Juergen Raunest

Morbidität und Letalität bei hüftgelenknahen Femurfrakturen im höheren Lebensalter Ergebnisse einer prospektiven Studie

ZusammenfassungZiel der vorliegenden Studie ist eine Isolierung individueller Dispositionen und Risikofaktoren, die im peri- und postoperativen Verlauf nach Versorgung koxaler Femurfrakturen zu Komplikationen und Letalität disponieren. Patientengut und Methodik. In einer konsekutiven Serie von 278 Patienten (Alter: 78,7±6,2 Jahre) mit einer operativ versorgten koxalen Femurfraktur wurden präoperativ anhand definierter Kriterien internistische Vorerkrankungen und Risikofaktoren dokumentiert und mit perioperativen Komplikationen in einer multivariaten Analyse korreliert. Letalität und Todesursachen wurden in einem postoperativen Beobachtungszeitraum von 1 Jahr erfasst und in Bezug zu Vorerkrankungen und Operationstrauma gesetzt.Eine Mulitmorbidität im Sinne ≥3 relevanter Vorerkrankungen bestand bei 117 Patienten; eine solitäre Vorerkrankung lag in 25 Fällen vor; lediglich 19 Patienten waren ohne Risikofaktoren. Mit einer Prävalenz von 64,4% dominierten kardiovaskuläre Erkrankungen, gefolgt von Diabetes mellitus (21,9%) und pulmonalen Erkrankungen (20,1%). Ergebnisse. Unspezifische perioperative Komplikationen traten bei 118 Patienten (42,4%) auf. Hierbei überwogen in 25,5% kardiovaskuläre Folgeveränderungen, obstruktive Ventilationsstörungen (10,1%) und Pneumonien (12,2%). 21 Patienten (7,6%) verstarben perioperativ, weitere 55 im ersten postoperativen Jahr (27,3%). Multimorbide Patienten erlitten mit 68,4% gegenüber dem Restkollektiv mit 23,6% signifikant häufiger postoperative Komplikationen (p<0,001).In der multivariaten Analyse ergibt die Kombination “Multimorbidität” und “Lebensalter >78 Jahre” ein signifikant erhöhtes Risiko zum komplizierten oder letalen perioperativen Verlauf. Hierbei bildet die Kombination von kardiovaskulären, pulmonalen und renalen Vorerkrankungen eine signifikante Disposition. Schlussfolgerung. Im Vorfeld der Operation müssen die entsprechend disponierten Risikopatienten identifiziert werden, um ihnen eine adäquate perioperative Vorbereitung und Überwachung zukommen zu lassen. Darüber hinaus unterstreichen die Ergebnisse die essentielle Bedeutung einer operativen Frühversorgung innerhalb von 12–24 h nach dem Trauma. Im Hinblick auf eine erfolgreiche Frührehabilitation stellen primär belastungsstabile Osteosyntheseverfahren die Operation der Wahl dar.AbstractThis study was designed to determine risk factors and individual dispositions associated with morbidity and mortality in the operative treatment of hip fractures in elderly patients. Patients and methods. In a prospective clinical trial, a consecutive series of 278 patients (mean age: 78.7±6.2 years) with a hip fracture treated by internal fixation or arthroalloplasty was recorded prospectively concerning preexistent diseases and risk factors. Based upon a multivariate analysis the data were related to perioperative complications and mortality. A follow-up during the first postoperative year was performed to determine mortality rate and causes of deaths. Polymorbidity within the meaning of 3 preexistent diseases was present in 117 cases; a solitary disease was found in 25 patients. Only 19 patients were without significant risks representing a comorbidity of 93.2%. In 64.4% diseases of the cardiovascular system were detected followed by diabetes mellitus (21.9%) and diseases of the respiratory tract (20.1%). Results. In the postoperative course systemic complications were observed in 118 patients indicating a general morbidity of 42.4%. According to the preexistent diseases recorded, cardiovascular complications (25.5%), obstructive ventilatory diseases (10.1%) and pneumonias (12.2%) were the most common complications. During hospital stay 21 patients died (mortality: 7.6%). A total of 76 patients died during the first postoperative year corresponding to a mortality rate of 27.3%. Postoperative complications were observed in patients with polymorbidity at 68.4% which differs significantly with the morbidity of low-risk patients at 23.6% (p<0.001).Multivariate analysis revealed a combination of polymorbidity and age beyond 78 years as significant risk factors towards morbidity and mortality. In detail, a prevalence of cardiovascular insufficiency, pulmonary disease and disturbance of renal function was found to be a significant disposition. Conclusions. During the preoperative course high risk patients should be identified according to the data presented above in order to take all measures necessary in critical care during the perioperative period. Furthermore, the results underline the importance of an early operative treatment within a posttraumatic period of 12–24 hours. Concerning the method of fracture stabilization procedures allowing a primary full loading should be favoured with regard to early rehabilitation.

