Duodenal anomalies and the ampulla of Vater

The results of the surgical correction of congenital duodenal anomalies in infants free of severe prematurity, mongolism or other intestinal anomalies are most favorable. Several uncommon defects involving the second part of the duodenum, which required special attention to the anatomic proximity of the ampulla of Vater and the terminal portion of the common bile ducts have been encountered. The recognition of this intimate relationship may prevent inadvertent injuries to these structures, further improving the results of operative procedures for these difficult congenital malformations.     

Sheath detachment during coronary arteriogram

Angiographic procedures are technically difficult when soft-tissue scarring and deformity are present at the site of vascular access. This case demonstrates the rare complication of catheter-sheath separation during an attempted coronary arteriogram. The patient had deformity and soft-tissue scarring due to bilateral lower-extremity amputation secondary to blast injuries sustained in Vietnam.     

Covering soft tissue defects

In the past, the main emphasis in the treatment of complex limb injuries was placed upon the reconstruction of bony defects. Recently, however, reconstructive soft-tissue procedures have gained the attention they deserve. The salvage of a severely injured extremity depends rather on the feasibility of reconstructive surgical tissue procedures than on restoration of the bony defect. Sufficient vascularity is an essential condition for fracture healing and the prevention of post-traumatic complications like osteomyelitis and pseudarthrosis. If primary closure of a soft-tissue defect is not possible, preliminary covering has to be obtained with artificial skin replacement (vacuum sealing) until definitive covering with muscle or musculocutaneous flaps can be achieved. With the microvascular restorative techniques available today even complex soft-tissue problems can be solved. Nevertheless, an appropriate infrastructure and a trained and skilled surgeon are essential.     

Circulating factors as markers and mediators of endothelial cell dysfunction in preeclampsia

3 different types of complex spinal trauma are defined: Type I means a multilevel contiguous or non contiguous unstable injury, type II is described as a spinal injury with concomitant thoracic or abdominal lesion, type III stands for the coincidence of spinal injury and polytrauma. Overlapping of different types occurs. Type I: The incidence amounts according a german multicenter study to about 2.5%. Multilevel injuries need to be stabilized for a long distance from posterior. With a thorough analysis the segments to be fused are determined. Type II: The leading thoracic injury is a lung contusion which occurs in up to 50% of the cases. A CT scan of the thorax during the first diagnostic screening is recommended. Early reduction and stabilization from posterior should be aimed at. During the first two weeks anterior procedures are contraindicated. Abdominal injuries are to be found in 3-4% of all spinal injuries. All organs could be affected. A typical constallation is the "seat-belt syndrome" with lesions of the upper abdominal organs and a flexiondistraction injury of the upper lumbar spine. The main problem is to make the diagnosis of both components initially. Most of the patients may be treated in one operation by first taking care of the abdominal injury and than stabilizing the spine. The prognosis of this combination is favorable. Type III: In 17-18% of all polytraumatized patients lesions of the spine are to be diagnosed. From these only one third need surgical care. From 680 patients with operatively treated fractures of the thoracolumbar junction 6.2% were polytraumatized according to the multicenter study mentioned above. The risk of missing a spinal injury in polytrauma totals approximately 20%. Surgical stabilization should be performed in the primary phase (day-1-surgery). Additional injuries, potentially time consuming operations with a high blood loss sometimes necessitate a different approach. Non stabilized spinal injuries apparently do not have the same negative effect on the whole organism as long bone fractures. In the early phase of treatment on the C-spine only anterior procedures and on the thoracolumbar spine only posterior techniques should be applied.     

Traumatic ostearthritis of the hip joint and its treatment (author's transl)

The author describes the various origins of osteoarthrosis following hip joint injuries. Since beginning osteoarthrosis can't be stoped, he emphasizes the surgical treatment of joint fractures including accurate reduction and stabilization of the fragments. In respect of this, intracapsular fractures of the neck of the femur always require a stabile fixation. In all cases the micro-injuries of the articular cartilage should be considered. The different possibilities of post-traumatic degenerative arthritis are discussed and the methods of operative procedures presented.     

Distal femoral fractures

Techniques of operative treatment of supra- and intercondylar fractures have changed in recent years. These changes refer to reduction techniques and implant selection. Operative approach concepts, which remained unchanged for several decades were critically evaluated and modified to a minimal invasive osteosynthesis [MIO]. This included for intraarticular fractures a trans-articular joint reconstruction and a retrograde plate osteosynthesis (TARPO). This technique result in better operative visualization and management of intraarticular comminution, saver fracture healing and better functional outcome. For extraarticular fractures a minimally invasive percutaneous plate osteosynthesis (MIPPO) via stab incisions only or retrograde intramedullary nailing is available. Beside that new strategies and techniques for the avoidance of axial malalignment, rotational deformities and leg length discrepancies are described, as well as a new plate generation (LISS: less invasive stabilization system), which behaves more like an internal fixator. The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by a high energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. The patients in this group with severe injuries need a detailed treatment algorithm, because the surgeon's individual skill, enthusiasm and wishful thinking frequently led to unsatisfactory results. A decision making scheme is presented specifically addressing timing and treatment modalities.     

