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ABSTRACT: In unstable metaphyseal and diaphyseal forearm fractures the treatment of choice is percutaneous Kirschner wire (K-wire) fixation or elastic stable intramedullary nailing (ESIN), respectively. The optimal treatment for the diametaphyseal transition zone is still a matter of debate.
The diametaphyseal transition zone was defined as the square over the "physis of distal radius and ulna" minus the square of "physis of distal radius alone". Transepiphyseal intramedullary K-wire fixation was performed in unstable fractures affecting this transitional area. The operative, postoperative and functional outcomes were assessed and compared to previously treated patients who were treated using other techniques (plate, external fixator or ESIN).
10 patients received transepiphyseal intramedullary K-wire fixation. Additionally the ulna was stabilized by antegrade ESIN in 5 cases. Cast immobilization was performed for 39, sports restriction for 43 and metal removal was done after 50 days. No complications, bone malalignment, or functional deficits occurred (mean follow-up: 17 months). 13 patients were treated using alternative options. 3 patients had plates with cast immobilization for 26 days, sports restriction for 63 and metal removal after 287 days. 5 patients were treated by external fixation for 54 days. Their sports restriction was 73 days. The remaining 5 patients had ESIN. In 1 of these cases additional cast immobilization was necessary. Their sports restriction was 51 days and metal removal was done after 88 days. In 4 cases a malalignment >10° of the radius was documented, and 1 patient had a functional deficit of forearm pro-/supination.
Transepiphyseal intramedullary K-wire fixation in unstable diametaphyseal forearm fractures is a minimally invasive, quick and technically easy treatment option but requires additional immobilization. Our data suggest that this technique offers advantages compared to alternative treatment options.
European Journal of Pediatric Surgery 10/2010; 20(6):395-8. · 0.81 Impact Factor
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ABSTRACT: Intestinal neuronal dysplasia (IND B) is still a subject of controversy. The aim of this paper is to review the present state of knowledge on IND B. A summary is given of the technical and diagnostic criteria which have to be considered in order to arrive at a reliable diagnosis. In addition, the available therapeutic interventions are discussed.
Between 1992 and 2001, 3984 colonic mucosal biopsies from 1328 children were investigated. Nerve cell staining was performed on native tissue sections: 15 microm thick cryostat sections, which, after spreading and drying on a microscopic slide, have a final thickness of 4-5 microm, with dehydrogenase reactions (lactic dehydrogenase, nitroxide synthase, succinic dehydrogenase). The biopsies were taken 8-10 cm above the dentate line (proximal to the ampulla recti, because of the caudo-cranial increase of giant ganglia proximal to the 4 cm biopsy) with a sufficient amount of submucosa. The criteria for IND is 15-20 % submucosal giant ganglia with more than eight nerve cells in 30 sections of a single biopsy (i.e. four to seven giant ganglia).
The diagnosis of IND B is quantitative. A diagnosis of IND B was made over the past 10 years in 51 Hirschsprung resections (about 5 per year; 6 % of all Hirschsprung cases), and in 92 children with chronic constipation (about 9 children per year; 2.3 % incidence). Up to their fourth year of life, most children with isolated IND can be treated conservatively. This is due to the delayed maturation of the enteric nervous system which is characteristic of IND B. Only children who showed an additional hypoplastic hypoganglionosis were treated surgically. Children with Hirschsprung's disease (HD) and IND B proximal to the aganglionosis often showed, in those cases with a disseminated IND, postoperative disturbances in intestinal motility.
The diagnosis of IND B requires that biopsies are taken proximal to the ampulla recti (about 8-10 cm above the dentate line) with a sufficient amount of submucosa. The biopsies must be cut rectangular to the surface of the mucosa. A diagnosis of IND B can be made only if, in the submucosa of 30 serial sections, 15-20 % of all ganglia are giant ganglia with more than eight nerve cells. Ganglioneuromatosis (MEN2B) must be clearly differentiated from IND. The clinical course of IND B depends on the extent of disturbed bowel innervation, the severity of motility failure, and the coexistence of MH. The conservative management of isolated IND is possible in most children. In individual cases, however, a transient enterostomy or a segmental resection is unavoidable.
