Quality of life in patients with multiple injuries--basic issues, assessment, and recommendations.

BACKGROUND: While the primary goal of trauma care continues to be the preservation of life, interest has begun to focus on disability and quality of life of those who survive. Numerous instruments have been developed to measure personal well-being, impairment, or subjective life-satisfaction. But there is no consensus regarding which instruments are most appropriate to use in multiply injured patients, and comparison of results are difficult. OBJECTIVE: The objective of this multinational conference was to arrive at a consensus regarding the measurement of quality of life in survivors of multiple trauma. Specifically we sought to identify the best time intervals for measurement and a minimum set of instruments. METHOD: The group reviewed instruments currently in use for quality of life measurement in multiply injured patients. A structured discussion covered the following topics: definition of the population, the concept of quality of life, the importance of different domains of quality of life at different time points, the type of measures and their validity, consistency, and practicability, the mode of administration, subject burden, and availability of population norms. RESULTS: The group suggested three time points, after 3, 12 and 24 months, for the assessment of quality of life after multiple injury. The Glasgow Outcome Scale (GOS) was suggested as an overall global outcome measure including death and vegetative state. The EuroQol was proposed to permit economic analysis, and the SF-36 as a validated global quality of life measure. CONCLUSION: While most selected measures are psychometrically sound, many have had limited use in the setting of multiple injuries. Researchers and clinicians may use these suggestions as a source of information when developing a measurement strategy.

The Langerhans' cell histiocytosis (eosinophilic granuloma) of the cervical spine: a rare diagnosis of cervical pain.

We present the case of a 44-year-old man who complained of cervical pain. He was treated with physiotherapy and analgetics. Because of persistent pain, computed tomography (CT) scan and MRI were performed. They revealed an osteolytic destruction of the fourth cervical vertebra. The patient was treated surgically for removal of the tumor and stabilization of his cervical spine. Histology of the osteolytic material led to the diagnosis of an eosinophilic granuloma of the cervical spine. This case report describes the incidence, clinical significance, background and therapy of an eosinophilic granuloma of the spine.

Does the mode of data collection change results in a subjective knee score? Self-administration versus interview.

Our objective was to compare the effect of two methods of data collection on results in a functional knee score. Two Lysholm scores were obtained for 61 patients 1 year after anterior cruciate ligament surgery at the same clinic visit. First, the patients completed a self-administered questionnaire, and second, the Lysholm score form was completed by the investigator in the course of a patient interview. A comparison of the scores revealed that the mean score was significantly lower with self-administration (self, 89.3 +/- 10.6; interviewer, 92.2 +/- 7.4) (P = 0.0035, Wilcoxon rank sum test). The assignment to one of four categories (excellent, good, fair, poor) was also significantly altered by the manner of data collection. Nineteen patients (31%) were assigned to different categories based on the mode of data collection. We believe that the major reason for a better score result with an interview was the presence of interview bias. The more the investigator is involved in the treatment of the patient, the greater the influence of this bias may be. To avoid such potential bias we suggest that a standardized self-administered questionnaire be used as the method of choice for obtaining subjective data in clinical settings.

Prehospital detection of uncontrolled haemorrhage in blunt trauma.

The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n = 353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et al., 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

Arthroscopy of the knee in children and adolescents.

Arthroscopy of the knee was performed in 104 patients under 18 years of age, 41 in children (aged 8 to 15) and 63 in adolescents (aged 16 to 18). Most frequently lesions of the patella were found (in 45% of all diagnoses in children and 29% in adolescents), in most cases because of acute or recurrent dislocation of the patella. The incidence of meniscal lesions increased with age. The most frequent therapeutic procedure performed in children was a lateral release (34%), in adolescents a partial meniscal resection (31%). In children 43% of arthroscopies were diagnostic, in adolescents 21%. Preoperative diagnosis was shown to be incorrect or incomplete arthroscopy in 41% of children and 24% of adolescents taking arthroscopic findings as a golden standard. Preoperative diagnosis had highest accuracy for dislocation of the patella, 90% of dislocations were diagnosed correctly before arthroscopy. The lowest accuracy of clinical diagnosis was found for meniscal lesions; only 36% of meniscal tears were suspected preoperatively. In 35 of 38 patients with hemarthrosis a relevant knee lesion was found, in 23 of these patients arthroscopic therapy was performed. This justifies our concept for arthroscopy of every knee hemarthrosis. Besides superficial chondral lesions in 8 patients there were no complications associated with the procedure. It is concluded that arthroscopy of the knee in children and adolescents is a safe procedure with high diagnostic and therapeutic value.

