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D Nast-Kolb

Publications and source records attributed to D Nast-Kolb.

At least 109 records · Page 6Linked to original sources
PubMed1996

[Intramedullary nailing of lower leg fractures with minimal soft tissue injuries].

The importance of intramedullary nailing (IM) for closed and type I tibial shaft fractures is evaluated on the basis of a review of the recent literature (1991-1996) and the data on 61 patients that underwent a reamed (RTN; n = 31) or an unreamed (UTN; n = 26) procedure. There was no difference between the two groups in age, fracture type or localization. Soft tissue trauma prevailed with 38% type I open fractures in the UTN group (RTN group, 3%). Both groups showed about the same proportion of good and very good results (criteria of Johner and Wruhs; 89% RTN and 88% UTN), which corresponds to the results of other authors (83%-96% RTN; 79%-96% UTN). The rate of nonunions is about the same with 6% (RTN) and 4% (UTN), respectively, and there were no infections. In accordance with the literature, we found earlier osseous reunion after unreamed nailing (RTN = 18 weeks vs UTN = 12 weeks). This corresponds to early, painless, full weight-bearing after an average of 10.3 as opposed to 13.8 weeks in the RTN group. Except for earlier osseous reunion reamed and unreamed TN proved to be equivalent procedures. As a precondition, if more endostium is affected, reaming should be performed after stabilization of the soft tissue damage, and fractures of the metaphysis should be interlocked in two dimensions (using all interlocking possibilities) if treated with the more unstable UTN, along with reduced weight-bearing for at least 6 weeks. The implant should be chosen in compliance with individual demands, taking the higher intramedullary stability of the RTN into consideration and the endostium-preserving insertion of the UTN.

Bone Nails↗
PubMed1996

[Intramedullary nailing of the humerus as an alternative to conservative therapy and to plate osteosynthesis].

For humeral shaft fractures conservative treatment, plate osteosynthesis and IM nailing are possible options according to the localization, type of fracture or additional soft tissue problems. While the majority of humeral shaft fractures is still treated conservatively, today an increasing number of fractures is felt to be suitable for ORIF. Pseudarthroses, pathological fractures, multiple fractures or polytrauma, very severe open fractures, soft tissue interposition or concomitant nerve or vascular injuries are all indications for operative treatment. We think that plate osteosynthesis is still the standard. IM interlocking nailing has been shown to be advantageous for early rehabilitation and low radial nerve damage rates. In IM nailing it is still necessary to improve the implants and implantation techniques. A retrograde extra-articular nailing technique with elastic implants is preferable. The preliminary results for a newly developed elastic nail ("Monachia Nail") in 18 patients are very promising with respect to the implantation technique, fracture healing and functional rehabilitation.

Bone Nails↗
PubMed1996

[Intramedullary nailing in multiple trauma].

The indication and best time for intramedullary nailing of long bones in the multiple trauma patient is still controversial. While in the Anglo-American literature primary intramedullary nailing is regarded as the method of choice, differentiated management is preferred in German-speaking countries on account of reports about the pathogenesis of trauma shock. On the one hand, it has been shown that severe thoracic injury greatly influences the course after multiple trauma and, in particular, its combination with femoral fracture represents an increased risk. On the other hand, every surgical intervention represents an additional trauma for the patient. Intramedullary reamed nailing of femur fractures represents considerable trauma, whereas unreamed intramedullary nailing of the femur or intramedullary stabilization of the tibia or humerus causes (in descending order) fewer changes. For early respiratory care (e.g., changing between the prone and supine position), however, primary stabilization of long bones is required. External fixation of the femur appears to be the method of choice for the severely injured patient. Definite fracture healing can be achieved by a change to intramedullary nailing in a secondary operation.

Bone Plates↗
PubMed1995

[Postoperative homeostatic imbalance after trauma surgical interventions of various degrees in polytrauma].

