R. Küchle

Mid- to long-term results after bipolar radial head arthroplasty

BACKGROUND Radial head arthroplasty is considered the treatment of choice for unreconstructable radial head fractures in the acute fracture situation. Although short-term results in the current literature are promising, replacement of the radial head remains controversial as long-term results are still missing. We report our 8.8-year results after treatment with a bipolar radial head prosthesis by Judet. MATERIALS AND METHODS In our department, 19 patients were treated with bipolar radial head arthroplasty between 1997 and 2001. Seventeen of these patients-14 men and 3 women-were examined retrospectively after 106 months (range, 78-139). Of these, 9 patients were treated primarily, 7 patients secondarily, and 1 because of a tumor. RESULTS On the Mayo Elbow Performance Score, 6 patients achieved excellent results, 10 good, and one fair. The mean DASH score was 9.8 (range, 0-34). No differences were seen between primary and secondary implantation. Flexion averaged 124° (range, 110-150°), the extension deficit was 21° (range, 0-40°), pronation 64° (range, 30-90°), and supination 64° (range, 30-90°). The following complications were seen: 2 dislocations and 8 cases of degenerative changes of the capitellum, 1 with severe erosion. Signs of ulnohumeral arthrosis were found in 12 patients. No evidence of loosening, radiolucencies, or proximal bone resorption was detected. CONCLUSION Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judets bipolar prosthesis.

Diagnosing and Staging of Pancreatic Carcinoma – What Is Necessary?

The aim of the present prospective observational study was to diagnose and stage pancreatic carcinoma with a minimum of diagnostic procedures. Our experiences in 307 patients with a histologically confirmed pancreatic carcinoma show that for diagnosing pancreatic carcinoma sonography and computed tomography are sufficient in 95% of the cases. The combination of both has a sensitivity equal to that of endoscopic retrograde cholangiopancreatography (ERCP; 96.8 vs. 98.7%; n.s., χ2 test). ERCP is only indicated in cases with negative sonography and computed tomography, and suspicion of pancreatic cancer. For tumor staging, the routine performance of angiography cannot be recommended in view of the fact that although it provides greater sensitivity for the evaluation of an infiltration of the portal vein (80% for angiography vs. 22% for sonography or computed tomography), it is associated with a lower positive predictive value (56.4 vs. 68 and 72%) which results in a lower accuracy. Despite recent advantages in diagnostic technology, less than 50% of unresectable tumors were identified preoperatively at a 10% false-positive rate. The major reason for unresectability is infiltration into the mesenteric axis, which cannot be identified laparoscopically. Laparoscopy or percutaneous biopsy is recommended only in the presence of a tumor with suspicion of distant metastasis detected by radiological imaging and requiring histological confirmation. In conclusion, sonography and computed tomography as the only diagnostic images are sufficient for diagnosing and staging of pancreatic carcinoma in more than 95% of the patients. Only a small number of patients needs further diagnostic procedures.

Internal Fixation of Proximal Humeral Fractures: Current Concepts

AbstractFractures of the proximal humerus are an increasingly common type of injury. Mainly elderly patients with osteoporotic bone are affected. Whereas non-displaced and stable fractures are managed successfully with conservative treatment, there is no general agreement on the surgical strategy for displaced and unstable two- to four-part fractures. The clinical outcome is influenced by the fracture type and concomitant injury to the rotator cuff. Extensive surgical manipulation of the soft tissues, non-anatomic and/or unstable fixation as well as technical errors are important contributing factors to poor clinical results.Goals of surgical treatment are to restore anatomy, to achieve fixation that is stable enough to allow early mobilization, to avoid secondary displacement and not to harm the blood supply of the humeral head in order to minimize the risk for avascular necrosis.Minimally invasive procedures using closed reduction are advantageous for protection of the arterial blood supply. Plate fixation offers superior biomechanical stability. There is a recent tendency to use fixedangle implants for proximal humeral fractures in order to avoid secondary loss of fixation. Locked plates acting as internal fixator as well as intramedullary nails better adapt according to the biomechanical and anatomical characteristics of the proximal humerus. First clinical experience with those implants is encouraging but they do not compensate for an insufficient surgical technique.

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fractures of the humerus can be nailed with satisfying results. Basic ideas for humeral nailing are less invasive approaches to the humerus, less soft tissue damage, e.g. lower rates of radial nerve palsy, closed reduction and the biomechanical aspects of a central implant with elastic fixation properties. Nailing of diaphyseal humeral shaft fractures is an equivalent alternative to plating; nailing of proximal metaphyseal humeral fractures is still new and needs more reliable scientific data to clear its advantages compared to other fixation techniques. Nailing of distal metaphyseal humeral fractures is no serious option at the moment. Angular stable interlocking systems show better fixation qualities for proximal fractures or fracture components. Although in very osteoporotic bone cutouts are registered. Static interlocking is advisable. High torsional stability of the fracture fixation has to be achieved, since significant torsional load occurs during the usual movement of the upper limbs. As there is an important learning curve, possible complications of intramedullary nailing have to be kept in mind and avoided by a careful operation technique.

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.

Intramedullary osteosynthesis of the ulna in revision surgery

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.