[Differential transplant selection in cruciate ligament surgery]. / Differenzierte Transplantatauswahl in der Kreuzbandchirurgie.

Over the past century numerous graft materials have been used for the reconstruction of the cruciate ligament of the knee. Among the autologous tissues that are currently recommended as graft materials, the central bone patellar tendon bone graft, a quadrupled hamstring graft and the central quadriceps tendon graft have the greatest clinical significance. With some limitations, allograft materials can also be used. Each of the three mentioned grafts has specific features regarding morphological and structural properties, graft fixation and graft incorporation. Clinical studies have failed to identify any of the three grafts as superior to the others. When choosing the graft for surgery the different anatomy and function of the anterior and posterior cruciate ligaments have to be considered. For the treatment of multiple ligament injuries and for revision cases, thorough preoperative planning is necessary and modified graft selection may be required.

[Acute injury to the lateral ligament of the ankle joint in the athlete]. / Die akute Aussenbandverletzung des Sprunggelenks beim Sportler.

The ankle sprain is one of the most common injuries in sports. It is useful to classify the grade of injury clinically. Stress x-rays, stress ultrasound or radiographic examinations are not necessary. Based on the analysis of 24 controlled studies we conclude that functional treatment is sufficient. It does not lead to higher subjective or objective instability nor to a greater number of reinjuries. Functional treatment has no complications. Although controlled studies about the treatment of athletes are missing, but there is no reason for a different treatment in athletes.

[Therapy of traumatic anterior shoulder dislocation: current status of therapy in Germany. Are there scientifically verified therapy concepts?]. / Die Therapie der traumatischen vorderen Schulterluxation: Aktueller Stand der Therapie in Deutschland. Gibt es wissenschaftlich gesicherte Therapiekonzepte?

There are no generally accepted concepts for the treatment of traumatic anterior shoulder dislocation. The objective of this study was to ascertain the current treatment for traumatic shoulder dislocations in German hospitals and to compare this with the data reported in the literature. A total of 210 orthopedic surgery departments were asked for their treatment strategy in an anonymous country-wide survey; 103 questionnaires (49%) were returned for evaluation. Additional imaging (ultrasound, CT, MRI) beyond the routine X-rays is performed in 82% of clinics for primary shoulder dislocation (94% in recurrent dislocation). A young, athletic patient (< 30 years old) would be operated on for a primary traumatic shoulder dislocation in 73% of hospitals (98% in recurrent dislocation). In contrast, a patient of the same age, with a moderate level of sporting activity would be treated conservatively in 67% of cases (14% in recurrent dislocation). Similarly, for an active, middle-aged patient with a demanding job, 74% of responses favored conservative treatment after a primary dislocation and 6% after a recurrent dislocation. Older patients (> 65 years old) are usually treated conservatively after a primary or recurrent shoulder dislocation (99%, 69%). For a primary shoulder dislocation the most popular surgical reconstruction is a Bankart repair (75%). For recurrent shoulder dislocation several different operative techniques are seen (Bankart 29%, T-shift 26%, Putti-Platt 8%, Eden-Lange-Hybbinette 22%, Weber osteotomy 13%). Based on our literature review, we found: (1) The clinical examination of both shoulders is important to diagnose hyperlaxity; (2) Routine CT or MRI is not necessary for primary traumatic shoulder dislocations; (3) A young, athletic patient should undergo surgical reconstruction after a primary shoulder dislocation; (4) The operation of choice for primary and recurrent dislocation is the Bankart repair; (5) There is no sufficient evidence that an arthroscopic Bankart repair is as good as an open procedure; (6) There are limited indications for other operative techniques, as they are associated with a higher recurrence and arthrosis rate.

[The displaced proximal humeral fracture: is there evidence for therapeutic concepts?]. / Die dislozierte proximale Humerusfraktur: Gibt es gesicherte Therapiekonzepte?