The management of complex orthopedic injuries

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.     

Damage control for urologic injuries

Damage control techniques are applicable to a wide range of urologic injuries. When it is determined that the patient's condition requires that additional reconstructive efforts be delayed to a subsequent operative procedure, various temporizing procedures may be instituted for urinary tract injuries, including externalized stenting and drainage. Successful institution of the damage control approach requires close communication and cooperation between the general surgery trauma team and the surgical subspecialists involved in the patient's care.     

Fractures of the elbow

Elbow fractures encompass a spectrum of severity from low energy nondisplaced fractures to high energy fractures with associated severe soft-tissue injury. Treatment is based on fracture pattern, patient age, bone quality, associated soft-tissue injuries, and associated fractures. The basis for treatment relies on the knowledge of the complex osseous and soft-tissue anatomy of the elbow. The goals of operative and nonoperative treatment are to achieve a stable, anatomic reduction that allows early motion to maximize function.     

Mortality in multiple trauma patients with fractures

A multicentered study was performed to determine the mortality rate of patients with multiple injuries with major pelvic and long bone fractures who have early total care of their injuries. A 2-year review of patients with ISSs > or = 18 with major fractures treated at the trauma centers in Buffalo, New York, Camden, New Jersey, Nashville, Tennessee, Baltimore, Maryland, Tampa, Florida, and Seattle, Washington was performed. This group of 676 patients was compared with a similar group of 906 patients from the American College of Surgeons' Multiple Trauma Outcome Study. Mortality was significantly reduced in the patients who had early total care of all their injuries including fracture stabilization for patients less than 50 years of age and those 50 years and older. In a subgroup of patients less than 50 years of age and an ISS of 18-34 and 35-45 there was a mortality reduction from 11.8% to 5.1% and from 25.8% to 11.5%, respectively, when the fractures were managed acutely. Similar reductions in mortality were found in the patients 50 years of age and older with early fracture stabilization with a reduction from 26.4% to 8% in patients with ISSs of 18-24 and a reduction from 42.3% to 18.4% in the patients with ISSs of 35-45. This study clearly shows the additional benefit of early fracture stabilization in reducing mortality rates in the patient with multiple injuries.     

The role of anterior surgery in the treatment of thoracolumbar fractures

Operative treatment of thoracolumbar burst fractures or fracture dislocations is a relatively modern development. Anterior decompression and stabilization play a significant role in the treatment of thoracolumbar burst fractures. This article reviews the clinical indications and describes a one-staged operative technique for anterior instrumentation following anterior decompression.     

Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study

STUDY DESIGN: The opinions of orthopedic surgeons and neurosurgeons were compared regarding appropriate management of selected cervical injuries and the timing of stabilization. OBJECTIVE: To determine whether there is consistency of opinion regarding the management of cervical trauma. SUMMARY OF BACKGROUND DATA: Numerous forms of management for cervical trauma exist, but there are few consistent recommendations. No previous study has been done to determine uniformity of preferences of the surgeons who manage these injuries. METHODS: Thirty-one orthopedic surgeons and neurosurgeons were given a brief clinical situation and pertinent radiographic studies of five selected cervical injuries. Management options included halo and nonhalo orthoses, traction, and various forms of anterior and/or posterior procedures. The surgeons rated, in whole numbers from 1 to 10, their opinions on the appropriateness of each technique. Each surgeon was given a case of a "generic" cervical injury, in which stabilization was required and for which preoperative alignment was adequate in traction. They gave opinions on the timing of stabilization, with a choice of four time frames. Four neurologic situations were rated, ranging from intact to complete cord injury. RESULTS: Of 46 possible responses to the five test cases regarding appropriateness, 18 ranged from 1 to 10, the largest possible variation. Only 2 had a range of 5 or less, implying better consensus among tested surgeons. Mean values ranged from 1.9 to 9.5. Agreementamong respondents regarding appropriateness was slight with a range of kappa statistics from 0.09 to 0.14. Of 16 possible responses regarding timing, 14 were within a range of 8 or higher. Within 24 to 72 hours was the generally preferred time frame, with all possible responses showing a range of 3 or 4. Results of a multiple analysis of variance showed no significant differences among respondents. CONCLUSION: There is a large variety of opinion regarding appropriateness of specific operative and nonoperative management procedures and surgical timing among the surgeons polled who manage cervical trauma. This implies that there is no widely accepted standard management procedure for many of these injuries.     

Gunshot wounds to the mandible and midface: evaluation, treatment, and avoidance of complications

As American society becomes progressively violent, an ever-increasing number of gunshot wounds are being seen across the United States. Particularly challenging are injuries that involve the mandible and midface, not only because of problems with reconstructing bone and soft-tissue defects but also because of emergent problems with airway obstruction and neurovascular compromise. We present 40 cases of gunshot wounds to the mouth, mandible, and maxilla treated at Wake Forest University Medical Center during the past 7 years. The focus of this retrospective analysis is on emergency evaluation and treatment, complications encountered, and operative techniques used for reconstruction. Special emphasis is placed on recognizing and avoiding the complications of these injuries.     

