Intramedullary Nailing of Metaphyseal Fractures of the Lower Extremity.

Intramedullary nailing is a worldwide accepted technique for stabilization of fractures of long bones. Technique, instruments and implants primarily have been developed for the fixation of short (transverse and oblique) diaphyseal fractures. First generation nails were hollow and slotted, which gave them some elasticity. When the tip of the nail passed the fracture gap, picked up the opposite fracture fragment and was driven further down, the longitudinal axis of the bone was restored and the extremity realigned. Bone length was restored by closure of the fracture gap. The tight connection between the deformable hollow nail and the inner cortex at the isthmus realized a press-fit, which achieved a very stable bone-implant construct. The nail had the function of a weight-shearing implant. Interlocked nails represent the second-generation nails. They changed the spectrum of indications for nailing considerably. Not only short middle-third shaft fractures, but shaft fractures of all types (from transverse to comminuted) and all localizations can be stabilized with an interlocked nail. Due to interlocking, length and rotation are controlled. The nail bridges the area of instability, being a weight-bearing implant. Small diameter, solid nails formed the next generation of nail implants. They were conceived for the provisional treatment of fractures with an enhanced risk of postoperative infection such as open fractures or closed fractures with severe soft tissue damage. They were increasingly used for minimal invasive treatment of closed fractures without soft tissue damage as well, as reaming was not necessary and endosteal blood supply less damaged. Nevertheless, it became clear that they were connected with a higher incidence of implant failure and revision surgery. Another development was the creation of nails with multiple and angular stable interlocking options. Major advantage is that high stability is obtained in the fracture fragment, in which multiple interlocking is used. This property gives the possibility of nailing fractures close to a joint with a short fracture segment (24). Nevertheless, intramedullary nailing of metaphyseal fractures remains controversial. Major complications to be avoided are malalignment, delayed union, nonunion and implant failure due to suboptimal fracture reduction (23).

The influence of bone allograft processing on osteoblast attachment and function.

In order to assess the influence of eight different sterilisation and disinfection methods for bone allografts on adhesion, proliferation, and differentiation of human bone marrow stromal cells (BMSC), cells were grown in culture and then plated onto pieces of human bone allografts. Following processing methods were tested: autoclavation (AUT), low-temperature-plasma sterilisation of demineralised allografts (D-LTP), ethylene oxide sterilisation (EtO), fresh frozen bone (FFB), 80 degrees C-thermodisinfection (80 degrees C), gamma-irradiation (Gamma), chemical solvent disinfection (CSD), and Barrycidal-disinfection (BAR). The seeding efficiency was determined after one hour to detect the number of attached cells before mitosis started. The cell viability was determined after 3, 7, and 21 days. Tests to confirm the osteoblastic differentiation included histochemical alkaline phosphatase staining and RT-PCR for osteocalcin. Human BMSC showed greatest attachment affinities for D-LTP-, 80 degrees C-, and CSD-allografts, whereas less cells were found attached to AUT-, EtO-, FFB-, Gamma-, and BAR-probes. Cell viability assays at day 3 revealed highest proliferation rates within the FFB- and 80 degrees C-groups, whereas after 21 days most viable cells were found in D-LTP-, 80 degrees C-, CSD-, and Gamma-groups. BAR-treatment showed a considerably toxic effect and therefore was excluded from all further experiments. Highest AP-activity and gene expression of osteocalcin were detected in the D-LTP-group in comparison with all other groups. In summary, our results demonstrate that cell adhesion, final population, and function of BMSC are influenced by different disinfection and sterilisation methods. Therefore, processing-related alterations of BMSC-function may be important for the success of bone grafting. The experimental setup used in the present work may be useful for further optimisation of bone allograft processing.

The relationship between DNA content, clinicopathology and prognosis in enteropancreatic carcinoids.

BACKGROUND/AIMS: The clinical behavior of carcinoid tumors is sometimes difficult to determine from their histological appearance. The aim of the present study was to evaluate whether the DNA distribution pattern seen in carcinoid tumors can be correlated with histopathological parameters and the patient's clinical course and prognosis. METHODOLOGY: The paraffin-embedded material of 44 enteropancreatic tumors underwent deparaffinization, was rehydrated, and mechanically and enzymatically processed into a single cell solution. For evaluation of the DNA histogram, analysis was performed with the help of an automatic single cell cytophotometric study. RESULTS: A correlation was seen between the DNA content and tumor stage (p = 0.01), radicalness of surgery (p = 0.03), tumor localization (p = 0.02) and patient's age (p = 0.05). In univariate analysis, patient's age (p = 0.04), tumor localization (p = 0.03), tumor stage (p = 0.0001), radicalness of surgery (p = 0.0006) and DNA content (p = 0.01) influenced prognosis. In multivariate analysis including these parameters, only tumor stage had an independent influence on prognosis. CONCLUSION: The clinical relevance of DNA measurement in carcinoid tumors is still unknown.