INTRODUCTION: There is no general agreement on the operative treatment of displaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have been favoured during the past decade. The indication for primary shoulder prosthesis is controversial. The purpose of this report was to evaluate the scientific evidence of current treatment recommendations. METHODS: Relevant articles were retrieved from "Medline" and "Knowledge-Finder" using the combined search strategy for the keywords "proximal humerus" and "fracture". Retrieved articles were evaluated according to the criteria of evidence-based medicine. RESULTS: The analysis retrieved 3 randomized, 4 prospective, and 26 retrospective studies and a number of review articles relevant to the subject. Limitations of most publications were due to small study populations, differences in patient selection and fracture classification as well as measurements of outcome. According to these studies good functional results can be achieved in dislocated two-part fractures treated with minimal osteosynthesis in the elderly and T-plate fixation in younger patients. For three- and four-part fractures minimally invasive techniques seem to be more favourable in the elderly. However, there is some evidence that alternative therapies such as conservative treatment and plating can be successful in defined populations. A general indication for primary implantation of a prosthesis in four-part fractures in the elderly is not supported by the literature. CONCLUSION: We conclude from our analysis that the scientific evidence for treatment recommendations of displaced proximal humeral fractures is still limited.

[Conservative or surgical therapy of acromioclavicular joint injury--what is reliable? A systematic analysis of the literature using "evidence-based medicine" criteria]. / Konservative oder operative Therapie der Schultereckgelenkverletzung--was ist gesichert? Eine systematische Literaturanalyse nach Kriterien der "evidence based medicine".

There is controversy about the therapy for third-degree acromioclavicular dislocation according to Tossy and Rockwood's classification. Both operative and non-operative treatment is reported to have satisfactory results in the literature. The purpose of this study was to analyze the literature in a systematic manner based on the criteria of evidence-based medicine. It was our hypothesis that there is no scientific evidence for the superiority of one treatment over the other. A total of 370 papers were retrieved and classified into three groups: (1) randomized controlled trials; (2) comparative retrospective studies; and (3) retrospective studies. In three studies that were graded with high evidence, the major outcome for both operative and non-operative treatment was similar. The advantages of non-operative treatment include a shorter period of rehabilitation and a significantly lower complication rate while the advantages of operative treatment include a low rate of persisting subluxation of the AC joint. Similar results were found for retrospective comparative and long-term studies. For retrospective studies without controls, both operative and conservative therapy are described with good and excellent results, ranging between 80 and 97%. In conclusion, there is good evidence on the therapy of third-degree acromioclaviculary dislocation studies. The functional result according to the literature is similar, and complications associated with therapy occur more often with operative treatment. Conservative treatment appears to be the method of choice for third-degree acromioclavicular dislocations unless the patient's preference is operative therapy.

[Therapy of phantom pain with salmon calcitonin and effect on postoperative patient satisfaction]. / Phantomschmerztherapie mit Lachscalcitonin und Einfluss auf die postoperative Patientenzufriedenheit.

In this prospective clinical study we examined the intravenous application of salmon-calcitonin in eight patients with severe phantom limb pain (Visual Analogue Scale = 50-100). The patients presented at the Acute Pain Service (APS) section of the Second Department of Surgery, University of Cologne. Six of eight patients (75%) had no phantom limb pain after 10 days of intravenous treatment with salmon-calcitonin (maximum of five cycles of calcitonin infusion). Systematic follow-up examinations after 3, 6 and 12 months showed long-term success. Patient satisfaction was examined with a numeric rating scale (NRS 1-6) between the single infusion cycles. When patient satisfaction was low, the physician modified the time period or drug dosage between infusions. This study shows good or excellent results in patient satisfaction for six of eight patients (75%). A prospective randomized trial is required to verify the excellent results of intravenous salmon-calcitonin in a larger population. Alternative pharmacological and operative treatments of phantom limb pain are critically reviewed and assessed.

[Tendon injuries in sports]. / Sehnenverletzungen beim Sport.

Epidemiologic data on the incidence of tendon injuries in these actively engaged in sports are missing. The significance of the tendon injury lies in the prognosis for any further sporting activities, the risk of chronicity, and thus the impairment of functional capacity (fitness). Pathogenesis, clinical features and treatment of the most essential tendon injuries are presented, based upon a literature search. The choice between conservative and operative treatment of tendon injuries is great of practical significance.

[Ambulatory treatment of extensor-tendon injury in general surgery]. / Die ambulante Behandlung der Strecksehnenverletzung in der Allgemeinchirurgie.

