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Conclusion: True vein graft aneurysm is a complication that occurs very rarely. In the current literature
the frequency is reported to be in the range of 1-2%. The etiology remains unclear even if histopathologic
studies suggest that atherosclerotic degeneration, with endotelial damage, media necrosis and
fibrous proliferation could induce lesions and local weakness of the vein wall. True aneurysms of vein
grafts need to be managed with the same criteria applied to arterial aneurysms, to prevent the risk of
rupture and distal embolization.
62.11
Fatal aortic rupture despite, successful endovascular management of a thoracic intramural hematoma
A. Stellmes, F. Dick, J. Schmidli (Berne)
Objective: Intramural aortic bleeding involves a localized dissection with the associated risk of aortic
rupture. Therefore, surgical management is recommended for expanding intramural hematoma. Endoluminal
cover of the origin of the hemorrhage is usually thought adequate to prevent aortic rupture.
Methods: We report the death of a 79 year old man whose thoracic intramural hematoma ruptured
with fatal outcome despite successful deployment of a stent-graft over the lesion.
Results: The patient presented with sudden-onset, left-sided thoracic pain and marked arterial hypertension.
He was under oral coumarins for atrial fibrillation. The computer tomography (CT) revealed
an acute intramural hematoma along the entire thoracic aorta, which was also elongated and massively
kinked. As no pleural effusions were seen, he was initially managed conservatively. However, at
eight days follow-up, a repeated CT showed expansion of the hematoma and appearance of pleural
effusions. A torn intercostal artery at the convexity of the kinking was identified as likely source of the intramural
hemorrhage, and the patient underwent urgent endovascular repair involving placement of a
15 cm stent-graft across the intercostal artery. The procedure was uneventful and in the intraoperative
angiography the emersion of contrast had stopped. However, the thoracic aorta ruptured nonetheless
one day later into the thoracic cavity and the patient died. The postmortem showed that the rupture had
occurred in fact in the segment covered by the stent-graft; additional macroscopic intimal entry tears
were not found. However, the expanding hematoma had disrupted further intercostal sidebranches
intramurally above and below the stent-graft-cover, which must have led to continued pressurization
of the hematoma.
Conclusion: In this case, endoluminal cover of the origin of the intramural hematoma was inadequate
to prevent aortic rupture, since the process expanded above and below the stent-graft. Therefore, complete
endoluminal coverage of the diseased aorta should always be considered in expanding intramural
hematoma.
General Surgery – Trauma: Lower Extremities 63
63.1
Percutaneous iliosacral screw fixation for fractures and disruptions of the posterior pelvic ring – technique
and perioperative complications
G. Osterhoff, C. Ossendorf, G. A. Wanner, H.-P. Simmen, C. M. Werner (Zurich)
Objective: Percutaneous iliosacral screw placement allows minimally invasive early definitive fixation
of fractures and disruptions of the posterior pelvic ring. The objective of this study is to describe the
technique using conventional C-arm, evaluate the perioperative complications, and to point at possible
pitfalls.
Methods: Thirty-two consecutive patients undergoing percutaneous pelvic ring fixation using cannulated
screws between 10/2008 and 11/2009 were enrolled and analysed. Cannulated screws (7.3mm)
were inserted in the supine position using conventional C-arm fluoroscopy (inlet, outlet, and lateral
view). Reduction and accuracy of screw placement was evaluated postoperatively by CT scans and
conventional X-rays. Fracture healing and outcome were assessed during regular follow up examinations
at 6 weeks, 3, and 6 months, respectively.
Results: Fifteen patients underwent unilateral, 17 patients bilateral screw fixation. In total 74 screws
were placed. Mean age of the patients was 51±18 years. Mean operation time including positioning of
both patient and C-arm, and wound closure was 18±8 min per screw. Two patients died during their
stay at hospital from unrelated causes. Mean follow up of the remaining 30 patients was 5±3 months.
Time to full weight bearing in 24 patients was 9±4 weeks. Six patients were still not able to put full
weight on the operated extremity at last follow up (mean 3±3 months), partially due to concomitant
injuries. Patients without concomitant injuries that affected walking were able to bear full weight after
8±4 weeks (n=17). Three patients had persistent postoperative hypaesthesia in the L5/S1 dermatoma.
No motor weakness was apparent in any of the patients, and no postoperative bleeding due to
the insertion of an iliosacral screw was observed. Secondary surgery due to screw malpositioning or
loosening had to be performed in 3 patients.
Conclusion: Percutaneous iliosacral screw fixation is a rapid and definitive treatment for posterior pelvic
ring injuries with a low risk of secondary bleeding during posterior pelvic stabilisation. The procedure
using standard C-arm fluoroscopy was found to be safe in the hands of surgeons acquainted with
knowledge of the pelvic anatomy and its fluoroscopic correlations.
54 swiss knife 2010; 7: special edition
63.2
Experience with 1282 proximal femur fractures in 5 years
Ü. Can, A. Platz (Zurich)
Objective: The incidence of proximal femur fractures in the elderly is increasing and has been projected
to rise exponentially over the coming decades. With the introduction of DRGs in 2012 these patients
will have a great impact on public health costs. Our aim was to control our quality of treatment and to
evaluate suggestions for further improvement.
