Wolf Mutschler

Flexible intramedullary nailing for stabilization of displaced midshaft clavicle fractures: technique and results in 87 patients.

Backgroundu2003Elastic, stable intramedullary nailing (ESIN) with titanium nails is a promising minimally treatment for displaced midclavicular fractures, which may be an alternative to plate fixation (ORIF) or even nonoperative treatment. We describe the surgical technique and outcome in 87 patients. Methodsu2003The nail was inserted at the medial inferior end of the clavicle in 83 patients and in the acromial end in 12 patients. An open fracture reduction via an additional small incision was necessary in 53 patients and closed manoeuvre was successful in 42. Implant removal was performed in 82 patients. Resultsu2003The functional status of 87 patients after 13 months reached 6.8 (0–43) points on the DASH score and 81 (46–100) points on the self-reported Constant score. The fracture healed in correct anatomical axis in 80 of 87 patients, 2 cases ended in a nonunion. Implant migration of the nail occurred in 4 patients, who required early implant removal. Repeated nailing was necessary in 2 patients in whom the nail missed the lateral medullar canal, and plate fixation was necessary in 2 other patients who had secondary dislocation after early nail removal. Interpretationu2003Flexible intramedullary nailing, a minimally invasive technique for stabilization of displaced midshaft clavicle fractures, has minor risks and complications.

Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study

BackgroundFor patients safety reasons, current American Heart Association and European Resuscitation Council guidelines recommend intraosseous (IO) vascular access as an alternative in cases of emergency, if prompt venous catheterization is impossible. The purpose of this study was to compare the IO access as a bridging procedure versus central venous catheterization (CVC) for in-hospital adult emergency patients under resuscitation with impossible peripheral intravenous (IV) access. We hypothesised, that CVC is faster and more efficacious compared to IO access.MethodsA prospective observational study comparing success rates and procedure times of IO access (EZ-IO, Vidacare Corporation) versus CVC in adult (≥18 years of age) patients under trauma and medical resuscitation admitted to our emergency department with impossible peripheral IV catheterization was conducted. Procedure time was defined from preparation and insertion of vascular access type until first drug or infusion solution administration. Success rate on first attempt and procedure time for each access route was evaluated and statistically tested.ResultsTen consecutive adult patients under resuscitation, each receiving IO access and CVC, were analyzed. IO access was performed with 10 tibial or humeral insertions, CVC in 10 internal jugular or subclavian veins. The success rate on first attempt was 90% for IO insertion versus 60% for CVC. Mean procedure time was significantly lower for IO cannulation (2.3 min ± 0.8) compared to CVC (9.9 min ± 3.7) (p < 0.001). As for complications, failure of IO access was observed in one patient, while two or more attempts of CVC were necessary in four patients. No other relevant complications, like infection, bleeding or pneumothorax were observed.ConclusionPreliminary data demonstrate that IO access is a reliable bridging method to gain vascular access for in-hospital adult emergency patients under trauma or medical resuscitation with impossible peripheral IV access. Furthermore, IO cannulation requires significantly less time to enable administration of drugs or infusion solutions compared to CVC. Because CVC was slower and less efficacious, IO access may improve the safety of adult patients under resuscitation in the emergency department.

Consistency of Long-Term Outcome of Acute Rockwood Grade III Acromioclavicular Joint Separations After K-Wire Transfixation

BACKGROUNDnSurgical approach to acute Rockwood grade III acromioclavicular (AC) joint injuries demands satisfying and reliable treatment results of shoulder function in the long term. This study investigates the operative outcome of acute grade III AC joint separations after temporary K-wire transfixation of the AC joint over the years. We hypothesize, that the well-established temporary articular transfixation of acute Rockwood grade III AC joint dislocations with K-wires provides good and consistent functional outcome at long term.nnnMETHODSnSeventy patients who underwent temporary articular transfixation of the AC joint followed by a standardized rehabilitation program and early physiotherapeutic exercising were divided into three follow-up cohorts. The treatment results were investigated 1 to 2 years (short-term, group A, n = 18), 3 to 5 years (mid-term, group B, n = 33), and 6 to 10 years (long-term, group C, n = 19) after surgical procedure. The outcome was measured using a standardized functional patient questionnaire including Constant score, ASES rating scale, SPADI, and XSMFA-D score. The results given in average and mean +/- SD were compared between the three cohorts by calculating the Kruskal-Wallis one way analysis for variance on ranks.nnnRESULTSnAverage patient age at time of surgical therapy was 37 (+/-11) years without significant difference between the three cohorts. Independent of follow-up period all patients demonstrated good functional treatment results in the long run expressed by an over all Constant score of 88 (+/-10) points, ASES rating scale of 29 (+/-3) points, SPADI of 3 (+/-9) points, XSMFA-D function score of 13 (+/-2) points, and XSMFA-D impairment score of 4 (+/-1) points, respectively. The comparison of the three follow-up groups proved no significant differences in outcome over a maximum follow-up period of up to 10 years. However, the longer the follow-up period, the tendency of the promising treatment outcome becomes more stable.nnnCONCLUSIONSnTemporary K-wires fixation of acute Rockwood grade III AC joint separations enable good long-term results in shoulder function. The achieved functional outcome parameters reveal a high consistency in the long run over the years.