Extensor tendon injuries are mostly treated by younger general surgeons. Good follow-up results in the zone 2, 3, 4 and 6 of VERDAN are observed only 6 to 17 percent (fig. 1), which may be explained by: 1. the complicated anatomy of the extensor tendon in zone 2 to 4, 2. lack of attention to handsurgical principles, 3. infections in up to 40 per cent, which appear especially in connection with extensive soft tissue damage, 4. posttraumatic arthrosis (fig. 3) caused by lesions of the finger-joints or temporary KIRSCHNER wire fixation. The highest restriction of movement is found in the finger-joint distal to the injury (fig. 2.) The degree of flexion deficit in all finger-joints always exceeds the degree of extension deficit (fig. 4). The extension deficit alone is, therefore, not a satisfactory criterion in follow-up. The use of KIRSCHNER wire fixation by the inexperienced and the adoption of conservation therapy for zones 1 and 2 cannot be recommended.

[Fluorescent microscopy studies of osteosynthesis and bony defect filling with cyanoacrylate]. / Fluorescenzmikroskopische Untersuchungen über Osteosynthesen und Knochendefektauffüllungen mit Cyanoacrylat.

Bone defects and osteotomies of the rabbit tibia were stabilized by a mixture of ethyl cyanoacrylate and bone meal. Healing of osteotomy or new bone formations growing through the defect could not be observed.

[55 years of osteomyelitis (author's transl)]. / 55 Jahre Osteomyelitis.

This study deals with the problem of osteomyelitis by presenting 875 patients treated at Goettingen University, Department of Surgery between 1924 and 1978, with particular emphasis on methods of treatment, frequency of recurrences and change in pathogenic organisms which had become more apparent within the past decades. There was 555 haemotogenic cases, 320 of post-traumatic origin.

Comparative study of therapies for fibular ligament rupture of the lateral ankle joint in competitive basketball players.

This retrospective study compares the results of different therapies for fibular ligament rupture in a homogenous group of professional athletes. The endpoint "competitive sports" was an outcome consideration. Subjects were examined by means of a standardized questionnaire and a structured interview. One hundred and seventy-nine of the questionnaires were completed and returned for evaluation. All of the basketball players with severe ankle sprain (supination trauma with swelling, pain, and inability to bear stress) were included. Those players with fractures of the foot, pronation trauma, or additional distal fibula or tibia fractures were excluded from this study. Of the 179 basketball players 160 (89%) had suffered severe ankle sprain. The treatment was divided into three groups: primary surgery (N = 35), plaster cast (N = 39), and functional treatment (N = 89). While simple ligament injuries (Grade I and II) were mostly treated functionally, complex ligament injuries (Grade III) were usually operated on. A total of 119 (74%) of the players reported no further pain. For pain reduction surgical and functional treatments showed advantages over plaster treatment. In the surgical group 63% of the players judged their regained stability to be equivalent to that of their healthy leg. Only 50% of the players in the plaster and functional groups believed their ankle joints to have regained the same stability as before their injuries. Despite the achievement of good results through surgery, there were clear differences in the players' assessments of their performance in competitive sports. Most subjects (92%) did not have any problems in everyday life regardless of which kind of therapy had been chosen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reliability of clinical examination of the shoulder in comparison with arthroscopy. A prospective study]. / Zuverlässigkeit der klinischen Untersuchung der Schulter im Vergleich zur Arthroskopie. Eine prospektive Studie.

The results of clinical shoulder examination including 20 special tests were compared with subsequent arthroscopic findings in 45 patients. The sensitivity of the clinical diagnosis was 73%. Impingement syndrome was correctly diagnosed in 19 of 22 cases (86%), rotator cuff tears in 7 of 9 cases (78%). The highest sensitivity for stage II impingement was found for the supraspinatus test (85%) and the lift-up test (92%); the sensitivity of these tests for rotator cuff tears was 100% and 89% respectively. Differentiation between impingement syndrome with and without rotator cuff tear by one of these tests alone was not possible because of their low positive predictive values (26% and 56%). In contrast, in 90% of patients with negative rotator tests the rotator cuff was complete, while the negative predictive value of the supraspinatus test was 100%. Instability was confirmed in only 53% of cases; the Leffert test had the highest positive predictive value (73%). In conclusion, the clinical diagnosis of a shoulder lesion cannot reliably be achieved by single tests; rather overall evaluation by an experienced clinician is necessary.