European Journal of Pediatric Surgery 01/2005; 14(6):384-91. · 0.81 Impact Factor
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ABSTRACT: The orthopedic treatment is the first choice in shaft fractures of the humerus in children. Angulations of more than 10 degrees need reduction, in that case anesthesia should be used for surgical stabilization. The preferred method is the elastic-stable intramedullary nailing (ESIN). In adolescents, even unreamed interlocking medullary nails are used. The primary paresis of the radial nerve is not an indication for nerve exploration in principle, but may be useful in special fracture situations. In subcapital fractures, more distinct angulations can be left untouched because of the highly potent epiphyseal plate. In severe displaced fractures, reduction and stabilization by ESIN is recommended in patients over the age of 10 years. The method is even applicable to pathological fractures in juvenile bone cysts. In adolescents after the start of epiphyseal plate closure, angle-stable implants are an alternative.
Der Unfallchirurg 02/2004; 107(1):8-14. · 0.61 Impact Factor
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R Rassouli,
A M Holschneider,
M Bolkenius,
G Menardi,
M R Becker,
K Schaarschmidt,
P Illing,
C I Hagel,
S Holland-Cunz,
W Löffler, [......],
M Schreiber,
G Tewes,
G H Willital,
F Höpner,
F Seifarth,
U Cattarius-Kiefer,
D Bürger,
B Engec,
T Monse,
J Benneck
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ABSTRACT: In contrast to other countries, no collective study of Rehbein's procedure in German-speaking nations has been performed. Therefore, our intention was, analogously to Goto and Ikeda's (10) Japanese study in 1984, Kleinhaus's (13) study on Swenson's procedure in 1979, Bourdelat's (2) French-Canadian investigation into Duhamel's technique in 1997 and Martuciello's (11) and Teitelbaum's (16) follow-up in the year 2000, to perform a follow-up study of Rehbein's technique of deep anterior resection.
The data of 200 patients from 22 German-speaking centers in Switzerland, Austria and Germany were collected. These data were gathered by questionnaire and the children were followed up in the individual participating hospitals for at least 3.5 years after the procedure. The procedure was performed between 1993 and 1997, over a 5-year period. The questionnaire contained 74 items including anamnestic data, diagnostic postoperative treatment and reoperations.
Concerning the incidence of anastomotic leaks and resolving anastomotic strictures there was no significant difference between the results in our series and those of the collective analyses made by Hofmann von Kap-herr (7), Holschneider (9) and Sherman (18). In 6.6 % of the 191 patients an anastomotic leak and in 9.9 % a rectal stricture, which had to be dilated, was observed. Concerning late complications, 22.8 % of the children suffered from constipation, 4.3 % from encopresis, 10.6 % from enterocolitis and only 0.5 % from enuresis. The frequency of constipation diminishes over the years. A comparison of the different large series in the literature clearly shows that the incidence of constipation is higher after Rehbein's procedure and the frequency of urinary incontinence and encopresis higher following Swenson's, Soave's and Duhamel's techniques. The incidence of enterocolitis is less after Rehbein's procedure than after Swenson's, Soave's and Duhamel's techniques.
The different results in the literature are due to the individual experience of the author, the very different follow-up methods and the date of follow-up. Therefore, the different results are hard to compare with our study. Nevertheless, Rehbein's anterior resection still could be presented as an adequate and important method to treat Hirschsprung's disease.
European Journal of Pediatric Surgery 07/2003; 13(3):187-94. · 0.81 Impact Factor
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ABSTRACT: Juvenile bone cysts usually are asymptomatic and may manifest as pathological fractures. Since the new method of flexible intramedullary nailing (" Elastic Stable Intramedullary Nailing" - ESIN or " Embrochage Centro- Médullaire Elastique Stable" - ECMES) has demonstrated superb results in the treatment of non-pathologic fractures of the long bones in childhood, this method is rapidly gaining popularity for the treatment of spontaneous or pathological fractures. Given the self-limiting natural history of juvenile bone cysts with eventual spontaneous healing, our goal is to stabilise the pathological fracture and the biomechanically weakened humerus. We treated 15 patients with 16 pathological fractures (one re-fracture) due to juvenile bone cysts of the proximal humerus. All fractures healed completely without pseudarthrosis. Complications were a secondary fracture in otherwise correctly positioned nails. Five of the 15 implants remain in situ, in 6 cases a repeat osteosynthesis was necessary, in one case the nails had to be changed because of the re-fracture. Ten of the 15 juvenile bone cysts healed over a period of 3 years, the nails were removed and so far there have been no further fractures in this group. In the other 5 cases, the juvenile bone cysts have progressively filled with sclerotic bone, and the nails remain in situ.
