[Results of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures]. / Ergebnisse der Ballonkyphoplastie in der Behandlung von osteoporotischen Wirbelkörperfrakturen.

The aim of this study was to evaluate the reduction of pain, improvement of sagittal alignment, complications and intermediate term results of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (VCF). The study group consisted of 87 patients with 145 VCFs which were not responsive to non-operative treatment. All data were collected prospectively. Improvement of sagittal alignment (Cobb and kyphotic angles, anterior, middle and posterior height) was determined from CT scans. Pain was evaluated by means of a visual analogue scale (VAS). Postoperative CT scans revealed a significant reduction of the mean kyphotic angle of 5.7 degrees (range 2-24 degrees ) and a significant reduction of pain from 7.8+/-2.4 to 2.0+/-1.5 in the VAS (improvement of pain in 95.5% of patients). An asymptomatic leakage of cement was observed in 28 out of 145 vertebrae (19.3%). The outcome of 35 patients with 51 VCFs was evaluated after a mean of 13 (range 12-70) months (CT and VAS) and there was a persisting reduction of pain and no loss of reduction. In this group of patients new symptomatic fractures were evident in 4 and clinically asymptomatic (only seen on CT) fractures were detected in 5 out of 35 patients, 7 fractures were adjacent to and 2 fractures were remote from the initially treated level. In two patients an asymptomatic moderate loss of reduction was detected. These intermediate term results indicate that kyphoplasty reduces pain and improves sagittal alignment in patients with VCF. However, in 26% of patients new fractures occurred, predominantly in adjacent levels but approximately 50% of these fractures were clinically asymptomatic.

Metastases and multiple myeloma generate distinct transcriptional footprints in osteocytes in vivo.

Osteocytes are the most abundant bone cells, playing important roles in tissue maintenance. Little is known of how they react in vivo to cancer stress. Here we present a comparative study of the effect of a bone-residing tumour (myeloma) and metastases of bone-remote cancers on osteocytes. While no differences in morphology of the bone are seen, the changes in the transcriptome of osteocytes are specifically related to the tumour stress present. Screening approximately 22 000 genes in osteocytes prepared from cryosections of native bone using laser-supported microdissection, we observed approximately 1400 and approximately 1800 gene expression differences between osteocytes dissected from normal bone compared with those associated with metastases and multiple myeloma, respectively. The genes up-regulated due to the stress exerted by metastases were repressed by multiple myeloma and vice versa, indicating stress-specific footprints in the transcriptome of osteocytes. Functionally, the stressors seem to impose selective pressures on signalling pathways such as that of TGFbeta, a major player in bone biology. Our data show for the first time that the transcriptome of osteocytes in vivo becomes strongly affected by cancer stress, generating gene expression footprints which, in contrast to comparable morphological changes, appear to relate to the nature of cancer and might thus become helpful in distinguishing different bone diseases.

[MDCT after balloon kyphoplasty: analysis of vertebral body architecture one year after treatment of osteoporotic fractures]. / MDCT nach Ballonkyphoplastie: Analyse der Wirbelkörperarchitektur 1 Jahr nach Behandlung osteoporotischer Sinterungsfrakturen.

PURPOSE: To evaluate the value of MDCT in the monitoring of vertebral body architecture after balloon kyphoplasty and observe morphological changes of the vertebral body. MATERIAL AND METHODS: During a period of 26 months, 66 osteoporotic fractures of the vertebral bodies were treated with percutanous balloon kyphoplasty. The height of the vertebral body, width of spinal space, sagittal indices, kyphosis und COBB angle, and cement leakage were evaluated by computed tomography before and after treatment and in a long-term follow up. Statistical analysis was performed by calculating quantitative constant parameters of descriptive key data. In addition, parametric and distribution-free procedures were performed for all questions. RESULTS: After kyphoplasty, the treated vertebral bodies showed a significant gain in the height of the leading edge (0.15 cm; p < 0.0001) and in the central part of the vertebral body (0.17 cm; p < 0.0001). The height of the trailing edge did not change significantly. A corresponding gain in the sagittal index was found. The index remained stable during follow-up. Treated vertebral bodies as well as untreated references showed a comparable loss of height over the period of one year. The shape of the vertebral bodies remained stable. In comparison to these findings, treated vertebral bodies showed a reduced loss of height. A significant change in kyphosis und the COBB angle was noted. In total, pallacos leakage was detected in 71 % of cases. CONCLUSION: MDCT is an accurate method for evaluating vertebral body architecture after treatment with balloon kyphoplasty. Morphological changes in the vertebral bodies, and complications such as pallacos leakage and progression of osteoprosis can be accurately documented. The significant increase in the vertebral body height after treatment is closely correlated with a gain in the sagittal index and reduced kyphosis and COBB angle.