The objective of this study was to evaluate and compare the derangement of body homeostatis and the inflammatory response after different types of traumatological operations in patients with multiple injuries. These were determined in a total of 60 operations. The procedures comprised osteosynthesis of the femur (n = 28), the pelvic girdle (n = 11) the spine (n = 8), and facial and basal skull reconstructions (n = 13). Specific and unspecific parameters of the inflammatory response were determined on the morning of the operation, immediately after the procedure, every 6 h on the 1st day and 48 h after the end of surgery. After all types of operations (pelvis, femur, spine, face/basal skull) significant alterations were observed for neutrophil elastase, C-reactive protein, interleukin 6, interleukin 8, antithrombin III, partial thromboplastin time and other parameters. The degree of postoperative changes differed significantly (Kruskal-Wallis test, P < 0.05) among the four types of operations for lactate, heart rate, PO2/FiO2 ratio and nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and C-reactive protein. The changes were most pronounced after operations on the pelvic girdle, followed by procedures in the femoral, spinal, and facial/basal skull regions. We conclude that a considerable inflammatory response and pronounced disturbance of body homeostasis follow traumatological operative procedures, varying in severity with the type of surgery. Several parameters allow quantitation of the surgical trauma and differentiation between different operations/regions. Further research should focus on the interrelationship between pre-existing preoperative inflammation and the additional trauma inflicted by surgery in patients with severe injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute-Phase Reaction↗
PubMed1995

[Cost analysis of clinical treatment of polytrauma patients].

In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation. Thus the total costs must be presumed higher. A relationship between costs of treatment and injury severity (ISS) appeared in polytrauma only by a cost reduction in early deceased very severely injured patients (ISS > 70). The primary diagnosis (injury pattern and severity) cannot predict the incidence of complications increasing the costs of treatment. In the presented study we did not find a correlation between age and treatment costs.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

[Fracture healing after intramedullary nailing of simple tibial shaft fractures. A clinical comparison of reamed and unreamed procedures].

From January 1990 to June 1993, 56 patients with simple tibial shaft fractures were treated in the Surgical Department of the University/Municipal Hospital in Munich by primary intramedullary nailing, and 44 of these patients were followed up. The results in 17 who underwent unreamed intramedullary nailing (UTN) were compared with those in 27 in whom reamed procedures (RTN) were applied. There was no difference between the two groups in age, fracture type and localization. Soft tissue trauma prevailed, with 35% I degrees open fractures in the UTN group (RTN group, 3%). UTN patients were operated on an average of 45 h after trauma, and RTN patients, 5 days after trauma. Both groups showed about the same proportion of good and very good results (criteria of Johner and Wruhs), with 83% in the UTN group and 84% in the RTN group. The rate of complications was the same in both groups (11%), and we did not find any kind of infection. Two complications requiring revisions (nonunion, perforation of the nail) after UTN stress the importance of two-dimensional barring in the main fragments (especially when close to the metaphysis) and of reduced weight-bearing for 6 weeks after the operation. The slightly greater intramedullar instability after UTN did not cause a higher rate of nonunions or of fracture healing in a wrong position than RTN. The X-ray findings showed beginning osseous reunion after 13 weeks in the UTN group. This corresponds to earlier painless full weight-bearing after an average of 9.7 weeks, as against 12 weeks in the RTN group.

Adolescent↗
PubMed1995

[Effect of early intubation on the reduction of post-traumatic organ failure].

In a prospective multiple trauma study lasting from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on posttraumatic (multiple) organ failure (M)OF was compared with that of delayed intubation (DI) in 131 patients with multiple injuries (ISS 37). The indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and other severe injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) were intubated early and 19 patients (14.5%) required intubation and artificial ventilation in the later course, whereas in 6 subjects (4.5%) spontaneous respiration was adequate. The pattern of injured body regions did not differ substantially between the two groups, but the severity of injury was significantly greater (p < 0.001) in the EI group (ISS 39) than in the DI patients (ISS 29). Among the EI patients, 67% developed at least one OF, 45% respiratory failure (RF), and 28% multiple organ failure (MOF); 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%), and even a higher (n.s.) incidence of MOF (37%) and mortality rate (26%). In view of the significantly less severe injuries in the DI group, the observed OF and mortality rates are inappropriately high compared with the incidence of OF and death in the EI group.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1994

Early intubation in severely injured patients.

