Der Unfallchirurg
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Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. ⋯ The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.
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Non-union is defined as an insufficiently consolidated fracture in which healing without a surgical intervention is no longer foreseeable. Several underlying predispositions and factors have to be taken into account in order to optimize the diagnostics, classification and surgical treatment of this complex and challenging pathology. ⋯ A practicable and precise classification of the different types of non-union can only be successful based on a focussed diagnostic procedure using radiologic and functional diagnostic tools, which guide the surgeon in establishing the optimal treatment. This also includes modern functional imaging examinations, such as CEUS and DCE-MRI.
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Review
[Perioperative management in the treatment of trauma for rheumatics under immunosuppression].
With an almost 3.5% manifestation rate in Germany, rheumatoid arthritis is a relatively frequent disease. Due to the involvement of diverse locations on the skeleton and often multiple comorbidities, treatment of these patients in cases of acute trauma potentially represents a substantial risk. The anti-inflammatory drug treatment harbors dangers, such as delayed wound healing and infections in the perioperative management of these patients. ⋯ If necessary, orthopedic or internist rheumatologists should be consulted for additional support. Absolute and urgent surgical interventions do not constitute a contraindication with respect to the antirheumatic medication but should be considered in the assessment of the perioperative risk profile. A close cooperation with anesthesia, the meticulous control of intraoperative positioning and postoperative management are of particular importance.
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Periprosthetic fractures in patients with underlying rheumatic diseases can be a special challenge depending on the extent, bone quality and septic complications. ⋯ The treatment of periprosthetic fractures with underlying rheumatic diseases necessitates the specific consideration of the multiple accompanying conditions. In general, extra-articular manifestations, average younger age, increased susceptibility to infections, multiple joint involvement and the basic medication must be taken into consideration. The local poorer bone quality can require an adaptation of the surgical technique. These factors are summarized in a treatment algorithm for periprosthetic fractures in patients with rheumatism taking the stability of the prosthesis, the infection status, the etiology, the localization and extent of the fracture into consideration.
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Since the introduction of biologicals and small molecules for the treatment of inflammatory rheumatic diseases, these patients are more active and therefore sustain more accidents. The hands and feet are most affected by inflammatory rheumatic diseases, especially rheumatoid arthritis, and are also very exposed to injuries. Therefore, rheumatoid patients have a high coincidence of injuries and rheumatic destruction of the hands and feet. ⋯ This is necessary to avoid fundamental errors in the treatment of fractures and optimally used anesthesia for the benefit of the patient. The close cooperation between trauma surgeons and orthopedic rheumatologists is urgently recommended in the treatment of these injuries. Whenever possible, the treatment should be carried out conservatively because surgical treatment has a higher risk compared to the normal population due to the immunosuppressive treatment.