European Journal of Pediatric Surgery 03/2003; 13(1):44-9. · 0.81 Impact Factor
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ABSTRACT: Vasoactive intestinal peptide (VIP) is the most important peptidergic transmitter in intestinal relaxation. VIPergic nerves are reduced in aganglionosis (AG). Corresponding findings in intestinal neuronal dysplasia (IND) are sparse. It is unknown whether superficial mucosal VIP receptors are reduced in AG, IND, or hypoganglionosis (HYP) compared to concentrations in morphologically normal innervated colon (MNIC). Cryostat sections from 38 colonic biopsies (23 patients with AG, IND, or HYP, 15 with MNIC) were incubated with radioactive iodinated (125)I-VIP. Receptors were analyzed by autoradiography. Radioactive-marked receptors trigger the precipitation of metallic silver as silver grains within a photographic emulsion. Grains were quantified by image analysis, calculating the percent covered cell surface. Statistical analysis was done by Mann-Whitney and Kruskal-Wallis tests (significance #E5/E5#<0.05). VIP receptors covered 4.31% of the cell surface in MNIC. The values were significantly reduced in AG (2.72%; #E5/E5#=0.012) and IND (2.93%; #E5/E5#=0.008). The two HYP biopsies showed the lowest values (1.83%). Aganglionic colon could be distinguished from healthy proximal segments and IND from habitual constipation. In AG and IND, even the superficial mucosal VIPergic innervation seems to be impaired. The reduction of mucosal VIP receptors in developmental faults of the enteric nervous system may thus be an indicator of a sensomotor disturbance.
Pediatric Surgery International 05/2002; 18(4):264-8. · 1.25 Impact Factor
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Der Unfallchirurg 09/2001; 104(8):788-90. · 0.61 Impact Factor
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P P Schmittenbecher
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ABSTRACT: Elastic stable intramedullary nailing (ESIN) is well established for stabilizing pediatric diaphyseal fractures. Indications are all femur shaft and instable diaphyseal forearm fractures, selected instable lower leg and malaligned humerus fractures. Intraoperative problems (6.5%) include the need for open reduction, cortical perforation by a nail tip and bursting of a third fragment. Postoperative problems (6.4%) are mainly induced by skin irritation at the place of implantation. Complications (8.4%) result from wrong indication with subsequent malalignment and instability. Re-fractures are seldom seen. Typical iatrogenic nerve injuries (superficial radial nerve) need technical variation. Prevention of most complications and mistakes requires the exact consideration of guidelines for indication and technique even in a supposed easy procedure.
Kongressband / Deutsche Gesellschaft für Chirurgie. Deutsche Gesellschaft für Chirurgie. Kongress. 02/2001; 118:435-7.
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ABSTRACT: Commonly available information on intestinal neuronal dysplasia (IND) is sparse. Especially well documented long-term courses are lacking. The aim of this study was to correlate defecation as a clinical parameter of the long-term course in malformations of the enteric nervous system with the morphological diagnosis. 57 children with intestinal neuronal dysplasia (IND) or aganglionosis with cranial intestinal dysganglionosis (agIND), diagnosed between 1983 and 1992, were analysed including histomorphological classification, collection of clinical data and evaluation of the defecation mode by questionnaire as a parameter of the long-term course. Of 29 dysganglionic (IND) patients, 9/29 cases (31 %) had been treated conservatively, 18/29 cases surgically (62.1%), in two children (6.9%) no therapy had been necessary. All 28 patients with Hirschsprung's disease and cranial IND (agIND) underwent resection. 46 of the children could be followed up 3.64 years after the end of the main therapeutic period and with a mean age of 6.7 years at the time of follow-up; 43.5% of the analysed children still showed severe constipation. 23.9% only were really cured; 15.2% had normal defecation still using conservative treatment and 17.4% had diarrhea. No significant difference was found between both groups, IND and agIND, and the results were independent of treatment modality. The results were much worse than in idiopathic constipation as reported in the literature and even worse in comparison to unselected Hirschsprung collectives. It has to be concluded that in IND with chronic constipation intensive long-term care is necessary and it is crucial that treatment algorithms should be outlined urgently together by pediatric gastroenterologists and pediatric surgeons. AgIND seems to need more extended resection following an exact histomorphological mapping by biopsies taken during enterostomy procedure.