Behandlung der Wirbelsäulenfraktur bei ankylosierender Spondylitis

ZusammenfassungAnhand von Kasuistiken werden auf dem Hintergrund einer Literaturübersicht klinische Richtlinien zur Versorgung der Wirbelsäulenfrakturen bei M. Bechterew abgeleitet. Durch pathologische Veränderungen der Knochenstruktur ist der primäre Frakturnachweis anhand konventioneller Röntgenaufnahmen schwierig. Die Indikation zur CT- bzw. MRT-Untersuchung ist dementsprechend weit zu stellen. Aufgrund der hohen Frakturinstabilität und der Häufigkeit neurologischer Komplikationen nach Sekundärdislokation besteht mehrheitlich eine Indikation zur operativen Stabilisierung. Hierbei ist eine langstreckige Osteosynthese über mindestens 5 Bewegungssegmente bei dorsaler oder kombiniert ventraler Instrumentierung erforderlich.AbstractClinical guidelines for the treatment of vertebral fractures associated with ankylosing spondylitis are derived from case reports and a review of literature. The coincidence of paravertebral calcifications and fracture formations leads to problems in the establishment of a proper initial diagnosis. Therefore computed tomography and magnetic resonance imaging have to be employed to define the extent of fracture and the presence of spinal lesions. As a rule vertebral fractures based upon spondylitic alterations are extremely unstable and tend to secondary dislocation with a high risk of spinal cord injuries. Operative osteosynthesis is the method of choice in the fracture treatment. A successful stabilization requires an extended spondylodesis comprising at least five vertebral segments by a dorsal or a combined ventral instrumentation.

[Clinical results of Palmer's primary cruciate ligament insertion without augmentation].