Changes in the extracellular matrix of the vein wall--the cause of primary varicosis?

BACKGROUND: Conflicting theories on the development of primary varicosis have led to the molecular biological investigation of the vein wall or, more accurately, of the extracellular matrix. It was the aim of this study to quantify matrix expression and to compare pathological changes in the vein wall with valve-orientated staging of varicosis, in order to determine indicators of the primary cause of varicosis. MATERIALS AND METHODS: Three hundred seventy-two tissue specimens of greater saphenous veins were obtained from 17 patients with varicosities and categorised according to Hach stage and procurement site. The specimens were compared with 36 specimens collected from six patients without varicosities, incubated with fluorescence-stained antibodies for collagen 4, laminin, fibronectin and tenascin prior to being assessed with confocal laser scan microscopy. In addition, 22 vein specimens (16 varicose, 6 normal veins) serving as negative controls were investigated. RESULTS: Image analysis and statistical evaluation showed that compared with normal veins, varicose veins are associated with a significant increase in matrix protein expression for collagen 4, laminin and tenascin. A trend towards an increase in matrix expression was further observed for fibronectin. There was, however, no difference between varicose veins and clinically healthy vein segments inferior to a varicose segment. CONCLUSION: If the findings of the present investigation can be confirmed by other studies, alterations in the vein wall may be regarded as the primary cause of varicosis and valvular insufficiency as the result of these changes.

[Effect of the surgeon on treatment quality in acute appendicitis]. / Der Einfluss des Operateurs auf die Behandlungsqualität bei akuter Appendicitis.

The quality of the surgical therapy in cases of acute appendicitis is influenced by the rate of perforating appendicitis, the rate of bland appendicitis and the perioperative morbidity. During a prospective follow-up 271 patients were treated at our department between 1 April 1993 and 30 July 1996. The rate of perforating appendicitis was 3.7%, and that of bland appendicitis was 19.6%. The rate of perforating appendicitis did not differ significantly according surgeon, who decided to operate. However, the number of patients with bland appendicitis did differ significantly among different operators. There were also significant differences in the rate of wound infections. No correlation was found between the rates of perforating and bland appendicitis was not found. In summary the operator affects the quality of the surgical treatment in cases of suspected appendicitis by differences in the timing and performance of the surgical procedure.

[Systematic clinical quality assurance in surgery]. / Systematische klinikinterne Qualitätssicherung in der Chirurgie.

Between April 1993 and December 1995 the perioperative courses of 3183 patients were recorded within the frame work of a quality assurance project at the Department of Surgery, University of Mainz. The age of the operated patients and the rate of morbidity increased significantly during the observation period. Morbidity and mortality were not correlated to increasing need for intensive care. Morbidity was dependent on the surgical approach and also on the surgeon. On the other hand, high numbers of operations did not necessarily correlate with low complications rates. The concept described makes it possible to compare quality assurance among different hospitals, helps surgeons to recognize and improve their weak points, and serves as an additional method for monitoring the quality of treatment in the clinic.

[Laparoscopic cholecystectomy in high risk patients]. / Die laparoskopische Cholecystektomie beim Hochrisikopatienten.

As opposed to the advantages of laparoscopic cholecystectomy, patients with cardiopulmonary impairment may be endangered by the haemodynamic and respiratory effects of the pneumoperitoneum. Between June 1990 and December 1995, laparoscopic cholecystectomies were performed in 19 high-risk patients (ASA IV) and 465 patients with a lower operative risk (ASA I-III). Out of 484 patients, 24 (5%) suffered intraoperative cardiopulmonary complications. Three belonged to the high-risk group (15.8%) and 21 to the lower risk groups (4.5%). General postoperative complications occurred in 14 cases (2.9%), whereby patients of the ASA IV group were, again, concerned more often [15.8% (n = 3) of ASA IV versus 2.4% (n = 11) of ASA I-III]. The number of days spent in hospital was 7.6 +/- 4.96 days in the high-risk group versus 4.8 +/- 2.23 days in groups ASA I-III. The evaluation as a high-risk patient indicates an elevation of the perioperative rate of complications in laparoscopic cholecystectomy; however, it is not basically a contraindication for this operative method.

[Cholecystectomy in high risk patients. A comparison between conventional and laparoscopic procedures]. / Die Cholecystektomie beim Hochrisikopatienten. Ein Vergleich zwischen konventionellem und laparoskopischem Verfahren.