European Journal of Pediatric Surgery 03/2000; 10(1):17-22. · 0.81 Impact Factor
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ABSTRACT: Between 1991 and 1993, 106 newly diagnosed cases of Hirschsprung's disease (HD) were prospectively analyzed for the association of HD and intestinal neuronal dysplasia (IND) at ten pediatric surgical departments in central Europe. Hirschsprung-associated IND (HaIND) was found in 40% of cases. IND was disseminated in one-third and localized in two-thirds of the patients. Initial clinical symptoms were related to the length of the aganglionic segment, but not to the presence of HaIND. An enterostomy performed in 72 cases (67.9%) was located in a segment of pathologically innervated bowel in 50% of all cases, but in 72% of cases of HaIND. The proximal margin of the resected bowel showed pathological innervation in 44% of cases. Supplemental biopsies from the intestine (apart from diagnostic suction biopsies and biopsies at the enterostomy site) led to the first identification or definition of length of associated IND in 17.9% of cases. Postoperatively, the presence of long-segment aganglionosis or associated IND implied a delay in the restoration or normal defecation. Persistent constipation was found in 40% of patients with associated disseminated IND at follow-up at 6 months, compared to 20.6% in patients with isolated HD. These children needed secondary interventions more often than patients with associated localized IND or isolated HD. HaIND thus has clinical implications for the postoperative course if IND is disseminated.
Pediatric Surgery International 02/1999; 15(8):553-8. · 1.25 Impact Factor
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ABSTRACT: Pathological or spontaneous fractures in childhood are rare and are mostly caused by benign bone diseases; the fractures must be treated on an individual basis, as there are no constant rules. Since the new method of osteosynthesis called "elastic stable intramedullary nailing" (ESIN) or "embrochage centro-medullaire elastique stable" (ECMES) has demonstrated the best results in the treatment of normal fractures in childhood, this method is rapidly being used in the treatment of spontaneous or pathological fractures. We report our experience in the treatment of spontaneous fractures in childhood with "elastic stable intramedullary nailing", in nine patients with ten fractures. The pathological diagnosis was in 5 cases a juvenile bone cyst; in addition, there were cases of histiocytosis X, lymphangiomatosis, hemangiomatosis and osteoporosis (one each). The location was the femur (two cases) and humerus (seven cases). All fractures healed completely without pseudarthrosis; as complications we saw one incidence of osteomyelitis, one of a second fracture after "elastic stable intramedullary nailing" and one coxa vara in a child with histiocytosis X of the proximal femur. In the 5 children with juvenile bone cysts the nails are still in situ; in two cases the nails had to be changed.
Der Unfallchirurg 07/1996; 99(6):410-4. · 0.61 Impact Factor
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ABSTRACT: Today pancreatitis is classified only as acute or chronic. In pediatric surgery it seems more practical to distinguish traumatic from non-traumatic cases. To show whether there is also a difference in the management of these two groups we analysed all patients treated between 1977 and 1991 for pancreatitis. It was most impressive that traumatic cases were operated on in 86% and the rate of pseudocysts reached 61.5% whereas non-traumatic pancreatitis required surgical intervention in 50% and developed pseudocysts in 17%. Following trauma elevation of serum enzyme concentration lasted longer in a significant number of patients but became normal without any hint of further complications. In non-traumatic pancreatitis it is recommended that surgery should be avoided and reserved for complications. Exceptions are obstructions of the pancreaticobiliary ducts which need early removal to prevent chronicity of the disease and functional loss of the organ.
European Journal of Pediatric Surgery 05/1996; 6(2):86-91. · 0.81 Impact Factor
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ABSTRACT: Intestinal neuronal dysplasia type B (IND B) represents a congenital malformation of the enteric nervous system causing disorders of intestinal motility, e. g., chronic constipation. We report a newborn who primarily suffered from intussusception and peritonitis. He required a subtotal colectomy for gangrene, but since IND B had not been expected at this time, no specific immunhistochemical workup for IND was initiated. Following recurrent episodes of ileus and subileus within the next years, colonic biopsies were taken and histotopochemical staining revealed IND B. The remaining colon required resection; an ileorectostomy was performed and the patient is now asymptomatic. This case report discusses the causality of IND B for intussusception and stresses that in newborn patients the clinical presentation may be misleading, and adequate histochemical evaluation is essential for early detection.
Pediatric Surgery International 12/1995; 11(8):574-576. · 1.25 Impact Factor
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ABSTRACT: Rectal suction biopsy is the diagnostic procedure of choice in aganglionosis even if only mucosal tissue is obtained. In neuronal intestinal dysplasia it is essential to include parts of the submucous layer. Therefore some biopsies are unsuitable because they lack submucous tissue. In a retrospective analysis (1991-1993) this occurred in 34.9% of our biopsies. These samples were taken without attention to the level of suction. Prospectively we compared suction biopsies taken by a standard suction level (250-300 cm water column) with excision biopsies taken by scissors under speculum exposure in ten consecutive patients. Submucosa was missed in only one biopsy each, but two excision biopsies were made useless by mechanical traumatization. We conclude a correctly practised rectal suction biopsy still remains the procedure of choice for diagnostic screening in malformations of the enteric nervous system.