[Traumatic aortic injuries in severely injured patients]. / Traumatische Aortenverletzungen bei polytraumatisierten Patienten.

Herein we report our results of treatment of traumatic aortic ruptures in severely injured patients with either open surgery or endovascular stent graft repair. Data were analyzed retrospectively from the trauma registry of the DGU (Deutsche Gesellschaft fur Unfallchirurgie) over a time period from 1993 through 2002. All patients with traumatic rupture of the aorta were included and analyzed for injury severity (ISS), blood pressure (mmHg), hemoglobin (mg/%), and AIS (Abbreviated Injury Score) of the thoracic, abdominal, and upper extremity regions. Patients treated between 1998 and 2002 were further examined (operation within 24 h, duration of intervention, blood transfusion, and lethality with regard to either open surgical or endoluminal stent graft repair). Of 14,110 patients, 100 (0.7%) suffered from acute aortic rupture. Mean age was 38 years (+/-19) with an inhospital lethality of 39% (n=39). Mean ISS was 41 (+/-14); 36 patients were treated by open surgery and 5 patients by a stent-assisted endoluminal procedure. Lethality was 17% for open surgery and 0% for stent graft repair. Endovascular approach to traumatic rupture of the aorta is feasible and safe. It has been shown to reduce inhospital lethality and may offer an alternative to open surgery for severely injured patients.

[Diagnosis and immediate therapeutic management of chest trauma. A systematic review of the literature]. / Diagnostik und sofortige Therapiemassnahmen bei Verletzungen des Thorax. Eine systematische Literaturübersicht.

OBJECTIVE: Injuries to the chest contribute significantly to the morbidity and mortality in multiple injured patients. This systematic review focuses on evidence based initial diagnostics and emergency room management of chest trauma. METHODS: Clinical trials was systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: There are only a few studies that document the impact of injury mechanism and clinical examination of the patient. There is a positive correlation between crash severity or lateral impact with injury severity. Auscultation was found to be very sensitive in the detection of pneumothorax. Helical CT of the chest is most important in the initial work-up. Aortography is only indicated in selected cases. Whether tube thoracostomy is necessary in patients with occult pneumotharaces is still a matter of discussion. Indications for endotracheal intubation are poorly investigated and predominantly based on expert opinion. CONCLUSION: Numerous comparative studies (LE 2) dealing with emergency diagnostics and therapy of chest trauma are available, however only a few randomized studies do exist. Based on the available data a rational therapy of chest trauma is possible.

Solitary bone metastasis from myxoid liposarcoma.

BACKGROUND: Extrapulmonary metastasis is more common in liposarcoma than in other soft tissue sarcomas. However, osseous metastases are rare. CASE REPORT: We report the case of a 61-year-old woman with a solitary histologically proven bone metastasis of the right femur from primary myxoid liposarcoma of the left thigh. In September 2000 resection of the primary tumor was performed. Histology showed a high-grade liposarcoma with round cell differentiation. Postoperative radiotherapy with 60 Gy was performed. In a follow-up MRI examination 11 months after initial diagnosis, a suspicious formation in the marrow space of the right proximal femur was detected. CT-guided biopsy was performed and histology showed a metastasis from liposarcoma. PET examination confirmed the metastasis as solitary. Curettage of the metastasis was performed followed by radiotherapy with 60 Gy. The patient was without evidence of disease in the last follow-up. CONCLUSIONS: No standard treatment exists for the management of solitary extrapulmonary metastases from soft tissue sarcoma. Interdisciplinary cooperation is advised and the therapy concept should be chosen individually.

