Neuromuskuläres Defizit bei chronischer Sprunggelenkinstabilität

The peroneal reaction time (PRT) is used in the assessment of neuromuscular deficits in chronic functional ankle instability. Powered by the Editorial Manager® and Preprint Manager® from Aries Systems Corporation the present study was conducted to determine the PRT in a large collective of patients with chronic ankle instability because it is unclear if this parameter of neuromuscular deficit is prolonged. In this study 186 patients underwent a diagnostic algorithm consisting of anamnesis, clinical examination, X-ray and determination of the PRT on a tilting platform. A prolonged PRT as a manifestation of a neuromuscular deficit could be detected in the majority of the patients (n?=?143, 77?%). Comparing the affected and healthy legs 77 patients (41?%) showed a significant difference in talar shift (p?=?0.002) and talar tilt (p?=?0.04) in the radiological stress views. Of these 77 patients only 15 (8?%) showed radiological evidence of a mechanical problem. As a consequence of recurring ankle sprains a post-traumatic deficit in proprioception has to be expected in most cases. In general a conservative therapy approach should be followed including specific training to improve neuromuscular and proprioceptive deficits.     

Sensomotorik nach Kapsellabrumrekonstruktion bei chronischer Schulterinstabilität

The anterior capsulolabral reconstruction technique described by Jobe is a modified Bankart repair. The capsular shift is performed in a horizontal direction via a subscapularis split approach avoiding any incision of the muscle.Of 43 patients with posttraumatic anterior shoulder instability treated by anterior capsulolabral reconstruction, 35 were examined after 3.7+/-1.4 years, and of these, 29 (82.9%) had no pain; the external rotation deficit was 4.1+/-2.9 degrees .The average Constant-Murley score was 92.4+/-7.1 and the average ASES score was 93.3+/-8.4. The reluxation rate was 7.7%. This technique was shown to provide good clinical results, but only 69% of the patients were able to return to their prior sporting activity level. This particular problem was addressed by investigating the joint proprioception and the activity of the periarticular muscles. The results confirmed a persistent deficit of proprioception as well as a pathologic EMG pattern after anterior capsulolabral reconstruction, which may explain the problem of incomplete restoration of the function of the shoulder joint.     

Aktuelle Konzepte bei Schädel-Hirn-Trauma

Trauma und Berufskrankheit - Schädel-Hirn-verletzte Patienten bedürfen in allen Phasen der Traumabehandlung neurochirurgischer Versorgung. In der Primärphase werden raumfordernde...     

Aktuelle Versorgungsstrategien bei Schultereckgelenkinstabilitäten

Frequency and risk factors

The rising numbers of primary joint replacements and revision surgery as well as a changing age structure have led to an increase in intraoperative periprosthetic fractures. Risk factors are revision surgery, uncemented cups, stems and long stems, reduced bone quality and female sex. Preventive procedures have to be taken into consideration.

Therapy

The intraoperative diagnosis of this type of fracture is essential for adequate treatment and an excellent outcome without impairment in function or quality of life. The treatment focuses on fracture stabilization, prevention of propagation and on stable fixation of the prosthesis.     

Aktuelle Versorgungsstrategien bei Schultereckgelenkinstabilitäten

Trauma und Berufskrankheit - Verletzungen am Schultereckgelenk gehören aufgrund ihrer Häufigkeit zum klinischen Alltag. Rockwood(RW)-I- und -II-Läsionen werden initial konservativ...     