Laparoscopic cholecystectomy offers many advantages, but cardiopulmonary impaired patients may be endangered by the haemodynamic and respiratory effects of the pneumoperitoneum. Between June 1990 and December 1995, laparoscopic cholecystectomies were performed on 19 high-risk patients (ASA IV) and conventional cholecystectomies on 26 patients with the same operative risk (ASA IV). Out of 45 patients, 5 (11.1%) suffered intraoperative cardiopulmonal complications. Three belonged to the group with laparoscopic cholecystectomy (15.8%) and two to the group with open laparotomy (7.7%). General postoperative complications occurred in 15 cases (33.3%), whereby patients of the conventional cholecystectomy group were concerned more often [46.2% (n = 12) versus 15.8% (n = 3), P = 0.03]. The number of days spent in hospital after open cholecystectomy was higher (P = 0.01) (11.6 +/- 5.6 days in the laparotomy group versus 7.6 +/- 5.0 days in the laparoscopy group). The classification as a high-risk patient indicates an elevation of the perioperative rate of complications in laparoscopic and open cholecystectomy, whereby the rate of postoperative complications is lower in the laparoscopic group.

[Value of the CA 19-9 tumor marker in differential diagnosis of space-occupying lesions in the head of the pancreas]. / Stellenwert des Tumormarkers CA 19-9 in der Differentialdiagnose von Raumforderungen im Pankreaskopf.

In 96 patients (ductal pancreatic carcinoma, n = 34; periampullary carcinoma, n = 43; chronic pancreatitis, n = 19) the role of CA 19-9 in the diagnosis of lesions of the head of the pancreas were evaluated. The sensitivity for ductal pancreatic carcinoma was 73.3%, for periampullary carcinoma 48.8%, and specificity was 63.2%. Carcinoembryonic antigen was elevated only in every fifth patient. Even when combining the two tumor markers no increase in sensitivity could be observed. The low specificity of 63%, which decreased to 33% in the case of obstructive jaundice, does not allow adequate preoperative differentiation between cancer patients and those with chronic pancreatitis. In cases of postoperatively elevated CA 19-9 level the prognosis is worse than in patients with normal tumor markers.

[Systematic internal quality control in surgery 1993 to 1997]. / Systematische klinikinterne Qualitätskontrolle in der Chirurgie 1993 bis 1997.

From April 1, 1993 to Dec. 31, 1997, the perioperative course of 5690 patients was recorded prospectively and postoperative morbidity and lethality was determined in the framework of a program for a systematic internal quality control. Goal of the program is the demonstration of treatment quality which possibly out quality improvement. The share of old and sicker patients was significantly increasing during the observation period. Morbidity and hospital lethality remained constant despite a rising necessity of postoperative intensive care. High risk surgery was performed on more patients in the university hospital than in non-university hospitals. The rate of postsurgical complications was lower, length of stay was equal (surgery for inguinal hernia) or lower (cholecystectomy). The rate of not indicated appendectomy could be lowered and morbidity and lethality in the treatment of esophagus carcinoma was lowered by the application of this concept. For the partial duodenopanceatectomy, the examination of the individual surgeon as a risk factor revealed a significant dependence on the experience of the surgeon. There was only a tendency of this effect demonstrable in medium or small surgery like colon resection of gastrectomy. The rate of continence preservation in rectal carcinoma was increased to 75% combined with a drop of perioperative morbidity and length of stay. The systematic internal quality control allows for the assessment of treatment quality and the fast recognition of weak spots. It is a suitable complementary tool for quality improvement in the framework of quality management in surgical patients. The extension of the concept by recording postoperative quality of life and long time results is planned.

Intraoperative C-arm CT imaging in angular stable plate osteosynthesis of distal radius fractures.

The purpose of this study was to analyze the practicability and benefit of intraoperative C-arm computed tomography (CT) imaging in volar plate osteosynthesis of unstable distal radius fractures. During a 1 year period, intraoperative three dimensional (3D) imaging with the ARCADIS Orbic 3D was performed in addition to standard fluoroscopy in 51 cases. The volar angular stable plate oesteosyntheses were analyzed intraoperatively and, if necessary, improved immediately. The duration of the scan and radiation exposure dose were measured. On average, performance of the scan and analysis of the CT dataset took 6.7 minutes. In 31.3% of the surgeries a misplacement of screws was detected and correction was done immediately. C-arm CT imaging can easily be integrated in the normal course of surgery. As a complement to the standard 2D-fluoroscopy, the C-arm CT is a useful tool to evaluate the quality of osteosynthesis.