DIE CHOLECYSTEKTOMIE BEIM HOCHRISIKOPATIENTEN: EIN VERGLEICH ZWISCHEN KONVENTIONELLEM UND LAPAROSKOPISCHEM VERFAHREN

Summary. 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 occured in 15 cases (33.3 %), whereby patients of the conventional cholcystectomy 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.Zusammenfassung. Die laparoskopischen Cholecystektomie bietet eine Reihe von Vorteilen, denen eine erhöhte Gefährdung kardiopulmonal vorgeschädigter Patienten durch die hämodynamischen und respiratorischen Auswirkungen des Pneumoperitoneums gegenübersteht. In der Zeit von Juni 1990 bis Dezember 1995 wurden 19 Hochrisikopatienten (ASA IV) laparoskopisch und 26 Patienten mit gleichem operativem Risiko (ASA IV) konventionell cholecystektomiert. Bei insgesamt 11,1 % (n = 5) an intraoperativen, kardiopulmonalen Komplikationen traten diese in beiden Gruppen annähernd gleichhäufig auf. Allgemeine, postoperative Komplikationen sahen wir in 33,3 % (n = 15) aller Fälle, wobei die konventionell operierten Patienten vermehrt betroffen waren [46,2 % (n = 12) vs. 15,8 % (n = 3), p = 0,03]. Die Liegedauer war in der Gruppe der offen operierten Patienten mit 11,6 ± 5,6 Tagen im Vergleich zu 7,6 ± 5 (Gruppe der laparoskopisch operierten Patienten) verlängert (p = 0,01). Die Einstufung als Hochrisikopatient bedeutet insgesamt eine Erhöhung der perioperativen Komplikationsrate, wobei bei gleichem intraoperativen Risiko die postoperative Komplikationsrate bei laparoskopischer Cholecystektomie niedriger ist.

Die laparoskopische Cholecystektomie beim Hochrisikopatienten

Summary. 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 occured 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.Zusammenfassung. Den Vorteilen der laparoskopischen Cholecystektomie steht eine erhöhte Gefährdung kardiopulmonal vorgeschädigter Patienten durch die hämodynamischen und respiratorischen Auswirkungen des Pneumoperitoneums gegenüber. In der Zeit von Juni 1990 bis Dezember 1995 wurden 19 Hochrisikopatienten (ASA IV) und 465 Patienten mit minderem Operationsrisiko (ASA I–III) laparoskopisch cholecystektomiert. Bei insgesamt 5 % (n = 24) an intraoperativen, kardiopulmonalen Komplikationen traten diese bei den Hochrisikopatienten mit 15,8 % (n = 3) vs. 4,5 % (n = 21) häufiger (p = 0,027) auf. Allgemeine, postoperative Komplikationen sahen wir bei 2,9 % (n = 14) aller Fälle, wobei ebenfalls die Patienten der Gruppe ASA IV vermehrt betroffen waren [15,8 % (n = 3) in der Gruppe ASA IV vs. 2,4 % (n = 11) in Gruppe ASA I–III (p < 0,001)]. Die Liegedauer war in der Hochrisikogruppe mit 7,6 ± 4,96 Tagen im Vergleich zu 4,8 ± 2,23 Tagen (Gruppe ASA I–III) verlängert (p = 0,022). Die Einstufung als Hochrisikopatient bedeutet insgesamt eine Erhöhung der perioperativen Komplikationsrate bei laparoskopischer Cholecystektomie, stellt jedoch keine grundsätzliche Kontraindikation für dieses Operationsverfahren dar.

STELLENWERT DES TUMORMARKERS CA 19-9 IN DER DIFFERENTIALDIAGNOSE VON RAUMFORDERUNGEN IM PANKREASKOPF

Summary. 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.Zusammenfassung. Bei 96 Patienten (duktales Pankreascarcinom, n = 34; periampulläres Carcinom, n = 43; chronische Pankreatitis, n = 19) wurde der Stellenwert des Tumormarkers CA 19–9 in der Differentialdiagnose bei Raumforderungen im Pankreaskopf retrospektiv überprüft. Die Sensitivität betrug für das duktale Carcinom 73,5 % und für den periampullären Tumor 48,8 % bei einer Spezifität von 63,2 %. Das carcinoembryonale Antigen war nur bei jedem 5. Patienten erhöht. Durch Kombination beider Tumormarker ließ sich die Sensitivität serologischer Tests nicht steigern. Die schlechte Spezifität von 63 %, die beim Vorliegen eines Verschlußikterus bis auf 33 % sinkt, erlaubt keine zuverlässige präoperative Differenzierung zwischen einem Carcinom und einer chronischen Pankreatitis. Ein postoperativ erhöhter CA-19–9-Serumspiegel weist auf persistierendes Tumorgewebe hin und ist mit einer statistisch signifikant schlechteren Prognose als bei normalen Marker verbunden.Schlüsselwörter: Pankreascarcinom – CA 19–9.

Der Einfluß des Operateurs auf die Behandlungsqualität bei akuter Appendicitis

Summary. 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.Zusammenfassung. Die Behandlungsqualität bei akuter Appendicitis wird von der Quote an Appendixperforationen, der Rate entfernter blander Appendices und der perioperativen Morbidität bestimmt. Im Rahmen einer prospektiven Datenerfassung wurden zwischen 1. 4. 1993 und 30. 7. 1996 alle 271 unter dem Verdacht einer akuten Appendicitis operierten Patienten erfaßt. Die Rate einer perforierten Appendicitis betrug 3,7 %, bei 19,6 % der Patienten fand sich eine blande Appendix. Bezogen auf den für die Indikationsstellung verantwortlichen Facharzt ergaben sich keine signifikanten Unterschiede in der Rate an Appendixperforationen, jedoch signifikante Unterschiede der Quote von Patienten mit blander Appendix (6,5–26 %). Ebenso ergaben sich signifikante Unterschiede der Rate an Wundheilungsstörungen. Eine Korrelation zwischen der Rate an Perforationen und blander Appendices ließ sich nicht feststellen. Der Operateur beeinflußt damit die Behandlungsqualität bei Verdacht auf Appendicitis durch Unterschiede in der Indikationsstellung und im operativen Vorgehen.