Immunosuppression with FK506 increases bone induction in demineralized isogeneic and xenogeneic bone matrix in the rat.

The aim of the present study was to investigate a systemic induction of bone formation in rats by immunosuppression with FK506 (1 mg/kg body weight intraperitoneally [ip]) in a model of osteoinduction of isogeneic and xenogeneic demineralized bone matrix (DBM) for a period of 28 days. In particular, alterations of in vitro cytokine synthesis and changes of lymphocyte subsets were studied. DBM was implanted intramuscularly in the abdominal wall of Lewis rats (seven per group). Blood was sampled on days -7, 0, 7, and 28 for determination of in vitro tumor necrosis factor a (TNF-alpha) synthesis and lymphocyte subsets by flow cytometry (CD3+, CD4+, CD8+, CD45+, ED9+, and Ia+ antibodies). Ossicles of de novo formed bone and the tibias were removed on day 28 after double tetracycline labeling for histomorphometric analysis. Immunosuppression with FK506 significantly decreased lipopolysaccharide (LPS)-stimulated in vitro cytokine synthesis after 7 days and 28 days (p < 0.05). Compared with control animals FK506 treatment significantly increased the volume of induced bone in isogeneic (2.1 +/- 0.3 mm3 vs. 10.8 +/- 0.9 mm3) and xenogeneic (O mm3 vs. 4.7 +/- 0.8 mm3) DBM. Bone histomorphometry of the tibias revealed that immunosuppression increased both bone formation and bone resorption, accompanied by a significant reduction in the relative trabecular area (Tb.Ar). FK506 caused a decrease in the counts of CD8+ T cells probably because of destruction or dislocation of these cells. This suggests that the amount of CD8+ cells and the degree of T cell activation in terms of mean fluorescence intensity (MFI) may be associated with bone metabolism. In support of this, statistical analysis revealed a significant positive correlation between parameters of bone formation as well as bone resorption and the CD4+/CD8+ ratio. There was a significant negative correlation between parameters of remodeling of the metaphysis of the tibia and induced bone volume (BV), respectively, and MFI values of CD3+/Ia+ cells. These findings suggest an important role of T lymphocytes in bone formation and bone resorption in vivo. FK506 caused a marked increase of bone formation in DBM. However, the conclusion that immunosuppression increases fracture healing warrants further investigation.

Efficiency of chest computed tomography in critically ill patients with multiple traumas.

OBJECTIVE: The efficiency of secondary thoracic computed tomography (TCT) in critically ill patients with multiple traumas was assessed by comparison of TCT with chest radiograph findings. The subsequent therapeutic consequences based on the additional information of TCT were evaluated. SETTING: A six-bed trauma intensive care unit in a university hospital. DESIGN: Prospective, descriptive study. PATIENTS AND INTERVENTIONS: One hundred one computed tomographic (CT) examinations (mean, 2.6 per patient; range, 1-10) were performed in 39 patients, fulfilling the following indications for TCT: a) sepsis with suspected pulmonary focus (n = 41); b) deterioration of pulmonary gas exchange (n = 35); c) guiding the duration of intermittent prone positioning (n = 25). The information provided by TCT was compared with corresponding chest radiographs (CXR). Therapeutic consequences drawn after TCT were compared with the additional diagnostic information of TCT. The change of therapy was documented that would not have been undertaken or may have been delayed had TCT evaluation not been used. RESULTS: TCT was significantly superior to CXR in detecting pneumothoraces, pleural effusions, and pulmonary abscesses. Furthermore, a significantly higher accuracy regarding pulmonary densities was found. Subsequent therapeutic interventions ensued from 85 (84.2%) CT scans. After TCT, intermittent prone positioning was initiated in 31 patients, chest tubes were inserted in 16 patients, and intermittent prone positioning was terminated in 13 patients and was continued in 12 patients. Eleven thoracotomies were performed because of the TCT findings. The described therapeutic interventions were based on abnormalities seen on CT scans but were not evident in CXR in 58 patients (57.4%). Significant information that influenced therapeutic concepts was obtained in 66% (n = 23) of patients with pulmonary deterioration of gas exchange, in 61% (n = 25) of patients with sepsis, and in 40% (n = 10) of patients to guide the duration of intermittent prone positioning. Thoracotomy and specific drainage by tube thoracostomy was always dependent on the findings of TCT. CONCLUSION: Performed under the above displayed defined indications, TCT had an overall efficiency of 57%. It provided an increased sensitivity for intrathoracic lesions and a more comprehensive diagnosis of chest abnormalities.

