound is a powerful tool for recognition of free fluid after blunt abdominal trauma, whereas its role for detection of organ lesions remains to be defined. The objective of this study was to determine the diagnostic value of different ultrasound transducers for the precise detection of visceral damage rather than its surrogates in case of splenic injury. METHODS: After a standardized focused abdominal sonogram for trauma protocol to screen for hemoperitoneum, 37 slim, hemodynamically stable subjects with suspected torso trauma were investigated for the extent of parenchymal lesions of the spleen using a 3.5 MHz curved array and a 7.5 MHz linear device. Helical computed tomographic scanning was carried out as the reference standard in all cases. RESULTS: Twenty patients presented splenic damage. The 7.5 MHz transducer showed higher accuracy than the lower frequency probe for the detection of tissue irregularities (difference in proportions, 16.2%; 95% confidence interval, -1.9%-33.5%). A similar trend was observed for 13 lacerations subsequently progressing to two-timed splenic rupture that required surgery (absolute risk reduction, 8.1%; 95% confidence interval, -7.6%-23.9%). With an observed prevalence of 54% for the presence of splenic injury, organ lacerations could be excluded more confidently using the linear probe (posttest probability, 16% vs. 36%). CONCLUSION: In slim patients, higher frequency linear ultrasound probes can provide therapy-relevant information on the integrity of splenic parenchyma after blunt abdominal trauma.

Systematic review and meta-analysis of antibiotic therapy for bone and joint infections.

We set out to evaluate the clinical efficacy of individual antibiotic agents for bone and joint infections in adults. Published and unpublished controlled trials reported between 1966 and 2000 were reviewed to determine if they involved random or quasi-random allocation to systemically administered antimicrobials or local antibiotic therapy for osteomyelitis and septic arthritis. Quiescence of infection after 1 year of follow-up was defined as the primary outcome measure. 22 trials containing 927 patients were eligible for final analysis. Varying proportions of the entire study population could be evaluated with respect to primary and secondary endpoints. Methodological quality was poor among most studies, and interpretability of results was further limited by small sample sizes, missing descriptions of patient populations and disease characteristics, and the frequent application of concomitant antibiotics. A trend towards improved, long-lasting infection control was observed in favour of a rifampicin-ciprofloxacin combination versus ciprofloxacin monotherapy for the treatment of staphylococcal infections related to orthopaedic devices (absolute risk difference [ARD] 28-9%; 95% CI -0.7 to 54.4%). Obviously unbalanced comparative studies showed some benefit of ticarcillin for bone infections caused by Pseudomonas species. No significant differences in therapeutic efficacy were found among trials comparing oral fluoroquinolones with intravenous beta-lactam drugs for both end-of-treatment (OR 0.8; 0.5 to 1.4) and long-term results (OR 1.3; 0.8 to 2.1). A variety of drugs was used as controls, thereby leading to inconsistent findings of drug-related side effects. Only one randomised trial was suitable to investigate the impact of polymethylmethacrylate gentamicin bead chains compared with parenteral antibiotics for skeletal infections, although this study was biased by patients receiving both combined local and systemic antibiotic therapy. Whereas intention-to-treat evaluation suggested a therapeutic advantage of systemic over local therapy, this trend diminished in the per-protocol analysis (1-year follow-up ARD -2.3;-17.5 to 10.8%). There exists little high-quality evidence on antibiotic therapy for osteomyelitis and septic arthritis. The observed heterogeneity among patient populations and medical and surgical treatment concepts preclude reliable inferences from the available data.

[Recovery and duration of work disability after laparoscopic and conventional appendectomy. A prospective randomized study]. / Rekonvaleszenz und Arbeitsunfähigkeitsdauer nach laparoskopischer und konventioneller Appendektomie. Eine prospektiv-randomisierte Studie.

To evaluate whether laparoscopic appendectomy shortens the convalescence and the postoperative period until return to work when compared to conventional appendectomy, a prospective randomized trial was performed. The major endpoint of the study was the time until return to work; minor endpoints were postoperative pain, fatigue, operative time and postoperative morbidity. In all, 54 patients with a mean age of 29.5 +/- 10.1 years were randomized to open (n = 28) or laparoscopic appendectomy (n = 26). Age, sex, body mass index (BMI), American Society of Anesthesiology (ASA) rating, job status as well as histologic degree of inflammation of the appendix were comparable in the two groups. Operative time was 59.2 +/- 15.8 min for laparoscopic and 59.8 +/- 24.4 min for conventional appendectomy (P = 0.9). Some 16 laparoscopic appendectomies (62%) were performed by board-certified surgeons, while 23 conventional appendectomies (82%) were performed by residents (P = 0.003). Postoperative morbidity was comparable between the two groups. After laparoscopic appendectomy, pain was rated significantly lower on the first, second and fourth postoperative day when compared to the conventional group. There were no difference in postoperative fatigue between the groups. Time to return to work was 17.0 +/- 6.2 days in the laparoscopic group and 18.2 +/- 6.0 days in the conventional group (p = 0.5). Laparoscopic appendectomy has no advantages in terms of convalescence and time to return to work when compared to open appendectomy and should therefore be limited to selected cases.

