Biomedical subjects
Publications and source records attributed to J Poigenfürst.
If the iliotibial band should have a satisfactory function in order to improve suture or replacement of the anterior cruciate ligament the best point of fixation for tractopexy is the slope from the lateral femoral condyle to the femoral shaft in its dorsal third. In addition the position of the knee joint at the time of fixation is of importance. The angle should theoretically be 43 degrees.
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We report on 2 cases with complications after implantation of Biorod. These seem to be the result of tissue reaction to the material. According to the manufacturer, such complications have been observed in 6 to 10% of the cases. These observations have not been published so far.
Oto-audiograms were taken from 50 patients following skull and brain injuries. 22 of them (44%) showed a deterioration of their hearing which was of traumatic origin with high probability. 10 of them (20%) had deterioration of their hearing which was most questionably caused by the trauma. Between 1 and 1 1/2 years later 19 from 22 respectively 9 from 10 patients were reexamined all together. There were 9 improvements, 5 deteriorations and 10 unchanged oto-audiograms. As many injured people do not realize a one-sided deterioration of their hearing, oto-audiograms should routinely be made after head and brain injuries. The secondary deteriorations observed, demonstrate the necessity of otologic aftercare.
Early results obtained in 23 Monteggia-type fractures were analysed. Osteosynthesis of the fracture of the ulnar shaft has to be carried out according to the art. Application of a plate on the radial or the ulnar side always leads to secondary angulation. If primary resection of the radial head is carried out poor results must be expected. The fractured radial head should be reconstructed, replaced by an implant, or at least left in place until the fracture of the ulna is consolidated. In Monteggia type-I/6 fractures the coronoid process must be reliably stabilized. Conservative treatment is inadequate for Monteggia-type fractures.
This report deals with the surgical technique and the results of stabilisation of 10 medial ankle fractures using Biofix C rods. They are cylindrical, biodegredable rods. Biorod is constructed of self-reinforced composite material. It consists of polyglycolide matrix with polyglcolide fibers. The bending strength of the material before operation is more than 200 MPa, exceeding 20-30 times the strength of cancellous bone. The material looses its mechanical strength in hydrolitic conditions during 5-6 weeks and dissolves totally during the following months. Our experience with a self developed guiding tool for the implantation of the Biorod is presented. All fractures healed without any notable complications. As of the 8th day full weight bearing was allowed in a below knee plaster cast for 6 weeks.
According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. Deep breathing and expectoration were easier, so that the use of respirators and other artificial breathing aids could be avoided or at least reduced in duration in some cases. This makes the method particularly suitable for use in the management of polytraumatized patients. The standard dose was a mixture of 3.3 mg morphine and 37.5 mg bupivacaine (= 1/3 ampoule morphine + 15 ml Carbostesin 0.25%) every 12 h. When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).
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Only some fractures of the humerus-shaft or the shaft of radius and ulna can be called extra-articular fractures of the elbow. These fractures occur mostly in the still growing bone or in bones with abnormal structure. The treatment consists in adults in open reduction and osteosynthesis, in adolescents and children percutaneous methods of fixation can be recommended. Conservative and early functional treatment are only indicated in very few cases. Lesions of nerves and vessels are relatively common.
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The effect of either (randomized) Heparin/Dihydroergotamine (HDHE) or heparin-acenocoumarin (Hep/S) on the incidence of deep-vein thrombosis in the legs was studied in 212 women of more than 60 years of age with hip fractures. All patients were screened with the 125-I-fibrinogen uptake test (FUT) confirmed by a bilateral ascending venogram upon positive FUT. This revealed good sensitivity and specificity (85/84%) for the FUT. Deep vein thrombosis developed in 37.6% of the HDHE group and in 59.1% of the Hep/S group which was significantly different (p less than 0.005). The calculated thrombosis risk was significantly diminished (by 38% - p less than 0.005) in the HDHE group. Therefore we conclude that in traumatology Heparin/Dihydroergotamine seems to be the prophylaxis of choice.