[Osteoid osteoma--a diagnostic and therapeutic problem?]. / Das Osteoidosteom--ein diagnostisches und therapeutisches Problem?

INTRODUCTION: The aim of the following article is to summarize our experience in the treatment of osteiod osteomas, with special emphasis on diagnostic and therapeutic pitfalls. PATIENTS AND METHODS: A consecutive series of 14 patients with osteoid osteomas was treated surgically between 1985 and 1996. All tumors but one were located in the lower limb. The main symptom was pain, being worse at night and being responsive to oral salicylates (10/14 patients). As reported in other studies, the duration of symptoms was unacceptably long (mean 24 months). The classical pathognomonic symptoms were misinterpreted in many cases, leading to frustrating conservative and even operative therapies. RESULTS: Open biopsy prior to surgical excision is not indicated because of the typical clinical and roentgenographic imaging of these lesions. Surgical excision of the nidus is the treatment of choice and gives immediate pain relief. If the characteristic morphology is not evident in plain roentgenograms, conventional tomograms, radionuclide scans and computerized tomography are reliable tools. All patients were free of disease at a mean of 6.6 years after operation. CONCLUSION: In symptomatic patients with osteoid osteomas the excision of the nidus is the established diagnostic/therapeutic modality. Minimally invasive procedures seem to be alternatives to classical surgery.

Intermittent prone positioning in the treatment of severe and moderate posttraumatic lung injury.

OBJECTIVE: Severe posttraumatic lung injury is characterized by impairment of gas exchange and pulmonary densities. The influence of intermittent prone positioning on pulmonary gas exchange and parenchymal densities was investigated prospectively in patients with pulmonary injury after multiple trauma with blunt chest trauma. SETTING: A six-bed trauma intensive care unit in a university hospital. DESIGN: Prospective, descriptive study. PATIENTS: Twenty-two consecutive patients with pulmonary injury after multiple trauma with blunt chest trauma and acute lung injury (n = 11) or severe acute respiratory distress syndrome (ARDS) (n = 11) according to the definitions of the consensus conference on ARDS. INTERVENTIONS: Pulmonary densities were calculated planimetrically from computed tomographic scans of the chest before the first and after the last cycle of prone positioning. Indications for prone positioning were a) mechanical ventilation with FIO2 >0.5 at positive end-expiratory pressure >10 cm H2O for >24 hrs; or b) pulmonary densities in two or more quadrants being constant or increasing within 48 hrs. Arterial blood gas analysis was performed every 2 hrs. Intrapulmonary right-to-left shunt (Qs/Qt) and alveolar-arterial PO2 difference were calculated 2 hrs after the beginning and end of every prone and supine cycle, respectively. Patients were ventilated in the prone position for 8 hrs each day. MEASUREMENTS AND MAIN RESULTS: Every single posture change from the supine to the prone position resulted in a significant average increase in the oxygenation index of 28+/-8 torr (3.7+/-1.1 kPa) (p<.0001). There was a significant improvement in oxygenation (4.3+/-0.8 torr [0.57+/-0.11 kPa]) with time between two consecutive measurements in the prone as well as the supine position (p<.0001). Alveolar-arterial PO2 difference and Qs/Qt showed a significant decrease of 25+/-7 torr (3.3+/-0.9 kPa) and 1.1+/-0.46%, respectively, for every cycle of prone positioning. Statistical analysis revealed no significant alteration of gas exchange within every prone and supine cycle. Total static lung compliance improved significantly over time (p<.001). However, ventilation of patients in the prone position demonstrated a mean decrease in compliance of 2.1+/-0.72 mL/cm H2O. The response to prone positioning was similar in patients with ARDS and acute lung injury and revealed no significant difference. In both groups, the course of the oxygenation index and Qs/Qt over time was almost parallel. Posture changes were continued for 9.0+/-1.1 days. The oxygenation index showed an overall increase of 129+/-20 torr (17.2+/-2.7 kPa) from baseline supine at the end of prone positioning (p<.0001). Pulmonary densities were reduced significantly from 31.1+/-2.5% to 3.8+/-0.81%, Qs/Qt was reduced from 24.9+/-1.5% to 11.7+/-0.32%, and FIO2 was reduced from 0.43+/-0.04 to 0.26+/-0.02 (p<.01). Gas exchange improved in all patients, and no patient died immediately as a result of respiratory failure. CONCLUSION: Repeated prone positioning recruits collapsed lung tissue and improves gas exchange in trauma patients with blunt chest trauma and severe ARDS as well as in trauma patients with acute lung injury.

