Tibial lengthening using a retrograde magnetically driven intramedullary lengthening device in 10 patients with preexisting ankle and hindfoot fusion

Background and purpose — Motorized intramedullary lengthening nails (ILNs) have been developed as an alternative to external fixators for long bone lengthening. The antegrade approach represents the standard method for tibial ILN insertion. In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique that has not been evaluated so far. We report the outcome of this method in 10 patients.Patients and methods — This retrospective study included 10 patients (mean age 18 years [13–25]) with preexisting ankle and hindfoot fusion who underwent tibial lengthening with a retrograde ILN (PRECICE). The mean leg length discrepancy (LLD) was 58 mm (36–80). The underlying conditions were congenital (n = 9) and post tumor resection (n = 1). The main outcome measures were: ILN reliability, distraction achieved, distraction index (DIX), time to bone healing, consolidation index (CIX), complications, and functional results.Results — All patients achieved the goal of lengthening (mean 48 mm [26–80]). Average DIX was 0.6 mm/day (0.5–0.7) and mean CIX was 44 days/cm (26–60). Delayed consolidation occurred in 2 patients and healed after ILN dynamization or nail exchange with grafting. Toe contractures in 2 other patients were resolved with physiotherapy or tenotomy. Until last follow-up (mean 18 months [12–30]) no true complications were encountered, knee motion remained unaffected, and full osseous consolidation occurred in all patients.Interpretation — In patients with LLD and preexisting ankle and hindfoot fusion distal tibial lengthening using a retrograde ILN is a reliable alternative to the standard approach with equivalent bone healing potential and low complication rates leaving the knee unaffected.

Fully implantable intramedullary lengthening nails (ILNs) with mechanical (Guichet and Casar 1997, Cole et al. 2001) and motorized (Baumgart et al. 1997, Schiedel et al. 2014) drive systems have been developed as an alternative to external fixators for bone lengthening (Mahboubian et al. 2012, Black et al. 2015, Laubscher et al. 2016). Recently, magnetically driven ILNs in particular have become increasingly popular (Kirane et al. 2014, Wagner et al. 2017) and in contrast to external fixation provide an equally safe and more comfortable option for limb lengthening and deformity correction (Szymczuk et al. 2019, Horn et al. 2019). Antegrade or retrograde femoral and antegrade tibial lengthening with the PRECICE limb lengthening system (NuVasive, San Diego, CA, USA) has been assessed by several studies (Kirane et al. 2014, Schiedel et al. 2014, Shabtai et al. 2014, Tiefenboeck et al. 2016, Wiebking et al. 2016, Fragomen and Rozbruch 2017, Wagner et al. 2017, Iobst et al. 2018, Cosic and Edwards 2020, Nasto et al. 2020).In tibial lengthening the antegrade approach represents the standard method for ILN implantation (Fragomen and Rozbruch 2017). In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique for tibial nail insertion. Approach-associated affections of the knee joint like anterior knee pain (Rothberg et al. 2019) and—in immature patients—damage to the proximal tibial growth plate (Wagner et al. 2017, Frommer et al. 2018) can be avoided. Despite these potential advantages, the use of a retrograde tibial nailing approach and distal tibial osteotomy in patients with preexisting ankle and hindfoot fusion has not been evaluated so far.     

Online-Supervision von ehrenamtlichen Berater*innen einer Telefonberatung für Kinder und Jugendliche

Zeitschrift für Psychodrama und Soziometrie - Im vorliegenden Beitrag der Zeitschrift für Psychodrama und Soziometrie wird eine theoretische und praxisorientierte Zusammenfassung des...     

Effect of Combination Therapy of Hydroxychloroquine and Azithromycin on Mortality in Patients With COVID‐19

Conflicting evidence regarding the use of hydroxychloroquine (HCQ) and azithromycin for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection do exist. We performed a retrospective single‐center cohort study including 377 consecutive patients admitted for pneumonia related to coronavirus disease 2019 (COVID‐19). Of these, 297 were in combination treatment, 17 were on HCQ alone, and 63 did not receive either of these 2 drugs because of contraindications. The primary end point was in‐hospital death. Mean age was 71.8 ± 13.4 years and 34.2% were women. We recorded 146 deaths: 35 in no treatment, 7 in HCQ treatment group, and 102 in HCQ + azithromycin treatment group (log rank test for Kaplan–Meier curve P < 0.001). At multivariable Cox proportional hazard regression analysis, age (hazard ratio (HR) 1.057, 95% confidence interval (CI) 1.035–1.079, P < 0.001), mechanical ventilation/continuous positive airway pressure (HR 2.726, 95% CI 1.823–4.074, P < 0.001), and C reactive protein above the median (HR 2.191, 95% CI 1.479–3.246, P < 0.001) were directly associated with death, whereas use of HCQ + azithromycin (vs. no treatment; HR 0.265, 95% CI 0.171–0.412, P < 0.001) was inversely associated. In this study, we found a reduced in‐hospital mortality in patients treated with a combination of HCQ and azithromycin after adjustment for comorbidities. A large randomized trial is necessary to confirm these findings.