Methods: All patients, admitted to our hospital with a proximal femur fracture between 2005 and 2009
inclusive were identified from our proximal femur fracture registry. Collected data were analysed to
determine age, gender, length of stay, type of fracture and treatment, operation time, qualification of
surgeon and complications in term of revision surgery.
Results: A total of 1282 patients, mean age 82 years, were treated from 2005 to the end of 2009.
Surgical treatment consisted of Hemiarthroplasty (549 cases), Proximal Femur Nail (615), DHS (50),
3 Screws (18), non operative Therapy (33) and others such as Total Hip replacement (17). Surgery
was done by residents in 560 patients (44%). Mean operation time 84 min. We noted 105 surgicaly
treated complications (8.1%). Our records showed 43 deaths (4%). 120(12%) Patients went directly at
home, 424(41%) left for a rehabilitation clinic and 412(40%) patients were admitted in nursing homes.
Mean length of stay was 15 days.
Conclusion: Treatment of proximal femur fractures is daily business in our trauma department. Because
of the large number of patients with high co-morbidity, efficient standard treatment protocols
are needed to optimize outcome and costs. Management of patients with proximal femur fractures is
not only correct operative treatment but also planed and organized aftercare. Proximal femur fractures
are classical teaching operations. This has to be taken into account regarding future compensation
with DRGs.
63.3
Results of osteosynthesis with hook pin fixation in 67 consecutive femoral neck fractures
G. Peloni 1 , R. Flueckiger 2 , L. Regusci 1 , M. Brenna 1 , P. Medda 3 , P. Manfrini 1 , F. Fasolini 1 ( 1 Mendrisio,
2 Dornach, 3 Bellinzona)
Objective: To evaluate the outcome of closed reduction and hook-pin fixation in acute femoral neck
fractures.
Methods: 67 consecutive patients with femoral neck fracture treated with closed reduction and hookpin
fixation from December 2004 to February 2008 were prospectively studied. The main outcome
measurements were hip complication rate, reoperation rate and health-related quality of life.
Results: The patient evaluation was at 6 weeks, 3, 6 and 12 months. The F/M ratio was 3.2. Mean
patient age was 78 years (25-99). The Garden classification was: I 24%, II 18%, III 36%, IV 22%. The
mean time between admission and operation was 32 hours. All patients under 65 years were operated
within 6 hours. The mean time of operation was 42 min. The blood trasfusion rate was 7%.
The mean hospital time was 13 days (4-30). Weight bearing was forbidden in patients younger than
65 years (n=9), while direct unrestricted weight bearing was encouraged in all the others. Following
treatment, 38 patients (56,7%) returned in the previous living conditions and were living in their
own home. Total healing hip complications were 19,4%: 5 redisplacement, 3 avascular necrosis, 3
trochanteric fractures and 2 non-union. In undisplaced fractures (Garden I-II) total complications were
10,3%, none avascular necrosis nor non-union. In displaced fractures (Garden III-IV) total complications
were 26,3%. Total reoperations were 10 (20,8%), 2 osteosynthesis and 8 hemiarthroplasty. In
Garden I-II reoperations were 6,9%, 1 osteosynthesis and 1 hemiarthroplasty; in Garden III-IV reoperations
were 21%, 1 osteosynthesis and 7 hemiarthroplasty. Overall mortality was 4,5% and all patients
were Garden III-IV.
Conclusion: Closed reduction and hook-pin fixation is a good surgical option for undisplaced femoral
neck fractures (Garden I-II) and in patients younger than 65 years. In older and fit patients with displaced
fractures (Garden III-IV) arthroplasty provides a better outcome.
63.4
Management of bacterial infections after operative treatment of proximal femur fractures, a retrospective
analysis of 1033 patients
B. Martens, Ü. Can, J. Forberger, A. Platz (Zurich)
Objective: As proximal femur fractures are one of the most commonly treated, the number of infections
is comparatively low but still a relevant one. Since documented bacterial infection implements repeated
surgery, prolonged duration of hospitalisation and intensive medical treatment for the elderly patient,
it was the objective of this study to have an analytic retrospective look at the management of bacterial
infections after operative treatment in a high volume trauma-clinic.
Methods: All patients operatively treated for a fracture of the proximal femur from January 2005 until
December 2008 in our institution, were included in this single institution study. Femoral neck, per-, inter-
and subtrochanteric fractures were included. We reviewed medical records with emphasis on process,
surgical and infectiological measures.
Results: From 2005 to 2008 1033 patients underwent surgery for a fracture of the proximal femur. 80
(7.7%) patients were surgically revised as infection was suspected. Only in 17 cases (1.6%) suspicion
was substantiated with proven bacterial infection. Mean age was 85years (76-95). 76.5% monopolar
hemiarthroplasty (MHA), 17.6% Proximal Femur Nail (PFN), 5.9% Dynamic Hip Screw (DHS). Average
time of hospitalisation was 39.9 days (24-98). Mean number of surgical revisions was 1.82 (1-6).
Average time between primary surgery and first revision was 13.2 days (6-44). Causative organism
was a koagulase-negativ staphylococcus in 47.1%, staphylococcus aureus in 17.6%, enterococcus in
17.6%. Treatment involved surgical revision with the aim of bacteriological negative samples and antibiotic
therapy according to bacterial resistance. One patient deceased and one girdlestone situation
evolved, 15 patients recovered without implant removal.