In a prospectively studied trauma population from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on post-traumatic (multiple) organ failure (M)OF was compared with delayed intubation (DI) in 131 patients with multiple injuries (Injury severity score (ISS) 37). Indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and the severity of injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) have been intubated early and 19 patients (14.5%) required intubation and artificial ventilation later in the course, whereas 6 subjects (4.5%) could manage spontaneous breathing. The pattern of injured body regions and respiratory parameters on admission showed no remarkable difference in the two groups, but the severity of injury was significantly higher (p < 0.001) in the EI group (ISS 39) compared with the DI patients (ISS 29). Due to a significantly worse haemodynamic condition of the EI patients on admission, they showed significantly higher volume requirements throughout the resuscitation period. All patients were treated to a standard resuscitation protocol. Sixty-seven per cent of the EI patients developed at least one OF, 45% respiratory failure (RF), 28% multiple organ failure (MOF) and 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%) and an even higher (n.s.) incidence of MOF (37%) and mortality rate (26%). Corresponding to the significantly lower injury severity of the DI group, the observed OF and mortality rates are inappropriately high in comparison with the incidence of OF and death in the EI group. We conclude that EI of multiple injured patients within 2 h after trauma along with ventilatory support--even in alert patients without major chest trauma or signs of cardiocirculatory or respiratory insufficiency, but a known or suspected ISS > 24--may help to reduce post-traumatic organ failure and improve outcome.

Adolescent↗
PubMed1994

[Stabilization procedures in large soft-tissue and bone defects].

When stabilizing fractures with large soft tissue and bone defects, the primary concern is to avoid additional vascularization damage. Therefore, external fixation is still the standard method. In metaphysical fractures, joint transfixation should be avoided if possible. Concerning closed comminuted fractures of femoral and tibial shaft fractures, interlocking nailing shows the lowest complication rate. The introduction of unreamed nailing of open fractures shows the same low infection rate as external fixation, so it can be considered an alternative method. Early plate fixation is applied for fractures of the upper extremities as well as the proximal and distal femur, if secure covering with vital tissue can be provided. As this is not guaranteed in the case of the tibial shaft, plate fixation remains the absolute last resort. Concerning distal and proximal fractures of the tibial pylon and tibia head, plate fixation is very often applied for definitive stabilization. However, the secondary application represents a considerably lower infection and fracture-healing risk.

Adolescent↗
PubMed1994

[Treatment concept in infected bone and soft-tissue defects].

The first priority when treating infected bone and soft-tissue defects is the maintenance or reconstruction of vitality, vascularity and stability. This means that when signs of infection are apparent, this is an immediate indication for operative revision with protective preparations on the tissue and radical debridement. Treatment of the soft-tissue damage is carried out with local or microsurgically connected muscle flaps. As for stability, in early infection the retention of well-bonded implants is often possible. If not, it is often necessary to change over to external fixation. Reconstruction of bone damage is carried out after the infection recedes, and complete healing is finally achieved by further treatment changes to conservative means or further stabilizing treatment.

Adolescent↗
PubMed1994

[Operation planning of secondary interventions after polytrauma].

A prospective study of 135 secondary operations (> 24 h after trauma) in patients with multiple injuries (ISS 40.6 pts) was performed to determine specific and unspecific indicators of the inflammatory response that may indicate the degree of risk of postoperative organ failure in these patients. On the morning of the operation each patients' data were recorded and blood samples were collected. Patients were divided in those in whom respiratory, renal and/or hepatic failure developed or preexisting organ failure worsened by more than 20% from baseline within 2 days after the operation and those who had no complications. In 29 patients who were operated upon between 24 and 72 h after trauma only the pO2/FiO2 ratio allowed discrimination between the two groups. The overall accuracy of this parameter as a predictor of postoperative organ failure was 83%, with a sensitivity of 78% and a specificity of 85%. In 106 patients with secondary operations later than 72 h after trauma, neutrophil elastase, C-reactive protein and platelet count revealed the highest predictive accuracy, with cut-off values of 250 ng/ml, 11 mg/dl and 180 x 10(6)/ml, respectively. The combined accuracy of these three parameters in prediction of postoperative organ failure was 79% (sensitivity 73%, specificity 83%). In this group of patients the pO2/FiO2 ratio was of less value and blood pressure, heart rate, renal function parameters, lactate and coagulation parameters were of no value.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute-Phase Reaction↗
PubMed1994

[Early mortality in polytrauma. A critical analysis of preventable errors].