[The cloverleaf plate for osteosythesis of humeral head fractures. Definition of the current position]. / Die Kleeblattplatte zur Versorgung der Humeruskopffraktur. Eine Standortbestimmung.

In this prospective study we evaluated the functional and radiological results obtained in 62 patients who had been treated for fracture of the humeral head by internal fixation with a cloverleaf plate. They were examined postoperatively, after 14 weeks and after an average follow-up of 75 weeks. Nine patients (14.5%) had dislocated 2-part fractures, 36 had 3-part fractures (58%; additional dislocations of the greater or lesser tubercle), 13 patients (21%) had 4-part fractures and 4 (5.6%) had luxation fractures of the humeral head. Early functional physiotherapy was started on the third day after surgery. The complications observed were: subcutaneous infection (2 cases; 3.2%), haematoma (2 cases; 3.2%), temporal paraesthesia of the axillary nerve (1 case; 1.6%). Only 4 (6.5%) patients suffered from necrosis of the humeral head (partial in 3, total in 1); in 2 cases (3.2%) we switched to a different procedure; in both these patients a humeral head prosthesis was implanted; in both these cases the clinical result was poor because of progressive varus dislocation. To improve mobility we performed arthrolysis in 8 cases (12.9%) and acromioplasty in 10 (16.1%), in addition to removing the plates after fracture consolidation confirmed by X-ray examination. In the present study those of our patients who had been treated with open reduction and internal fixation with a cloverleaf plate achieved average Neer scores of 77+/-13 and average Constant scores of 72.4+/-18, and the rates of complications or revisions were low. "Good" or "very good" results were obtained according to the Constant score in 59% of the treated patients. Even patients with complex 4-part fractures had average Constant scores of 72.7 points ("good"). The accuracy of the refixation of the greater tubercle, sufficiently low fixation of the cloverleaf plate and avoidance of varus position when the humeral head was repositioned were significant parameters influencing the functional outcome in our patients.

[A method for systematic internal quality assurance in surgery]. / Methode der systematischen internen Qualitätssicherung in der Chirurgie.

Between April 1993 and December 1996, the data of 3183 patients were recorded and analyzed in a program for internal quality assurance at the Department of General and Abdominal Surgery of the University of Mainz. The measuring of perioperative risk, the finding of intraoperative influences and the objective rating of quality of treatment were achieved by means of eight different operation-specific documentation sheets and the data records of the operation theater. With our system it is possible to measure differences between several surgeons and also differences in comparison to national and international results. By means of prospective collection of patient data and the built-in control mechanisms we obtain a lot of exact and nearly complete data. The information gained not only reflects the performance of a department, but can also be used as an instrument for the planning of work and deduction. Through optimized therapy the program can lead to an improvement of quality.

[Change in the risk of gastroduodenal ulcer hemorrhage--preventive or elective operation?]. / Wandel des Risikos der gastroduodenalen Ulkusblutung--Prophylaktische oder elektive Operation?

Prophylactic (early elective) surgery of bleeding gastroduodenal ulcers is performed to avoid rebleeding with a supposed high risk. Because early elective surgery was burdened with high risk for complications and because surgery for rebleeding ulcers had no higher risk, we left these procedures and performed repeated endoscopic treatment of these patients instead. A retrospective analysis should clarify, whether the modified treatment since 1/90 changed the risk of bleeding gastroduodenal ulcers. Patients of other hospitals, who were assigned after unsuccessful attempts of conservative treatment were analysed separately from patients of the emergency ward of our department. In the second period patients from other hospitals were in worse condition, they had more concomitant diseases and more intense bleedings than in the first period. In our opinion this could be attributed to carrying too far conservative treatment. The frequency of operations decreased only little in this group, whereas the complication rate and the mortality increased slightly. With the abandonment of early elective surgery in patients of our emergency ward, we reached a decrease of the operative-frequency of more than 30%, a decrease of complications from 27.6% to 10.0% and of mortality from 10.3% to 0%. Over-all mortality was reduced from 9.8% to 4.7%.

[Evaluation and internal quality assurance in general and abdominal surgery]. / Evaluation und interne Qualitätssicherung in der Allgemein- und Abdominalchirurgie.

The measuring of perioperative risk, the finding of intraoperative influences and the objective rating of quality of treatment were achieved by our program of quality assurance. With our system it is possible to measure differences between several surgeons and also differences in comparison to national and international results. Through optimised therapy the program can lead to an improvement of quality.

[Does the extent of lymph node dissection have an effect on morbidity and prognosis after resection of the head of the pancreas for ductal or periampullary pancreatic carcinoma?]. / Hat das Ausmass der Lymphknotendissektion einen Einfluss auf die Morbidität und Prognose nach Pankreaskopfresektion wegen eines duktalen oder periampullaren Pankreaskarzinoms?