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is spreading worldwide since December 2019 and still no proven effective therapy has been found. First therapy proposed to treat coronavirus disease 2019 (COVID‐19) has been the association of lopinavir‐ritonavir, a protease inhibitor approved for HIV infection. However, Cao et al. observed no benefit comparing lopinavir‐ritonavir treatment of hospitalized patients with severe COVID‐19, ¹ and this treatment is currently not recommended. Currently, only remdesivir has been approved for COVID‐19 treatment, as it reduced recovery time by 4 days in 1,063 patients randomized to either remdesivir 200 mg loading dose followed by 100 mg daily or placebo for up to 10 days ² with a similar rate of adverse events between the 2 groups. ³ However, no effect on in‐hospital mortality was found.Chloroquine and its derivative hydroxychloroquine (HCQ), based on few preclinical studies, have also been proposed as therapies for COVID‐19. A Chinese randomized trial in patients with mild disease showed a significantly shorter recovery time in the group treated with HCQ vs. the standard of care along with a radiological improvement. ⁴ Differently, a retrospective study performed in the United States Veterans Health Administration medical centers found an increased mortality associated with the treatment with HCQ. ⁵ Moreover, an observational study has shown no significant association between HCQ use and risk of intubation or death. ⁶ Furthermore, a recent randomized controlled trial has found no differences between patients treated with HCQ plus the standard of care vs. the standard of care alone in terms of virus elimination. ⁷ On the basis of a very small nonrandomized study, azithromycin has been proposed as possible treatment in association with HCQ. ⁸ Azithromycin, is an antibiotic belonging to the class of macrolides, with some proven efficacy in acute respiratory distress syndrome. ⁹ , ¹⁰ It is known to have immunomodulatory properties through the polarization of macrophages toward the reparative state ¹¹ and the reduction in the production of pro‐inflammatory cytokines, such as IL‐8, IL‐6, TNF alpha, ¹² and iNOS expression. ¹³ Recently, two large retrospective studies evaluating in‐hospital mortality associated with the use of the combination of HCQ and azithromycin (or another macrolide, such as clarithromycin), have shown no benefits. ¹⁴ Despite the lack of a proven clinical efficacy and some concerns regarding the possible QT prolongations caused by the association of HCQ and azithromycin, ¹⁵ given the low price and the wide availability, the association of these two drugs has become the most used treatment in patients with moderate‐severe COVID‐19.Because of the urgent need to find answers to the many questions posed by the fight to SARS‐CoV2 infection and some negative evidences regarding the use of HCQ, we here propose a retrospective observational study to assess the efficacy of the combination of HCQ plus azithromycin for hospitalized patients with medium‐severe COVID‐19.     

Developing an Educational Framework for Urological Nursing: Using a World Café approach to gain an emerging international understanding of issues,challenges and responses

A series of three World Café events centred on the topic of developing an Educational Framework for Urological Nursing [EFUN] were held by the British Association of Urological Nurses [BAUN], the European Association of Urology Nurses [EAUN] and the Australian and New Zealand Urological Nursing Society [ANZUNS] between 2017 and 2019. About 376 urology nurses participated in these “conversations that matter” and generated 1047 individual response items that were grouped into themes to assist the three associations to take the creation of an EFUN to the next level. Areas explored centred on four aspects: what any agreed educational framework for urology nursing should contain; the academic level at which education should be provided; who should be recruited as collaborators on writing an educational framework and, lastly, just how any emergent framework should be used. Analysis of the conversational data indicate that there exists within the urological nursing community a collective wisdom regarding their educational needs and how these needs should be met.     

Annual Research Review: Rethinking childhood trauma-new research directions for measurement,study design and analytical strategies

Childhood trauma is a key modifiable risk factor for psychopathology. Despite significant scientific advances, traumatised children still have poorer long-term outcomes than nontraumatised children. New research paradigms are, thus, needed. To this end, the review examines three dominant assumptions about measurement, design and analytical strategies. Current research warns against using prospective and retrospective measures of childhood trauma interchangeably; against interpreting cross-sectional differences in putative mediating mechanisms between adults with or without a history of childhood trauma as evidence of longitudinal changes from pre-trauma conditions; and against directly applying explanatory models of resilience or vulnerability to psychopathology in traumatised children to forecast individual risk in unseen cases. The warnings equally apply to research on broader measures of adverse childhood experiences (ACEs). Further research examining these assumptions can generate new insights on how to prevent childhood trauma and its detrimental effects.