This paper presents the case report of a 54-years old truck driver who suffered from a transthoracic impalement injury after a rear-end collision accident. We analysed the transportation under spontaneous breathing, the diagnostic procedures in the shock room as well as the immediately performed procedures. During surgical treatment, temporary compression of the thoracic aorta was necessary because of cardiopulmonal instability of the patient. On basis of the treatment of this highly dramatic injury, the following three striking conclusions are deduced and are further discussed on the background of the current literature. 1. Compression of the thoracic aorta is highly effective. 2. explorative laparotomy provides security. 3. A perforating item should be shortened sufficiently.

BACKGROUND:A preoperative diagnostic imaging procedure is essential for therapy in cholecystolithiasis. According to the S3-Guidelines of the German Society for General and Visceral Surgery only an ultrasound scan is needed before a cholecystectomy. But an anatomic variant of the bile ducts or choledocholithiasis is poorly shown by an ultrasound. Because of this, we performed a magnetic resonance cholangiopancreatography (MRCP) routinely. This study was designed to show if the MRCP changed the treatment plan or changed the operation method. Furthermore, the sensitivity and specificity concerning abnormalities of the cystic duct, accessory bile ducts and choledocholithiasis should be determined.PATIENTS AND METHODS:During the time between January 1st 2005 and September 30th 2009 541 patients were included in this retrospective study.RESULTS:Among the 541 cases 98 pathologies were found. These included 51 choledocholithiasis, 20 accessory bile ducts and 13 abnormal cystic ducts. In 29 of the 51 cases of choledocholithiasis a therapeutic splitting was performed only because of the MRCP. In 22 cases the diagnosis was also possible because of the basic diagnostic procedures like ultrasound, laboratory tests and clinical appearance. So the diagnostic aimprovement due to the MRCP is 5.3 %. Four of the 20 accessory bile ducts and 6 of the abnormal cystic ducts were found during the subsequent operation. The sensitivity concerning the anatomic variants is very low (38.5 % concerning the accessory bile ducts and 50 % for the abnormal cystic ducts). But the sensitivity in detecting a choledocholithiasis is very high (94.7 %). There was no evidence in our study that MRCP prevented any complications. The operation method was not changed in any case because of the MRCP result.CONCLUSION:A routinely performed preoperative MRCP cannot be recommended.

Purpose: Delta Ligament injuries can be found in 50%-70% of the fractures of the upper ankle joint. There is no simple routine diagnostic measure available. The aim of this Study was to evaluate whether ultrasound is capable of identifying the single parts of the Delta Ligament in the upper ankle joints and to evaluate its use for diagnostic measures. Materials and Methods: The Delta Ligaments of 20 healthy subjects ((5 women and 15 men; 31 +/- 4.4 years) were examined. The four parts of the ligament were differentiated with ultrasound (7.5 MHz linear- array) and with MRI and their particular length and strength was measured. The obtained values were compared. Results: With ultrasound, three of the four parts of the Delta Ligament could be reliably differentiated from neighbouring structures. But only the length and strength of the Pars tibiotalaris posterior was measured correctly by ultrasound. For the remaining three parts of the ligament, the values obtained by ultrasound showed a statistically significant difference to those obtained with MRI (p <= 0.05). The length and/or strength of those parts was under- or overestimated by ultrasound. Ultrasound was not capable of differentiating the Pars tibiotalare anterior. Conclusion: Tie results of this study show the potential Of ultrasound to assess the single parts of the Delta Ligament qualitatively, whereby there are statistically significant differences (p< 0.0001 to p=0.046) in comparison to the MRI-concerning the quantitative evaluation of length and strength

BACKGROUND Large incisional hernias are mainly repaired today by tension free implantations of prosthetic meshes using various placement methods. The advantages of the intraperitoneal open technique (IPOM) using a polypropylene mesh that is coated with ePTFE on the side facing the intestine, are described. METHODS AND RESULTS 62 patients underwent an incisional hernia operation with the intraperitoneal positioning of a prosthetic mesh. The follow-up examinations after a range of 16.1 months showed a hernial recurrence rate of 6.4 %. A part of the resulting mesh infections (11.2 %) healed without surgical removal of the mesh. Clinical complications due to adhesion formation were not observed. CONCLUSION The tissue sparing intraabdominal positioning technique simplifies the necessary overlap using healthy tissue as a prerequisite for a sufficient hernia repair exploiting the intraabdominal pressure.