In order to assess the impact of errors on outcome and to identify the rate of preventable deaths we investigated 40 premature deaths that had occurred among polytraumatized patients (blunt trauma; average ISS 53 points) in a prospective study (years 1986-1992) in a level I trauma centre. On analysing the patients' course on the basis of a complete set of data we detected 41 management and timing errors, 15 mistakes in treatment and 8 diagnostic problems. According to the significance of the errors the patients could be divided into three groups: in group 1 (n = 12; 30%) no errors were found, in group 2 (n = 22; 45%) there were errors but these definitely had no influence on the outcome, and in group 3 (n = 6;15%) we ascertained errors with a possible influence on the deaths. In none of the 40 cases of premature death could it be definitely shown that the adverse outcome could have been avoided. In the care of polytraumatized patients there was a clear predominance of management and timing errors insofar as they accounted for 64% of all errors that occurred and had frequently preceded possibly preventable deaths (88% in group 3). To diminish sources of error in the management of polytraumatized patients we must demand that more accurate clinical standards and algorithms be developed and introduced into the treatment of such patients.

Adolescent↗
PubMed1994

[An algorithm for management of shock in polytrauma].

The initial management of patients with multiple trauma requires a well-defined plan of action for immediate and adequate therapy, that ensures fast recognition of life-threatening conditions and injuries. While treatment protocols for specific situations and injuries are fairly well defined, there are few such concepts for the overall management process. Therefore, we designed a comprehensive algorithm for in-hospital trauma care to give priority-based guidelines to the trauma room physician. The full management plan (diagnostic and therapeutic interventions in sequence) is implemented in seven flow charts. The first algorithm starts with the initial assessment of immediate life-threatening disorders of A (airways), B (breathing) and C (circulation) and is followed by the early stabilization and maintenance of vital functions. It is followed by six interrelated flow charts, based on disturbed physiological functions (respiration, circulation) and anatomical injuries (thorax, abdomen, head/brain, spine/pelvic girdle/extremities), which are worked up simultaneously and repeatedly. This algorithm is not only intended as an overall guideline for use the management of severely injured patients, but is also indispensable for quality assurance.

Algorithms↗
PubMed1994

[Practical and theoretical limits of score systems].

Trauma-scoring is a measurement of injury severity. Before conclusions can be drawn from their results, their validity, reliability and practicability need to be known. With respect to these factors the following statements may be proposed: some scores do have relatively low inter-rater reliability; retrospective interpretation of findings and diagnoses in the patient records may be equivocal; parameters contributing to the score may be lacking in some records; scoring may be time-consuming; the parameters selected to make up the score may not include all the relevant ones; the influence of time is neglected; different methods of patient selection may confound the interpretation of scoring results; most scores are only evaluated with respect to mortality; the scores are interpreted exclusively on the basis of statistical probabilities. We suggest that such scores as the ISS, PTS, (R)TS, which have been fairly well studied with respect to validity, reliability, and practicability, be prepared.

Humans↗
PubMed1993

Increased serum concentrations of procollagen type III peptide in severely injured patients: an indicator of fibrosing activity?