Monoaxial Versus Polyaxial Screw Insertion in Angular Stable Plate Fixation of Proximal Humeral Fractures: Radiographic Analysis of a Prospective Randomized Study

BACKGROUNDnMonoaxial and polyaxial screw insertion are used in angular stable plating of displaced proximal humeral fractures. Aim of the study was to compare both fixation techniques by radiographic evaluation.nnnMETHODSnProspective randomized treatment with monoaxial or polyaxial screw insertion in angular stable anatomic preshaped plates of displaced proximal humeral fractures. Analysis of standardized true anterior-posterior (true a.p.) and outlet-view radiographs at 1 day, 6 weeks, 3 months, and 6 months after surgery by two radiologists with respect to radiographic evidence of secondary varus displacement, cut out of screws, osteonecrosis, and hardware failure. Secondary varus displacement was defined as a varus decrease of the humeral head-shaft angle of > 10 degree in true a.p. radiographs.nnnRESULTSnSixty-six consecutive patients (48 women, [72.7%]; 18 men, [27.3%]; mean age 67.7 years [95% CI, 63.9-71.6]) with displaced proximal humeral fractures were evaluated in this study. Nineteen patients (29%) showed secondary varus displacement of > 10-degree angle. In 6 cases (9%), intra-articular cut out of screws was found. Furthermore, 1 case (2%) of nonunion was observed. No relationship between monoaxial and polyaxial screw insertion was found regarding occurrence of secondary varus displacement (monoaxial, 11/polyaxial, 8; p = 0.91) or screw cut out (monoaxial, 4/polyaxial, 2; p = 0.64). Prevalence of secondary varus displacement and hardware cut out was related to patients age (p = 0.02) and fracture pattern, according to Neer- and AO/OTA-classification (p < 0.001). The average immediate postoperative head-shaft angle was 135.2 degrees (CI, 132.3-138.1) in the group without radiographic complication, compared with 126.7-degree angle (CI, 123.6-129.7) among those with secondary varus displacement of > 10-degree angle and screw cut out (p < 0.001). Furthermore, in cases of an immediate postoperative head-shaft angle of < 130 degrees, there was a 48% incidence of secondary varus dislocation (n = 13) versus 15% in cases with a head-shaft angle > 130 degrees (n = 6, p = 0.004).nnnCONCLUSIONnMonoaxial and polyaxial screw insertion allow for mechanical stabilization in angular stable plating of unstable proximal humerus fractures. Radiographic evidence of secondary varus displacement of > 10-degree angle and screw cut out was seen similarly often in both fixation techniques. To avoid secondary varus displacement and screw cut out, restoration of a humeral head-shaft angle of > 130 degrees seems to be important in monoaxial and polyaxial fixation of proximal humeral fractures.