Background: Large incisional hernias are mainly repaired today by tension free implantations of prosthetic meshes using various placement methods. The advantages of the intraperitoneal open technique (IPOM) using a polypropylene mesh that is coated with ePTFE on the side facing the intestine, are described. Methods and results: 62 patients underwent an incisional hernia operation with the intraperitoneal positioning of a prosthetic mesh. The follow-up examinations after a range of 16.1 months showed a hernial recurrence rate of 6.4%. A part of the resulting mesh infections (11.2%) healed without surgical removal of the mesh. Clinical complications due to adhesion formation were not observed. Conclusion: The tissue sparing intraabdominal positioning technique simplifies the necessary overlap using healthy tissue as a prerequisite for a sufficient hernia repair exploiting the intraabdominal pressure.

Background. Acute ankle sprains can result in severe residual symptoms, such as chronic ankle instability from weakness of the ligamentous complex or neuromuscular deficits. Measuring peroneal reaction time (PRT) has become a commonly accepted procedure for evaluating proprioceptive deficits. Methods: The present experimental study was conducted to determine the effects of anthropometric factors on PRT in 120 healthy volunteers. The patients were asked to stand on a platform with a tilting mechanism. Surface electrodes were used to record peroneal muscle activity in response to sudden inversion stress. The reaction of the peroneal muscles was analyzed using electromyography. Results: The statistical analysis showed similar intra-individual and inter-individual values for PRT. The results for the muscle groups measurements, however, varied considerably. PRT seems to increase significantly with age (long peroneal muscle: p < 0.0001, short peroneal muscle: p = 0.004). Conclusions: PRT was found to be an objective parameter that is unaffected by extrinsic and intrinsic factors. The present study, however, also showed that PRT significantly increases with age. As for studies on PRT, as well as for clinical routine, it Is important to consider the patients' ages.

BACKGROUND:A ruptured anterior cruciate ligament (ACL) leads to both mechanical and functional instability. Functional instability is caused by proprioceptive deficit. The aim of this study was to determine whether the proprioceptive deficit can be reduced by using a controlled active motion (CAM) splint postoperatively.PATIENTS AND METHODS:A total of 50 patients with ACL rupture were randomized into two groups. After ACL plasty the PT group received postoperative physiotherapy, while the CAM group were managed with a CAM splint and physiotherapy. Proprioceptive ability was measured with a passive angle-reproduction test.RESULTS:On the day of discharge 80% of the patients in the CAM group and 25% in the PT group had a reduced proprioceptive deficit. Overall the main measured value in the CAM group improved by 83.7%, but deteriorated by 39.3% in the PT group. There was no significant difference between the CAM group and a healthy control group.CONCLUSION:Using a CAM splint in addition to physiotherapy after ACL plasty in comparison to physiotherapy alone decreases the proprioceptive deficit significantly. We recommend the use of a CAM splint in the postoperative management following ACL plasty.

AIM:This study was aimed at assessing the outcome of physical therapy based on both subjective patient's satisfaction and objective measurement of peroneal reaction time in patients with chronic ankle instability.METHOD:25 patients with chronic ankle instability based on functional deficits were included. Physical therapy consisted in a 6 weeklong program with muscle strengthening and coordination exercises for one hour, three times a week. Before starting physical therapy as well as two weeks after finishing the program, patients underwent both a clinical exam as well as measurement of their peroneal reaction time.RESULTS:Following physical therapy peroneal reaction time of the long (p = 0.0001) and short (p = 0.0003) peroneal muscles significantly decreased. Prior to physical therapy the Kitaoka score was calculated to be 72.2 (+/- 18.7), the post treatment value was 93.3 (+/- 11.7) with a p-value of < 0.001. As for subjective patient's assessment on a scale of 1-10 with 1 being the least and 10 the most satisfied with therapeutical outcome, patients gave an average post treatment score of 8.3 (+/- 1.9).CONCLUSION:Measurement of PRT can be used as a helpful diagnostic parameter, as a parameter for quality control and for verification of therapy results. Specific physiotherapy leads to good clinical results and increased PRT.