We examined the influence of lymph node dissection on morbidity and mortality of 13 patients after resection of the head of pancreas due to a ductal or periampullary carcinoma. In both groups the radicality of the operation was the main prognostic factor. In ductal pancreatic carcinoma the R-status was able to be determined better by normalisation of the postoperative Ca 19-9 serum level than by the evaluation of the surgeon or pathologist. For prognosis, the quotient of metastatic lymph nodes to resected lymph nodes indicates that an extensive lymph node dissection may increase the long term survival. A lymph node dissection is therefore to be recommended, especially since it does not increase the rate of postoperative complications.

[Intensive care medicine from the viewpoint of patients, their family and nursing personnel]. / Die Intensivmedizin aus der Sicht der Patienten, deren Angehörigen und des Pflegepersonals.

We wanted to know how our intensive care unit would be graded by the patients, their family members and the staff, as well as the impression that intensive care medicine made on them. A total of 82% of the patients and 90% of the family members were of the opinion that they owed their lives to intensive care medicine, and 100% of the patients and 96% of family members deemed intensive care medicine significant. The patients and their family members judged the medical and nursing care, the medical technology, the care of basic needs and their accommodation altogether positive. The nursing staff held a contrary opinion and were more critical. Competent explanation and transmission of information represented the most important factor in forming a positive opinion of intensive care medicine.

[Extent of radical surgery in carcinoma of Vater's ampulla]. / Zum Ausmass der Radikalität beim Papillenkarzinom.

The present series demonstrates that radical resection of ampullary cancer is the procedure of choice even in elderly patients. The most important factor influencing the survival rate is the extent of the lymph node dissection. The histopathological investigation of our pancreatoduodenectomy specimens demonstrates clearly that local excision of ampullary cancer may be indicated only in high risk patients with a pT1, well-differentiated tumor smaller than 0.6 cm in diameter.

Olecranon fractures in adults: factors influencing outcome.

In a retrospective, non-randomized study, we reviewed our experience with the operative treatment of olecranon fractures to find out which factors correlate with subjective complaints and functional outcome. A total of 95 consecutive olecranon fractures were operatively treated in our level I trauma institution between 1 March 1992 and 1 March 2000. Medical records and X-rays of all patients were evaluated. Three patients died, 23 were lost to follow-up. Fifty-eight of 69 available patients (84.0%) were reviewed clinically and/or radiologically after a mean time of 36 months. Fracture type, fracture classification, associated lesions, technical correctness of osteosynthesis, age and comorbidity were analysed. Radiological end result (intraarticular steps, gaps, arthrosis), subjective complaints, mobility of the elbow joint and muscle strength were evaluated. Patients with an unstable elbow (Mayo classification Type III and Schatzker-Schmeling classification Type D) had a higher loss of elbow function than others. There was a correlation between fracture morphology (fractures Type C and Type D in the Schatzker-Schmeling classification) and arthrosis. There also was a correlation between suboptimal osteosynthesis and arthrosis. There was no correlation between suboptimal osteosynthesis, implant loosening and secondary procedures. Patients more often expressed subjective complaints and loss of function in activities of daily life before than after metal removal. Primary elbow instability and fracture morphology are prognostic factors for elbow function and development of arthrosis after operative treatment of olecranon fractures. We, therefore, recommend the classification systems of the Mayo-clinic or of Schatzker-Schmeling. As many patients have complaints related to the implants, we recommend metal removal after fracture healing.

[Intramedullary osteosynthesis of the ulna in revision surgery]. / Intramedulläre Nagelosteosynthese der Ulna in der Revisionschirurgie.

The exact and adequate management of diaphyesal fractures of the forearm is necessary to ensure forearm motion. Unsatisfactory treatment can lead to loss of function and disability of forearm and hand movement, resulting in severe patient morbidity. Since the rotational and angulatory stresses at the fracture site are the superior factors which influence the outcome of the forearm fracture healing after surgical treatment, the implants must fulfill some general prerequisites including high biomechanical stability, less invasive surgical approach and adequate biological features. However, less clinical studies are known for cases of complicated ulnar fractures when additional revision surgery is necessary to restore form and function. Thus, the choice of implant in such difficult situations requires a profound knowledge and experience. In a series of seven clinical cases we report about the successful use of the ForeSight-nail in revision surgery of complicated ulnar fractures. The series include cases with refractures after plate removal, in-situ plate brokerage and a critical size bone non-union which were treated with interlocking intramedullary osteosynthesis technique.