Local effect of lung contusion on lung surfactant composition in multiple trauma patients.

OBJECTIVE: The aim of this study was to investigate the direct influence of lung contusion on pulmonary surfactant in multiple trauma patients. DESIGN: Prospective, nonrandomized study. SETTING: University hospital, trauma intensive care unit. PATIENTS: Eighteen multiple trauma patients with unilateral lung contusions and Injury Severity Scores >19 were studied prospectively. INTERVENTIONS: Bronchoalveolar lavage was performed daily until either day 7 or extubation. Samples from the side of lung contusion (n = 62) and the contralateral, uninjured side (n = 62) were obtained at the same time in 14 patients. Total phospholipids, total phospholipid classes, and surfactant apoprotein A were quantified. Additionally, surfactant function was measured with a pulsating bubble surfactometer in four patients. All data are presented as mean +/- SEM. Statistical analyses were performed using programs of SPSS for Windows 6.1.3 (SPSS Inc., Chicago, IL) (Student's t-test; p < .05). MEASUREMENTS AND MAIN RESULTS: Total phospholipids were significantly increased on the side of lung contusion (contusion side, 40+/-7 microg/mL; contralateral side, 21+/-3 microg/mL; p = .004). The percentage contents of phosphatidylcholine (contusion side, 87.1%+/-1.0%; contralateral side, 84.3%+/-1.0%; p = .04) and sphingomyelin (contusion side, 2.9%+/-0.3%; contralateral side, 1.9%+/-0.2%; p = .004) were significantly higher. In contrast, the percentage content of phosphatidylglycerol was significantly decreased (contusion side, 4.1%+/-0.1%; contralateral side, 6.9%+/-0.6%; p = .001). No alterations were found for the relative contents of phosphatidylethanolamine (contusion side, 2.4%+/-0.2%; contralateral side, 2.2%+/-0.2%; p = .47), phosphatidylinositol (contusion side, 3.5%+/-0.4%; contralateral side, 4.6%+/-0.5%; p = .06), and surfactant apoprotein A (contusion side, 7177+/-1404 ng/mL; contralateral side, 4513+/-787 ng/mL, p = .10). There was no statistical difference for minimal surface tension measured with the pulsating bubble surfactometer after 5 mins of oscillation (contusion side, 29.5+/-2.3 mN/m; contralateral side, 23.7+/-2.1 mN/m; p = .08). CONCLUSIONS: Direct damage of lung parenchyma by lung contusion alters the composition of surfactant. No additional changes in surfactant function were observed that would argue in favor of functional compensation.

[Injuries due to falls from a great height. A comparative analysis of injuries and their outcome following suicide-related and accidental falls]. / Verletzungen nach Fall aus grosser Höhe. Eine vergleichende Analyse von Verletzungsmuster und Verlauf nach suizidalem und akzidentellem Absturztrauma.