OBJECTIVES: To determine the serum concentrations of procollagen type III peptide in severely injured patients with different outcomes and to evaluate the relationship between serum procollagen type III peptide concentrations, sources of increased posttraumatic fibrotic activity (wounds, lung, liver, kidney), and decreased elimination of procollagen type III peptide (liver). DESIGN: Prospective study. SETTING: Surgical ICU, university hospital. PATIENTS: Fifty-seven patients (mean injury severity score: 38.5 points, range 13 to 75 points), between 16 and 70 yrs of age, treated in our institution within 6 hrs after the accident. MEASUREMENTS: Serial measurements were started on admission and continued on a 6-hr basis. After 48 hrs, the monitoring interval was extended to 24 hrs until recovery (but at least until day 14) or death. At each point of evaluation, pulmonary and circulatory function parameters and chest radiographs (once a day) were evaluated, the results were recorded, and blood samples were drawn to determine procollagen type III peptide, total bilirubin, creatinine, gamma-glutamyl transferase, polymorphonuclear elastase, and other parameters. Statistic evaluation was done with the Wilcoxon test, Spearman rank correlation, and a multiple regression model. RESULTS: Mean procollagen type III peptide serum concentrations (+/- SD) were significantly different in patients who died (8.0 +/- 3.8 U/mL) compared with those patients who survived with organ failure (2.7 +/- 1.3 U/mL) or without complications (1.4 +/- 0.5 U/mL), respectively. Significant correlations of procollagen type III peptide concentrations with the serum bilirubin concentrations (r = .7), days with need of mechanical ventilation (r = .64), PaO2/FIO2 ratio (r = -.6), polymorphonuclear elastase (r = .6), serum creatinine concentrations (r = .55), and injury severity score (r = .33) were observed. There was a tendency toward higher serum procollagen type III peptide concentrations in patients with severe skeletal injuries. CONCLUSIONS: Serum procollagen type III peptide concentrations in severely injured patients may be considerably increased in correlation with injury severity and outcome. Procollagen type III peptide serum concentrations seem to reflect the sum of increased collagen formation from wound healing and fibrogenesis of mediator-related organ damage (especially lung) and decreased procollagen type III peptide excretion due to impaired liver function. Further data are necessary to evaluate the role of hepatic elimination in these patients.

Adolescent↗
PubMed1993

[Operative injury in spinal surgery in the management of polytrauma patients].

The release of indicators and mediators of the posttraumatic inflammatory response following spine surgery was measured in patients with multiple injuries. Eight of a group of 113 patients (mean injury severity score 36) who underwent delayed operative stabilization of vertebral fractures (> 24 h after trauma) were studied. The following significant postoperative changes of blood levels (median values, Wilcoxon signed-rank test) compared with the preoperative starting point were found: polymorphonuclear granulocyte elastase rose from 220 to 337 ng/ml, cathepsin B from 84.5 to 135.5 mU/l, C-reactive protein from 9.1 to 11.6 mg/dl, lactate from 9.6 to 15.2 mg/dl and neopterin from 6.9 to 15.2 nmol/l, while antithrombin III fell from 107.5% to 84%, platelet count from 102 to 88 x 10(9)/l and pO2/FiO2-ratio from 361 to 260. The alterations in the blood levels of these parameters following spine surgery showed a pattern similar, albeit of lesser magnitude, to that which can be observed after severe accidental trauma. We conclude that the additional activation of the inflammatory response following surgery for vertebral lesions should be taken into account when planning these operations in patients with multiple injuries.

Acute-Phase Proteins↗
PubMed1993

[Minimal osteosynthesis of tibial pilon fracture].

Fifty-eight patients with a total of 60 pillion fractures of the tibia were treated, mainly operatively, in the Department of Surgery (Klinikum Innenstadt, University of Munich) from 1984 to 1989. After 1-4 years, it was possible to question 90% of the patients, and 75% were also examined clinically and radiologically. The most frequent cause of fracture was a heavy impact, whereas sporting injuries accounted for only 13%. Thus, there was a high incidence (39%) of severe fractures (type C, AO classification) with tissue damage. The initial operative procedure was minimal osteosynthesis in 77% of the patients and tibial plate fixation in 20%. Delayed wound healing was observed in 17% with a rate of osteitis of 5%. The follow-up examination showed good to excellent results in 74%, and in two-thirds of the patients only minor arthrotic changes or none of all were found. Despite less severe fracture types in the group with tibial plate stabilization they more frequently had impaired wound healing (27% vs 14%) and severe posttraumatic arthrosis (43% vs 18%) than patients with minimal osteosynthesis. The results are discussed.

Adult↗