Influence of acute hemorrhage and pneumoperitoneum on hemodynamic and respiratory parameters.

BACKGROUND: We examined the questions of whether resuscitated (compensated) acute hemorrhage enhances the negative effects of carbopneumoperitoneum on hemodynamic and respiratory parameters and whether pneumoperitoneum with helium has any advantages under these circumstances. Our investigation focused on the influence of acute hemorrhage with different gases on the cardiovascular and respiratory system as well as on hepatic and renal blood flow in a porcine model. METHODS: Cardiac and hemodynamic function were monitored via implantation of catheters in pulmonary artery, femoral vein, and artery. Renal and hepatic blood flow were recorded using a transonic volume flow meter placed at the renal and hepatic artery and portal vein. Twelve animals were randomly assigned to one insufflation gas (carbon dioxide [CO2] or helium [He]). Following baseline recordings, acute hemorrhage (20 ml/kg) was induced by continuous bleeding over 30 min. Animals then received a colloidal solution (20 ml/kg 6% hydroxyethylstarch solution) over 30 min. Pneumoperitoneum of 12 mmHg was established, and all parameters were measured after 30 min of adaptation. The major endpoints of the study were cardiac output (CO), arterial pressure (MAP), systemic vascular resistance (SVR), and central venous pressure (CVP), as well as blood flow in hepatic and renal artery and portal vein. RESULTS: While CO and hemodynamic parameter as well as hepatic and renal blood flow were markedly reduced after hemorrhage, they returned nearly to their previous levels after resuscitation. Pneumoperitoneum with 12 mmHg did not further depress the cardiovascular system or reduce hepatic and renal blood flow. Pneumoperitoneum did not alter hepatic or renal blood flow. Pneumoperitoneum with helium did not substantially change the reaction of the cardiovascular system after resuscitated hemorrhage. CONCLUSIONS: If hemorrhage is compensated by proper resuscitation and hypovolemia is avoided, laparoscopic surgery with pneumoperitoneum of 12 mmHg appears to be not harmful. Using helium as the insufflating gas had no clear advantage over the carbon dioxide model.

[Effect of pneumoperitoneum with carbon dioxide and helium on hemodynamic parameters after compensated acute hemorrhage]. / Einfluss eines Pneumoperitoneums mit Kohlendioxid und Helium auf hämodynamische Parameter nach kompensierter akuter Blutung.

If animals have been properly resuscitated after moderate bleeding and hypovolemia has been corrected with colloidal solution, pneumoperitoneum with 12 mmHg does not appear to be harmful in a porcine model. Helium showed no clear advantage as insufflating gas over carbon dioxide.

Open window thoracostomy in the treatment of esophageal or bronchopleural fistula with advanced mediastinitis and septic shock.

Mediastinitis and septic shock following esophageal or bronchopleural fistula are rare but serious conditions with a high mortality rate. Six patients were treated with open window thoracostomy (OWT) after primary suture repair and closed tube drainage had failed to cure the patient's condition. In all cases the clinical condition improved immediately. Two patients died later because of unrelated diseases. OWT should be considered in critically ill patients with broncho- or esophagopleural fistula when primary therapy fails to control the septic focus.

[Diagnosis and therapy of postoperative chyloperitoneum]. / Diagnose und Therapie des postoperativen Chyloperitoneums.

Chyloperitoneum is a rare complication of surgical procedures. We report a case of severe chyloperitoneum after abdominothoracic esophageal resection with two-field lymphadenectomy. After diagnosis was established, the lymph leak was located with oral iodine-marked fatty acids (123I-pentadecanoic acid) showing increased activation in the right middle abdomen. Because conservative treatment with total parenteral nutrition showed no decrease in chyle volume, relaparatomy was performed and the lymphatic fistula was successfully treated with suture ligatures. Pathophysiology and different options for localization and treatment of postoperative chyloperitoneum are discussed.