Der Unfallchirurg
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Living bone allotransplants (ATs) currently require long-term immunosuppression (IS), but this is impractical for extremity-preserving procedures. An alternative method to maintain viability of the transplant uses host-derived neoangiogeneic vessels combined with short-term IS. ⋯ This rabbit model demonstrated that increased bone turnover allows good healing but may temporarily weaken the allotransplant. However, by the more intense replacement of the graft with host-derived cells, this process may, in the long-term, ultimately result in a better transplant than an avascular graft.
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Despite significant advances in burn surgery and critical care, severe burn trauma defined as injuries covering more than 25% of the total body surface area, is still associated with high mortality and morbidity. Burn trauma is a whole body injury where peripheral dermal injury rapidly results in systemic inflammation and inflammatory core organ damage. The severe disturbance of internal homeostasis involves all vital organ systems and obligates early referral to specialized burn centers. ⋯ While early intensive care focuses on maintenance of tissue oxygenation and perfusion, surgical treatment deals with management of the burn wounds as a source of inflammation and infection. Here wound debridement and coverage is essential to abrogate systemic effects of inflammation and limit pathogen invasion. While control of early burn stages minimizes mortality due to burn shock, subsequent burn sepsis continues to be a formidable challenge for physicians and the main cause of burn mortality.
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The principle of the articulated external fixator following elbow dislocation and fracture-dislocations of the elbow joint is a helpful adjunct to the surgical armamentarium. It protects a difficult reconstruction of the joint surfaces, the capsule and the ligaments against potentially harmful forces while allowing passive and active motion to prevent arthrofibrosis due to long-term immobilization of the elbow joint. The articulated external fixator further represents a salvage procedure for delayed reconstructions and distraction arthrolysis, as well. A precise surgical technique is a prerequisite for the success of the procedure.
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Dislocations and fracture-dislocations of the elbow joint result in typical injury patterns of variable joint instability. A systematic and early in-depth analysis of the injury components offers the approach to the options of therapy and the evaluation of the risk potential of the individual lesion. Standardized diagnostic algorithms help to avoid an inadequate assessment of the extent of injury. ⋯ A great number of simple elbow dislocations have a good prognosis and can be managed with early motion due to the inherent joint stability after closed reduction. In contrast, the more rare osteo-ligamentous combination injuries have a poor prognosis if the corresponding injury components are not adequately recognized and addressed by a mostly technically demanding surgical treatment to avoid the otherwise impending typical complications. A standardized surgical algorithm may provide the basis to achieve a satisfactory functional result in this challenging clinical entity of elbow trauma.
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Patients with burn injuries to more than 10% of the body surface area (BSA) are in potential danger of traumatic hypovolemic shock and from 20% BSA a generalized burn edema can occur. In the preclinical setting an increased infusion therapy is generally unnecessary. Clinical circulation therapy is goal-directed taking hemoglobin concentration, hematocrit, MAP, diuresis, CVP and central venous sO(2 )into consideration. ⋯ If necessary, dobutamine is used to increase cardiac inotropy and cardiac output. Norepinephrine is only indicated in patients with significantly reduced SVR. Extended hemodynamic monitoring is necessary in all patients with prolonged catecholamine therapy.