Management of the rape victim

A woman's response to rape can be divided into three phases: an acute reaction, an intermediate stage and a period of resolution. Proper management of the physical and emotional problems of each phase, ideally by the woman's family doctor or gynecologist, may prevent future problems. Treatment during the first phase includes responding to the emotional needs of the patient as well as doing a pelvic and general physical examination to detect any injuries; information for possible legal procedures may be obtained quickly and efficiently. Follow-up particularly psychological, is important in the second and third phases.     

Arthroscopy in hand surgery

As arthroscopy of the wrist moves into the second decade, the trend for more indications for both diagnostic and therapeutic procedures will continue. It is only a matter of time before arthroscopic fusions, soft-tissue repairs, and "ectomy" procedures of all kinds become more commonplace. Whereas the advantages of the early therapeutic techniques in preserving soft-tissue structures and shortening recovery are now obvious, we will have to wait and see if the same holds true for more complicated bony and soft-tissue procedures in the next decade.     

Outcome and cost analysis for outpatient skin grafting

BACKGROUND: To reduce cost, outpatient surgery is advocated when feasible; however, the potential of compromising outcome is a concern. The purpose of this review is to assess patient outcome and cost for managing operative burn injuries without hospitalization. METHODS: During the past 18 months, 54 patients were identified with burns amenable to operative debridement and skin grafting without hospitalization. Twenty patients chose to be hospitalized and underwent prompt skin grafting. Operative skin grafting as an outpatient was chosen by the remaining 34 patients. Of these, four patients were subsequently hospitalized postoperatively (two for pain, one for cellulitis, and one for vomiting). RESULTS: Hospitalized patients and outpatients were similar in age and extent of burn; however, those hospitalized underwent skin grafting sooner after injury (2.1 +/- 0.4 days for inpatients vs. 11.5 +/- 0.8 days for outpatients; mean +/- SEM). Inpatients also had a significantly larger area skin-grafted (286 +/- 24 cm2 for inpatients vs. 178 +/- 14 cm2 for outpatients). Graft take was very good in each group. Cost, as indexed by patient charge, was substantially less for outpatients ($2,397 +/- $222) than for inpatients ($17,220 +/- $410). CONCLUSION: These results demonstrate a significant cost reduction with nonhospitalized operative care of burn injuries without any overt detriment in outcome, thus endorsing outpatient skin grafting when amenable. This review also illustrates that delaying operative intervention reduces the burn area required for grafting.     

Management of perineal and genital burns

Burn injuries to the perineum and genitals present the bedside care provider with a unique set of management problems. Traditionally, thermal injuries to these areas have been allowed to close by secondary intention, with epithelialization occurring from remnants protected within skin folds. Partial-thickness wounds of the perineum and genitals must be kept clean and free of bacterial infection to prevent necrosis and development of full-thickness injury. Although full-thickness thermal injuries to the penis and vulva are rare, they require special attention during the immediate postgrafting period to ensure complete engraftment. Control of scarring in this area requires tailor-made pressure garments, with customized inserts to provide controlled pressure to the skin folds.     

Operative arthroscopy into the next century

Until 10 years ago, operative arthroscopy was largely restricted to the knee. However, shoulder arthroscopy can now stabilize instability and repair rotator cuff tears. Operative procedures are seven being extended into the wrist and ankle.     

Treating achalasia: from whalebone to laparoscope

Reports of bile duct injuries are from tertiary care institutions and, therefore, may not report the spectrum of management that these patients receive in the care of these injuries. From June 14,1990 (the first operation) to June 30, 1995, 2654 laparoscopic cholecystectomies (LCs) were reviewed at this community hospital medical center to determine risk factors contributing to the etiology of these injuries, time and symptoms at presentation, duration of illness, and management of these injuries. None of the 13 general surgeons practicing during this time period had laparoscopic training in a general surgical residency. There were six major bile duct injuries (0.25%), of which five were available for further review. All occurred in women with cholelithiasis and chronic cholecystitis. Two operations were routine and two were associated with biliary tract anomalies. In two patients, the injuries were detected at LCs and definitive biliary-enteric anastomoses were performed immediately. Three patients presented at 2, 15, and 42 days after LC. In two patients, one or more operative procedures were performed before definitive repair and these patients were referred to tertiary care centers. One patient was managed with sequential CT-guided drainage catheters after attempted closure of the defect. The length of illness for these five patients was 8, 69, 348, 402, and 435 days with a follow-up of 245, 345, 531, 575, and 1088 days. Laparoscopic experience before injury by the operating surgeon was 3, 26, 35, 77, and 333 operations. Major biliary tract injuries occurred during routine cholecystectomy, length of illness was substantial for most patients, and biliary-enteric anastomosis was definitive for four of the five patients. The operating surgeons' "learning curve" did not seem as important as in other studies.