Underlying causes for chronic ankle joint instability have been classified in mechanical or functional disorders. The goal of this study was to measure peroneal reaction time (PRT) in patients with chronic ankle joint instability in order to determine whether the PRT in these patients is prolonged due to deficits in joint function.91 patients with chronic ankle instability were included in the study. In all of them a thorough history and physical as well radiographic imaging was performed and the PRT was calculated.Radiographic imaging showed a significant side-to-side difference between the injured and the normally- functioning ankle in only 30% (n=27) of the patients with chronic joint instability. In physically active patients (18-25 a, n=67), a significantly prolonged PRT was found in the long peroneal muscle (70.1 ms, +/- 10. 1 ms, p < 0.05) as well as in the short peroneal muscle (78ms, =/- 9.3 ms, p < 0.05) of the injured leg. There was no correlation between PRT and how often patients twisted their ankle or how fast they recovered.In biomechanics, there has been strict differentiation between mechanical and functional deficits causing ankle joint instability. We believe that these terms should not be isolated from each other; both together account for chronic ankle joint instability. As the main ankle stabilizing muscle group, the pronator muscles should be taken into consideration in diagnostic work-up as well as in therapeutic approaches for chronic ankle instability.

Impalement injuries are uncommon and only occasional reports exist in the literature, resulting in non standardized approaches. Depending on the location, completely different combinations of injuries occur, making every impalement unique. Nevertheless some basic principles for dealing with impalements exist. These principles, and some controversial statements in the literature on the value of preoperative diagnostics, especially CT, are discussed using the example of a spectacular thoracic impalement by a 2 x 2 cm square metal pole. Our deviation from the principal of removing an impaling object only under direct observation in this special case is also discussed.

In a prospective study, 19 patients with chronic ankle instability underwent clinical and radiographic reexaminations 36 months after anatomical reconstruction. In addition, dynamic pedography was conducted and peroneal reaction time measured on a tilting platform for an evaluation of functional aspects. Prior to this examination, 32 patients had been asked to fill in a questionnaire and make a detailed subjective evaluation of current discomfort, stability, flexibility and sporting abilities. Eighty-eight percent of the patients reported satisfactory results; only 3% complained of persistent instability. In 71% the ability to take part in sports had improved after surgery, and 85% of the patients reported unrestricted walking abilities. Supination ability was impaired in 5% of the patients at the follow-up. The radiographic examination showed restored ankle stability with a significant reduction of talar tilt and talar translation; a postoperative increase in signs and symptoms of arthrosis was not observed. Dynamic pedography showed a large degree of symmetry of plantar pressure distribution after surgery. There were no significant differences in peroneal reaction time in the repaired and intact ankles. The results of the study show that it is possible to restore ankle stability with anatomical reconstruction without impairing the range of movement in the ankle joint complex. Progressive osteoarthrosis can be prevented.

Background: If conservative therapy fails, the standard treatment for chronic ankle instability is surgical reconstruction of the lateral ligaments. For the last seventy years, the tenodesis principles have been used for reconstruction. Recently however, surgical reconstructions-respecting the intact joint anatomy-have been developed, thus called “anatomical reconstruction principles”. Methods: This study focused on the investigation of the range of motion of the ankle and the subtalar joint following anatomical reconstruction surgery. Three different types of anatomical reconstruction procedures were compared: Direct ligament repair, tendon graft and carbon-fiber implant. Results: All procedures restored the original range of motion of the subtalar joint, except for the plantarflexed/dorsiflexed positions. As for the talocrural joint, the tendon graft and the carbon fiber implant left a small laxity for movements of inversion/eversion and internal/external rotation. The direct repair procedure achieved a more accurate result and restored the physiologic kinematics almost completely. During each procedure the insertion points and the direction of the original ligaments were maintained. However, the different results for the procedure of direct ligament repair compared to the other two anatomical reconstruction procedures showed that this condition alone is not sufficient to perfectly restore the kinematics of the talocrural and subtalar joints. It is important to note that none of the procedures caused a restriction of the range of motion. Conclusions: The maintenance of the range of hindfoot motion decreases the risk of osteoarthritis as well as chronic pain or problems for the patient to walk on uneven surface. Therefore, we believe that standard therapy for chronic instability of the ankle should include direct surgical reconstruction of the ligaments. If this direct procedure cannot be performed because of poor quality of the ligaments an alternative anatomical reconstruction procedure should be considered.

Treatment of traumatic trans-symphyseal instability by internal plate fixation is the most common procedure. Besides the trauma-induced muscle damage, the implantation induces additional damage at the symphyseal origin of the m.rectus abdominis. The aim of this clinical case study was to examine whether,it is possible to reduce the iatrogenic soft tissue damage while correcting trans-symphyseal instability using an internal fixator.After a transverse skin incision, two pedicle screws were drilled into the corpus ossis pubis next to the symphysis. Afterwards the crossbar was implanted and fixed.Generally, implantation of two self-trapping pedicle screws using a skin incision with a length of 6 cm is possible. Additional detachment of the m. rectus abdominis is not necessary. As a result of the mobility of the skin and subcutaneous tissue, the implantation of the crossbar beneath the M.rectus abdominis is possible.Stabilization of traumatic trans-symphyseal instability by internal fixation is a safe and easy method. Additional soft tissue damage can be prevented, but to achieve multidirectional stability some small modifications of the implant are necessary.