The aim of this study was to compare the outcome and clinical course of multiple trauma patients with accidental or intentional (suicide related) fall from heights > 4 m. 211 patients with an injury severity score (ISS) > 17 were assigned to the following groups: I: intentional fall, n = 94; A: accidental fall, n = 117) and ISS (I: 28 +/- 1; A: 30 +/- 1), ventilation time (I: 16 +/- 2; A: 15 +/- 1) were not different. Significant differences were found in sex (m/f: I: 56/44; A: 73/27%), fractures of lumbarspine (I: 34; A: 15%), pelvis (I: 51; A: 38%), lower leg (I: 47; A: 20%), pilon (I: 15; A: 5%), and os calcis (I: 17; A: 9%). Liver lacerations occurred more often after intentional fall (I: 16; A: 6%). Single or multiple organ failure (MOF) was diagnosed significantly more often in group A(I: 1; A: 8%). Main cause of death in both groups was single or multiple organ failure (MOF: I: 47; A: 69%) or related to brain-injuries (I: 35; A: 19%). Prognosis and rehabilitation of multiple trauma patients after intentional fall is related to brain-injuries, spine-fractures and the functional outcome of the injured lower leg. Prognosis of patients after accidental fall is related to the development of MOF during the ICU-course.

Tikhoff-Linberg procedure for bone and soft tissue tumors of the shoulder girdle.

OBJECTIVE: To evaluate complications and the oncological and intermediate-term functional results in patients with bone and soft tissue tumors of the shoulder girdle who were managed with interscapulothoracic resection (Tikhoff-Linberg procedure). DESIGN: Case series of 19 consecutive patients during a 10-year period at a mean follow-up of 6.3 years (range, 1-11 years). SETTING: University hospital; referral center for musculoskeletal tumor surgery. PATIENTS: The initial diagnosis in this consecutive series of patients with shoulder girdle tumors requiring the Tikhoff-Linberg procedure was chondrosarcoma in 7 patients, Ewing sarcoma in 3 patients, malignant fibrous histiocytoma in 3 patients, solitary metastasis of thyroid carcinoma in 2 patients, osteosarcoma, synovial sarcoma, angiosarcoma, ancd neurofibrosarcoma in 1 patient each. According to the Musculoskeletal Tumor Society staging system, there were 6 in surgical stage IB, 10 in stage IIB, and 3 in stage III. Nine tumors involved the proximal humerus, 8 were located in the scapula or surrounding soft tissues, 1 in the lateral clavicle, and 1 in the acromioclavicular joint. INTERVENTIONS: For reconstruction of the proximal humerus after en bloc tumor resection an isoelastic cemented shoulder tumor prosthesis was inserted in every patient to restore arm length. MAIN OUTCOME MEASURES: Complications, and oncological and intermediate-term functional results. RESULTS: Twelve patients were alive with no evidence of disease. One of these patients died of nontumorous disease 2 years after surgery. One patient is alive with pulmonary metastases after 12 months. Six patients died of metastases at a mean (SD) interval of 18 months (range, 3-35 months) postoperatively. Two of these patients had additional local recurrence. A deep infection necessitated the explantation of the prosthesis in 1 patient. The mean functional score and SD according to the rating system of the Musculoskeletal Tumor Society was 72%+/-14% (range, 33%-87%) for the 12 surviving patients evaluated. Major complications (1 infection and 2 local recurrences) that may be attributed to the procedure occurred in 3 of the 19 patients. CONCLUSION: Despite an overall complication rate of 74% the Tikhoff-Linberg procedure proved to be a valuable surgical procedure for extended tumors of the shoulder girdle for functional and oncological outcome and is superior to forequarter amputation.

[How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?]. / Wieviel schwermehrfachverletzte Patienten können den biomechanischen Vorteil der Frühbelastbarkeit nach Femurmarknagelung nutzen?

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.

Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion.

BACKGROUND: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion. METHODS: The hospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications. RESULTS: There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5+/-7.0 versus 26.7+/-29.0 days) and group 2 (p < 0.02). In group 2 (ventilator time 30.8+/-33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure. CONCLUSIONS: In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

[Effect of primary femoral plate osteosynthesis on the course of polytrauma patients with or without thoracic trauma]. / Einfluss der primären Oberschenkelplattenosteosyntheses auf den Verlauf polytraumatisierter Patienten mit oder ohne Thoraxtrauma.

Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate osteosynthesis of femur fractures on major complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no lethal brain injury, age 16-65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, "N") or with relevant thoracic injury (AIS T > = 3, "T"). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E < 3, "O") or primary plate-osteosynthesis of femur fractures (< 24 h, "I"). 4 groups were performed: NO (n = 39, ISS 25 +/- 1, pneumonia 10%, ARDS 5%, lethality 10%); NI (n = 55, ISS 27 +/- 1, pneumonia 4%, ARDS 5%, lethality 4%); TO(n = 137, ISS 28 +/- 1, pneumonia 21%, ARDS 15%, lethality 16%); TI (n = 94, ISS 31 +/- 1, pneumonia 21%, ARDS 17%, lethality 15%). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.

[Tikhoff-Linberg interscapulothoracic resection in extra-compartmental tumors of the shoulder girdle]. / Die interskapulothorakale Resektion nach Tikhoff-Linberg bei kompartmentüberschreitenden Tumoren des Schultergürtels.

Ninetten consecutive patients with bone and soft tissue tumors of the shoulder girdle were treated with interscapulothoracic resection (Tikhoff-Linberg procedure) over a 10-year period. Twelve patients were alive with no evidence of disease at a mean follow-up of 6.3 (1-11) years and one patient is alive with local recurrence and pulmonary metastases after 15 months. Six patients died due to pulmonary metastases. Despite these complications, the Tikhoff-Linberg procedure proved to be a valuable operation for extended tumors of the shoulder girdle in terms of functional and oncological outcome and is clearly superior to forequarter amputation.

Estimation of condensed pulmonary parenchyma from gas exchange parameters in patients with multiple trauma and blunt chest trauma.

Pulmonary gas exchange in correlation with condensed lung volume was prospectively studied in 10 patients with multiple injuries and blunt chest trauma. The purpose was to find nomograms that allow the estimation of the extent of pulmonary density from gas exchange parameters. The condensed lung volume was determined planimetrically from serial transverse sections of chest computed tomographic scans. There was no correlation between condensed lung volume and mean pulmonary artery pressure, pulmonary vascular resistance, systemic vascular resistance, or cardiac index and a week negative correlation to the oxygenation index (PaO2/FIO2) (r2 = 0.46) and to the total static lung compliance (r2 = 0.29). A strong correlation between pulmonary density and intrapulmonary shunt fraction (Qs/Qt) (r2 = 0.95) as well as alveoloarterial PO2 difference (P[A-a]O2) (r2 = 0.86) was evident. By using linear regression equations (linear regression line with 95% confidence interval), nomograms were calculated. The extent of pulmonary density can easily be obtained from these nomograms by measuring Qs/Qt or P(A-a)O2. The presented nomograms may be helpful in monitoring the effect of treatment in patients with blunt chest trauma.

[Follow-up and prognosis of severe accidental trauma in the aged]. / Verlauf und Prognose schwerer Unfallverletzungen im Alter.

Multiple injuries in elderly patients are still a common problem. The present study was performed to investigate mortality and complications in multiple trauma patients aged 65 years or more. A total of 1154 multiple trauma patients with an injury severity score (ISS) of at least 18 points were divided in two age groups: Y: 16-64 years, n = 1022; O: 65-94 years, n = 132. Older patients were injured as pedestrians in most cases (69%), while younger patients were more frequently injured as car and drivers passengers (41%). ISS was comparable in both groups (Y 28 +/- 1, O 27 +/- 1). During ICU-therapy incidence of ARDS (Y 10%, O 11%), multiple organ dysfunction syndrome (MOF; Y 6%, O 9%) and pneumonia (Y 17%, O 21%) were comparable. In contrast, septic complications were more frequent in older patients (Y 19%, O 27%). Length of ICU stay (Y 19 +/- 2, O 18 +/- 1) and ventilation time (Y 14 +/- 2, O 17 +/- 1) were comparable. Mortality was significantly higher in older patients (Y 15%, O 53%). The major cause of death was sepsis in older patients (Y 15%, O 31%) and MOF in younger patients (Y 54%, O 29%). In conclusion, older trauma patients had a higher mortality due to the development of septical complications.