ZusammenfassungIn einer retrospektiven Studie wird der klinische Stellenwert der primären Kreuzbandreinsertion nach Palmer ohne Augmentation in der Behandlung akuter Kreuzbandrupturen anhand klinischer Langzeitbefunde von 51 Patienten diskutiert. Auf der Basis standardisierter Beurteilungskriterien ergab sich bei 38 Patienten ein gutes und sehr gutes Resultat, in elf Fällen wurde das Ergebnis als befriedigend und bei zwei Patienten als schlecht beurteilt. In zwei Fällen bestand ein deutlich positiver Lachman-Test in Verbindung mit einem Pivot-Shift-Phänomen Grad III. Eine mäßiggradige Instabilität mit einem Pivot-Shift Grad IIa bzw. IIb war bei zwölf Patienten festzustellen, während der Eingriff in 37 Fällen zur völligen Wiedererlangung der Gelenkstabilität geführt hat. Die Koinzidenz von Kreuzbandruptur und Innendbandläsion beeinträchtigt die postoperative Gelenkinstabilität signifikant (p<0,01). Die vorliegenden Ergebnisse lassen den Schluß zu, daß eine primäre Reinsertion des vorderen Kreuzbandes ohne synchrone Augmentation bei strenger Indikationsstellung, das heißt akute Ruptur, femoraler Ausriß und erhaltene Stabilität der Kollateralbänder, ein adäquates Operationsverfahren darstellt, das zur völligen Wiederherstellung der Gelenkstabilität geeignet ist.AbstractThe clinical importance of primary cruciate ligament reconstruction without augmentation-plasty is discussed on the background of long term results following 51 operations. Based on standardized methods of evaluation 38 patients had a very good and good result, in eleven cases the operation lead to a fair and in two cases to a poor result. A significant instability with a pivot shift grade III was recorded in two cases; twelve patients showed a low degree of instability whereas 37 patients had regained full stability. The coincidence of a cruciate ligament lesion and a rupture of a collateral ligament had a negative influence on the postoperative long term result (p<0.01). Our results suggest that a primary repair without augmentation-plasty is a qualified procedure for stabilizing the knee joint in cases with an acute femoral rupture without accompanying collateral lesions. In patients with old ruptures or a complex joint lesion primary repair with augmentation is recommended.The clinical importance of primary cruciate ligament reconstruction without augmentation-plasty is discussed on the background of long term results following 51 operations. Based on standardized methods of evaluation 38 patients had a very good and good result, in eleven cases the operation lead to a fair and in two cases to a poor result. A significant instability with a pivot shift grade III was recorded in two cases: twelve patients showed a low degree of instability whereas 37 patients had regained full stability. The coincidence of a cruciate ligament lesion and a rupture of a collateral ligament had a negative influence on the postoperative long term result (p less than 0.01). Our results suggest that a primary repair without augmentation-plasty is a qualified procedure for stabilizing the knee joint in cases with an acute femoral rupture without accompanying collateral lesions. In patients with old ruptures or a complex joint lesion primary repair with augmentation is recommended.

Acute acalculous cholecystitis in severely traumatized patients: a prospective sonographic study

SummaryAcute acalculous cholecystitis is a well known complication in severely traumatized patients. Existing data originate from retrospective analyses and episodic case reports. In a prospective ultrasonographic study 25 polytraumatized patients admitted to our intensive care unit between January 1, 1989, and December 31, 1989, were examined in daily intervals for this condition. Trauma scoring was performed according to the injury severity score (ISS) and polytrauma score (PTS). “Stress cholecystitis” was defined as a combination of hydrops of the gallbladder, an increased mural thickness (>3.5 mm), and the demonstration of “sludge.” We were able to demonstrate this diagnostic triad in four out of 25 patients (=16%). As a consequence early elective cholecystectomy was done in one patient. The remaining patients were treated conservatively. The incidence of stress cholecystitis in severely traumatized patients is probably higher than figures so far published suggest. Ultrasonography is a reliable method of early detection and follow-up for this complication.

The Incidence of Myocardial Contusion in 160 Patients with Blunt Chest Trauma Diagnostic Criteria and Outcome

The incidence of myocardial contusion after blunt chest trauma has been reported in 8.2 to 75% of trauma patients. We performed this study to report on the incidence of myocardial contusion in order to determine the frequency and to describe the type of complications in these patients.We conducted a retrospective analysis over a period of 4 years. There were 160 patients with a blunt chest trauma which were admitted to our hospital.Myocardial contusion occurred in 27 of our patients with blunt chest trauma (16.9%). In all these patients typical ECG-changes could be found during hospitalization (100%). The incidence of further pathological findings in the 27 patients was 30% for the auscultation, 37% for cardiac enzymes (MB-fraction), and 41% for the echocardiography. Cardiac complications like arrhythmias, cardiac failure and tamponade occurred in 20 patients (74%).Early diagnosis of myocardial contusion in patients with blunt chest trauma is important to prevent and to treat possible complications. ECG-controls have the highest sensitivity to detect a myocardial contusion, whereas cardiac enzymes and echocardiograms seem to be poor markers of blunt myocardial injury.

Die Lebensqualität des alten Menschen nach coxaler Femurfraktur — Ergebnisse einer prospektiven Studie

Ziel der vorliegenden prospektiven Studie ist eine Analyse der medizinischen und sozialen Rehabilitation des alten Menschen nach operativer Behandlung einer coxalen Femur-fraktur.