European Journal of Pediatric Surgery 11/1995; 5(5):277-9. · 0.81 Impact Factor
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ABSTRACT: Paediatric surgeons are engaged in different causes of chronic constipation. Aganglionosis usually needs surgical therapy, but in dysganglionosis a distinct differentiation is necessary between patients sufficiently treated by conservative methods and others requiring surgery. Sometimes the operation seems to be an "ultima ratio" in these patients. Otherwise surgery can be necessary early in enterocolitis, ileus or toxic megacolon. In the spectrum of anal malformations constipation may be a primary symptom (anal ectopia, anal stenosis, low anal atresia with anocutaneous fistula) or appears as a post-operative complication (intermediate or high anal atresia). In secondary megacolon, surgery is performed to remove the result of therapeutic negation over many years. The operation may be the supposition to follow up with conservative treatment. In the management of constipated patients an exact diagnostic clarification has a central position. This especially includes anorectal manometry, x-ray examination with contrast medium application and defaecography and as last rectal biopsy.
Kinderärztliche Praxis 11/1993; 61(7-8):250-7.
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Monatsschrift Kinderheilkunde 09/1993; 141(8):677-88. · 0.27 Impact Factor
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ABSTRACT: Pseudocysts of the pancreas are a rare cause of a mediastinal mass. They are clinically characterized by the combination of thoracic symptoms (shortness of breath, dysphagia, pleural effusions) with complaints in the upper abdominal quadrants and weight loss. The diagnosis is usually made by CT scan or MRI including upper abdominal views. Internal drainage via an abdominal route performed either as cystogastrostomy or cystojejunostomy is the treatment of choice.
European Journal of Cardio-Thoracic Surgery 02/1992; 6(1):46-8. · 2.55 Impact Factor
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ABSTRACT: Three newborns with congenital tracheoesophageal fistula were treated by endoscopic laser coagulation. After radiologic and endoscopic diagnosis, laser coagulation of the mucosal layer of the fistula followed using Nd:YAG laser light transferred through an uncovered quartz fiber of 600 microns diameter. The successful and uneventful course in two cases contrasts with the incomplete obliteration in one case caused by inadequate energy application and/or early localized instillation of contrast medium for radiologic control examination. The advantages of this method include elimination of an operative procedure, exclusion of operative complications, and the possibility of repetition in recurrent cases. Care must be taken to prevent esophageal and tracheal damage by use of this method.
Journal of Pediatric Surgery 02/1992; 27(1):26-8. · 1.45 Impact Factor
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ABSTRACT: At the Department of Pediatric Surgery, University of Munich, 1143 children up to 14 years of age were treated for forearm fractures between 1976 and 1985. Two-thirds of distal metaphyseal fractures affect only the radius, but diaphyseal fractures involve both bones in two-thirds to three-quarters of cases. In 97.8% of the cases, conservative therapy was administered. Follow-up examination was performed 3-13.5 years after treatment in 144 patients (including all with complications resulting from the fracture itself, the therapy or the healing). There were 32 who reported functional restriction, and 20 had reduced mobility of the wrist, most in supination/pronation. Very good and good results were found in 79.2%, satisfactory results in 13.9%, and unsatisfactory results in 6.9%. Meta- and diaphyseal fractures of both bones required 57% of all secondary reductions and 76.9% of a secondary operations. This applies to 70% of cases with more than 10 degrees deviation of axis at the end of treatment and most cases with severe functional restrictions later. In these cases more frequent operative management seems to be necessary to improve overall results.
Der Unfallchirurg 05/1991; 94(4):186-90. · 0.61 Impact Factor
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P P Schmittenbecher
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ABSTRACT: From 1986 to 1989 46 newborn were examined after correction of oesophageal atresia, defects of diaphragm or abdominal wall, to record postoperative cardial insufficiency. In 15 of 40 long-time pH metry analysis (37.5%) and in 11 of 22 x-ray studies (50%) a pathological result was found; in 8 times these findings were followed by operation and in 8 times by conservative therapy. pH metry is suitable even in very small newborn for postoperative screening of cardial function; if the results are positive, x-ray examination is supplementary to diagnosis and therapeutical planning.
Zeitschrift für Kinderchirurgie: organ der Deutschen, der Schweizerischen und der Osterreichischen Gesellschaft für Kinderchirurgie = Surgery in infancy and childhood 11/1990; 45(5):278-81.