Early down-regulation of the pro-inflammatory potential of monocytes is correlated to organ dysfunction in patients after severe multiple injury: a cohort study

IntroductionSevere tissue trauma results in a general inflammatory immune response (SIRS) representing an overall inflammatory reaction of the immune system. However, there is little known about the functional alterations of monocytes in the early posttraumatic phase, characterized by the battle of the individual with the initial trauma.MethodsThirteen patients with severe multiple injury; injury severity score (ISS) >16 points (17 to 57) were included. The cytokine synthesis profiles of monocytes were characterized on admission, and followed up 6, 12, 24, 48, and 72 hours after severe multiple injury using flow cytometry. Whole blood was challenged with lipopolysaccharide (LPS) and subsequently analyzed for intracellular monocyte-related TNF-α, IL-1β, IL-6, and IL-8. The degree of organ dysfunction was assessed using the multiple organ dysfunction syndrome (MODS)-score of Marshall on admission, 24 hours and 72 hours after injury.ResultsOur data clearly show that the capacity of circulating monocytes to produce these mediators de novo was significantly diminished very early reaching a nadir 24 hours after severe injury followed by a rapid and nearly complete recovery another 48 hours later compared with admission and controls, respectively. In contrast to the initial injury severity, there was a significant correlation detectable between the clinical signs of multiple organ dysfunction and the ex vivo cytokine response.ConclusionsAs our data derived from very narrow intervals of measurements, they might contribute to a more detailed understanding of the early immune alterations recognized after severe trauma. It can be concluded that indeed as previously postulated an immediate hyperactivation of circulating monocytes is rapidly followed by a substantial paralysis of cell function. Moreover, our findings clearly demonstrate that the restricted capacity of monocytes to produce proinflammatory cytokines after severe injury is not only an in vitro phenomenon but also undistinguishable associated with the onset of organ dysfunction in the clinical scenario.

Analysis of N-terminal pro-B-type natriuretic peptide and cardiac index in multiple injured patients: a prospective cohort study

IntroductionIncreased serum B-type natriuretic peptide (BNP) has been identified for diagnosis and prognosis of impaired cardiac function in patients suffering from congestive heart failure, ischemic heart disease, and sepsis. However, the prognostic value of BNP in multiple injured patients developing multiple organ dysfunction syndrome (MODS) remains undetermined. Therefore, the aims of this study were to assess N-terminal pro-BNP (NT-proBNP) in multiple injured patients and to correlate the results with invasively assessed cardiac output and clinical signs of MODS.MethodsTwenty-six multiple injured patients presenting a New Injury Severity Score of greater than 16 points were included. The MODS score was calculated on admission as well as 24, 48, and 72 hours after injury. Patients were subdivided into groups: group A showed minor signs of organ dysfunction (MODS score less than or equal to 4 points) and group B suffered from major organ dysfunction (MODS score of greater than 4 points). Venous blood (5 mL) was collected after admission and 6, 12, 24, 48, and 72 hours after injury. NT-proBNP was determined using the Elecsys proBNP® assay. The hemodynamic monitoring of cardiac index (CI) was performed using transpulmonary thermodilution.ResultsSerum NT-proBNP levels were elevated in all 26 patients. At admission, the serum NT-proBNP values were 116 ± 21 pg/mL in group A versus 209 ± 93 pg/mL in group B. NT-proBNP was significantly lower at all subsequent time points in group A in comparison with group B (P < 0.001). In contrast, the CI in group A was significantly higher than in group B at all time points (P < 0.001). Concerning MODS score and CI at 24, 48, and 72 hours after injury, an inverse correlation was found (r = -0.664, P < 0.001). Furthermore, a correlation was found comparing MODS score and serum NT-proBNP levels (r = 0.75, P < 0.0001).ConclusionsSerum NT-proBNP levels significantly correlate with clinical signs of MODS 24 hours after multiple injury. Furthermore, a distinct correlation of serum NT-proBNP and decreased CI was found. The data of this pilot study may indicate a potential value of NT-proBNP in the diagnosis of post-traumatic cardiac impairment. However, further studies are needed to elucidate this issue.

Hallux rigidus: Joint preserving alternatives to arthrodesis - a review of the literature.

Hallux rigidus describes the osteoarthritis of the first metatarsophalangeal joint. It was first mentioned in 1887. Since then a multitude of terms have been introduced referring to the same disease. The main complaints are pain especially during movement and a limited range of motion. Radiographically the typical signs of osteoarthritis can be observed starting at the dorsal portion of the joint. Numerous classifications make the comparison of the different studies difficult. If non-operative treatment fails to resolve the symptoms operative treatment is indicated. The most studied procedure with reproducible results is the arthrodesis. Nevertheless, many patients refuse this treatment option, favouring a procedure preserving motion. Different motion preserving and joint sacrificing operations such as arthroplasty are available. In this review we focus on motion and joint preserving procedures. Numerous joint preserving osteotomies have been described. Most of them try to relocate the viable plantar cartilage more dorsally, to decompress the joint and to increase dorsiflexion of the first metatarsal bone. Multiple studies are available investigating these procedures. Most of them suffer from low quality, short follow up and small patient numbers. Consequently the grade of recommendation is low. Nonetheless, joint preserving procedures are appealing because if they fail to relief the symptoms an arthrodesis or arthroplasty can still be performed thereafter.