In two trauma units 63 patients with 65 fresh fractures of the clavicle were treated by plating, applying strict indications for the selection of the patients for surgery. The straight reconstruction plate 3.5, DCP 2.7 and in very slim clavicles the straight reconstruction plate 2.7 proved to be the most useful implants. With correct indication and good operative technique plating leads nearly always to healing in anatomic position with good functional results. The course of 60 fractures could be analysed. 57 patients with 58 fractures were followed. One polytraumatised woman with bilateral fractures died. Seven complications with negative influence on the result were observed: four pseudarthroses following loosening, bending or breaking of the plate, three refractures after removal of the plate. There was no infection. That means, that technical complications with bad results occurred in about 1/10 of the operations. All seven were multiple fragment fractures in the middle of the clavicular shaft. It therefore seems that complications could be avoided by using a different technique or a different implant.
The optimal prior conditions for the following medical supply in the hospital can only be reached by quick and correct diagnosis and by starting the therapy immediately on the place of accident. After cardio-pulmonary restitution it is possible to realize the dimension of the trauma in a short time if you use first a cranio-caudal inspection and second an inspection of the extremities from peripher to central. By injuries of the vertebral column a short neurological general view is an indication for a complete or incomplete paralysis and so you can choose the correct method for the following rescue. Through reposition, splint and a correct bandage it is possible to lower the risk of infections especially by open fractures of the lower leg. The prior conditions of a correct primary therapy on the place of the accident are a faultless organisation of the life guard service and a high level of medical treatment.
At the Accident Hospital Lorenz Böhler and the Accident Hospital Meidling in Vienna, 48 patients with proximal humeral fractures were treated by closed reduction, intramedullary fixation with elastic pins and immobilization for two weeks in a Velpeau type stockinette (Gilchrist) between February 1985 and February 1986. The pins have a diameter of 2 mm. At there lower end there is a 20 mm long elastic curve which is ment to anker the pin in the entry hole to the intramedullary cavity, preventing sliding out of the implant. At the upper end the last 20 mm of the wire are angulated for 15 degrees. AO-classification was used. 39 patients had surgical neck-fractures. There were 34 displaced fractures (AO-type A 2/2), six dislocation- and more segment fractures and three epiphyseal separations of the adductiontype. The functional results of 36 patients were evaluated according to Neer's table. 29 patients had more than 80 points, four patients had more than 70 points and three had poor results. Reason for poor results was in one case a fracture with dislocation of the greater tuberosity which should have been treated by open reduction and the age in a 82 year old patient, who had a poor functional result after twelve weeks of treatment despite good fracture healing. There were no problems with wound healing, infections, myositis ossificans or Sudeck disease. Closed reductions of unstable surgical neck fractures and intramedullary fixation causes least damage to the soft tissues of the shoulder, leading to early good functional results.
Posterior dislocations of the shoulder can be caused by various mechanisms, the most common one, being epileptic seizures. Therefore many patients or their relatives hesitate to admit, how the injury has actually occurred. Spängler et al. published in 1975 several reasons why the diagnosis of "posterior subluxation of the humeral head" is often missed. Usually very typical errors in the evaluation of the clinical findings lead to misinterpretation of the radiograms. In spite of the fact that long-term results of untreated posterior subluxations can be surprisingly good, reduction must be achieved as soon as possible. Deep impression-fracture of the humeral head are the cause of recurrent dislocations. Various methods have been described to treat this condition by filling the defect with subscapularis tendon or cancellous bone. Avulsion-fractures of the posterior rim of the glenoid can successfully be refixed with small screws. In case of dislocation fractures through the anatomical neck, prosthetic replacement of the head leeds to satisfying results. So-called habitually dislocations are more common in boys and do usually not require surgery, as the inclination to dislocate becomes less frequent in later years. Only in adults operation may be indicated. Posterior apposition of a bone graft can be recommended.
The term "early infection" should only be used for infections of the soft tissues. Involvement of the major fragments or the medullary cavity indicates either delayed diagnosis or insufficient surgical revision. In addition to already postulated rules of treatment, two further conclusions are being drawn: 1. occasionally it is necessary to apply conservative methods of immobilisation. 2. if careful observation is guaranteed larger fragments may be left in place, as long as they are still in contact with one of the major fragments. At least partial revascularisation is possible.
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