Die Plattenosteosynthese hat sich zur internen Fixierung der transsymphysären Instabilität als Standardverfahren weitestgehend durchgesetzt. Häufig sind neben traumabedingten vorbestehenden Muskelansatzverletzungen ausgeprägte Weichteilschäden im Bereich des Ansatzes des M. rectus abdominis bei der Implantation des Osteosynthesematerials nicht zu vermeiden. Im Rahmen einer klinischen Fallstudie sollte daher untersucht werden, ob die Stabilisierung mittels Fixateur interne mit einem geringeren Weichteilschaden prinzipiell möglich ist.

Due to the advanced technical possibilities, there are now up to 30 different drainage systems available for soft tissue surgery. The differences between these systems involve the mode of drainage (open into the bandage, closed into bag/bottle), the kind of suction (gravity drainage, low-vacuum and high-vacuum up to 900 mbar) and the material of the tube (PVC, silicone or polyurethane). There also exists a marked controversy about the fundamental necessity for drainage after surgery. A survey of the literature indicates that there is a distinct discrepancy between scientific knowledge and daily routine action. For primarily uninfected wounds, the application of an open drainage system,with the secretion going directly into the bandage, is obsolete. Gravity drainage systems guarantee just as effective secretion drainage in comparison to high vacuum drainage according to Redon. In soft tissue wounds, high-vacuum suction leads to the sucking in of tissue and blood,whereby comparatively elevated quantities of secretion can be produced. During the removal of Redon-drainage, there is stronger pain than on the removal of gravity drainage systems consisting of silicone or polyurethane. Prophylactic insertion of drainage in uncomplicated thyroid surgery and for hernia repair is not necessary. Insertion of drainage for up to 72 h is not accompanied by an elevated infection rate. The routine microbiological examination of the tip of the drainage tube is not recommended.

Acute ankle sprain is predominantly treated by nonoperative management including the application of ankle braces and early functional physical rehabilitation. However there are a vast variety of different brace types.The extent of swollen tissue surrounding the injured ankle was examined by means of comparison between a two aircell orthosis system and a single aircell brace system. The results showed clearly that the use of the two aircell including orthosis system decreased the swelling significantly more than the other tested single aircell pneumatic brace. After treatment with the two aircell orthosis system the swelling decreased in the median around 67 mL. In comparison with this result the swelling after treatment with single aircell brace system decreased only around 28 mL.

Zusammenfassung Die chronische Instabilität des Sprunggelenkkomplexes stellt einen ernstzunehmenden Residualzustand nach akutem Supinationstrauma dar. Sie ist einerseits durch mangelhaften ligamentären Zusammenhalt, andererseits durch Defizite im neuromuskulären System begründet. Ein anerkannter Parameter zur Beurteilung des propriozeptiven Defizits ist die peroneale Reaktionszeit (PRT). In einer experimentellen Studie mit 120 Probanden wurde der Einfluss anthropometrischer Größen auf die PRT untersucht. Die Studienteilnehmer wurden einer raschen Winkeländerung auf einer Kippplattform ausgesetzt und anschließend die muskuläre Reaktion der Peronealmuskeln elektromyographisch analysiert. Die Ergebnisse zeigen, dass der objektive Parameter PRT gegen extrinsische und intrinsische Einflussgrößen weitgehend stabil ist. Jedoch zeigt die vorliegende Studie eine mit zunehmendem Alter signifikante Verlängerung der PRT. Daraus ergibt sich zwingend für zukünftige Studien und für die klinische Anwendung eine altersdifferenzierte Betrachtung der PRT.

Forty-nine patients (mean age, 54 years) admitted for displaced ankle fractures were observed retrospectively to determine by clinical examination and measurement of plantar pressure distribution whether successful surgical treatment of ankle fractures had led to gait symmetry. The mean follow-up was 36 months (range, 19–54 months). The deviation in gait was quantified using peak pressure. Using a clinical score, most of the patients had satisfactory results. The plantar pressure distribution showed significant load asymmetries of patients with satisfactory results and those with non-satisfactory results. Dynamic gait analysis allows quantification of gait asymmetry and clinically non-visible gait disorder.