Concentration kinetics of serum MMP-9 and TIMP-1 after blunt multiple injuries in the early posttraumatic period.

Metalloproteinases are secreted in response to a variety of inflammatory mediators and inhibited by tissue inhibitors of matrixmetalloproteinases (TIMPs). Two members of these families, MMP-9 and TIMP-1, were differentially expressed depending on clinical parameters in a previous genomewide mRNA analysis. The aim of this paper was now to evaluate the posttraumatic serum levels and the time course of both proteins depending on distinct clinical parameters. 60 multiple traumatized patients (ISS > 16) were included. Blood samples were drawn on admission and 6u2009h, 12u2009h, 24u2009h, 48u2009h, and 72u2009h after trauma. Serum levels were quantified by ELISA. MMP-9 levels significantly decreased in the early posttraumatic period (P < 0.05) whereas TIMP-1 levels significantly increased in all patients (P < 0.05). MMP-9 and TIMP-1 serum concentration kinetics became manifest in an inversely proportional balance. Furthermore, MMP-9 presented a stronger decrease in patients with severe trauma and non-survivors in contrast to minor traumatized patients (ISS ≤ 33) and survivors, initially after trauma.

Pathway analysis in microarray data: a comparison of two different pathway analysis devices in the same data set.

Oligonucleotide microarray technology has been developed to a very powerful and favorable biotechnique. However, it is an explicit challenge to judge the potential biological meaning of such extensive amounts of data. There are various-commercially available or free-software applications for pathway analyses on microarray data on the market. The aim of the present study was to test whether pathway analyses on the same data set using different commercially available devices lead to roughly comparable or massively diverging results and, if so, to give potential explanations. Two different commercially available pathway analysis programs (GeneGo and Pathway Studio 6) have been elected. The programs have been compared concerning their different analyses tools, underlying databases, database constructions, and network-building algorithms. The same data set has been uploaded into two different programs. Pathway analysis was performed according to the following three criteria: the five top networks, the five top diseases, and the five top canonical networks that are associated with the uploaded gene list. The different programs differ in extracting their information from the literature, in database construction, and network-building algorithms. The top networks, as suggested by the programs as to be most important, substantially differ from each other and share only one same gene. Concerning the most represented diseases in the data set, there are certain overlaps but no uniform results in the different applications. Pathway analyses of microarray data using preformed software devices offer valuable options for investigating on the biological relevance and function of a focus gene set. However, there is no standard in constructing such programs. This leads to substantial differences when investigating on the same data set using different devices. The intention of this work is to sensitize for the potentialities and also pitfalls doing pathway analysis using automated software tools.

Neurovascular complications due to the Hippocrates method for reducing anterior shoulder dislocations.

In spite of the fact that the Hippocrates method hardly has been evaluated in a scientific manner and numerous associated iatrogenic complications have been reported, this method remains to be one of the most common techniques for reducing anterior shoulder dislocations. We report the case of a 69-year-old farmer under coumarin anticoagulant therapy who sustained acute first time anterior dislocation of his dominant right shoulder. By using the Hippocrates method with the patient under general anaesthesia, the brachial vein was injured and an increasing hematoma subsequently caused brachial plexus paresis by pressure. After surgery for decompression and vascular suturing, symptoms declined rapidly, but brachial plexus paresis still was not fully reversible after 3 mo of follow-up. The hazardousness of using the Hippocrates method can be explained by traction on the outstretched arm with force of the operators body weight, direct trauma to the axillary region by the physicians heel, and the topographic relations of neurovascular structures and the dislocated humeral head. As there is a variety of alternative reduction techniques which have been evaluated scientifically and proofed to be safe, we strongly caution against the use of the Hippocrates method as a first line technique for reducing anterior shoulder dislocations, especially in elder patients with fragile vessels or under anticoagulant therapy, and recommend the scapular manipulation technique or the Milch technique, for example, as a first choice.