Risikofaktoren,präoperative liegezeiten und mortalität bei gerontochirurgischen eingriffen

Zusammenfassung In der Chirurgischen Klinik der RWTH Aachen wurden im Zeitraum vom 22.9.87 bis 12.2.92 1026 Patienten älter als 65 Jahre einer allgemeinchirurgischen Operation unterzogen. Die Daten dieser Patienten wurden hinsichtlich präoperativer Risikofaktoren, präoperativer Liegezeit, krankheitsbezogener Anamnesedauer und Mortalität analysiert. Als wichtigste präoperative Risikofaktoren wurden berücksichtigt: kardiovaskuläre Erkrankungen (45,9%), Hypertonie (28,7%), pulmonale Erkrankungen (19,4%) und Diabetes mellitus (16,8%). Patienten ohne Risikofaktoren wiesen die geringste Mortalität bei 1–2 Tagen präoperativer Vorbereitungszeit auf. Patienten mit 4 oder mehr Begleiterkrankungen zeigten die geringste Mortalität bei einer präope-rativen Liegezeit von 10–14 Tagen. Bei 30% der Patienten war die Anamnesedauer 2–10 Monate, bei 8,2% weniger als 24 h.

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Risk factors, pre-operative rest period, and mortality in geriatric surgery

A total of 1026 patients over 65 years of age underwent abdominal surgery during the period from 22 September 1987 to 12 February 1992 at the Surgical Department of Aachen Technical University. The data of these patients were analysed with respect to pre-operative risk factors, pre-operative rest period, their history and mortality. The following most important pre-operative risk factors were considered: cardiovascular diseases (45.9%), hypertension (28.7%), pulmonary diseases (19.4%) and diabetes mellitus (16.6%). Patients without pre-operative risk factors showed the lowest mortality rates if the preoperative rest period was 1–2 days only, whereas patients with four or more risk factors showed the lowest mortality rates if the period of rest was 10–14 days. Mortality after emergency intervention (16.54%) was about three times as high as after elective surgery (5.54%). The anamnesis was 2–10 months for 30% of the patients whereas 8.2% of the patients reported a history of complaints of less than 24 h.

     

Die präoperative Behandlung chronischer Ventilationsstörungen zur Erweiterung der Indikation bei thoraxchirurgischen Eingriffen

Ohne Zusammenfassung     

Aktuelle anästhesiologische Aspekte bei urologischen Patienten

Patients with coronary stents should take clopidogrel and acetylsalicylic acid for 4 weeks or 12 months after stenting. Stopping this medication early, e.g., for surgery, results in a 90-fold increase in the patient’s risk for myocardial infarction from stent thrombosis. The mortality due to perioperative acute coronary syndrome clearly exceeds that due to perioperative bleeding complications. If oral medication resulting in platelet inhibition has to be paused “bridging” with short-acting, intravenous GPIIb/IIIa antagonists is possible. In recent years perioperative β-blockade has been recommended for patients with high coronary vascular risk, and recently also for those with medium or low risk. Current studies, however, indicate that patients on β-blockers have increased perioperative mortality because of bradycardia, hypotension, and anemia. Therefore, anemia and hypotension should be rigorously avoided. Anesthetic management may have an influence on the postoperative course of cancer. Combined epidural-general anesthesia provides a benefit by minimizing the use of systemic opioids and volatile anesthetics. Presumably, this and a decreased response to surgical stress increase the ability of the patient’s immune system to deal with cancer dissemination and micrometastasis.     

Farbduplexsonographie bei chronischer und akuter Mesenterialarterienischämie

Background

Only a few articles have been published on the importance of duplex sonography for acute and chronic ischemia of the mesenteric artery and the criteria for stenosis show discrepancies.

Material and methods

A critical review of the literature between 1985 and 2013 on the validity of duplex sonography for acute and chronic ischemia of the mesenteric artery was carried out. A sonographic investigation concept was developed by which prognosis relevant, acute mesenteric artery stem occlusions can be diagnosed without time delay.

Results

Despite different criteria for stenosis, e.g. peak systolic velocity (PSV), end diastolic velocity (EDV) and the PSV/EDV ratio given in the literature, evaluation of the PSV appears to be the most accurate method. Although there is a lack of publications on acute mesenteric artery ischemia with adequate study design, our own concept of duplex sonography for evaluation over the length of the mesenteric artery stem with optimal instrument adjustment and spectral analysis of the bifurcation of the superior mesenteric artery, is an efficient time-saving method (in the prognosis-relevant early stage) in the diagnosis of ischemia of mesenteric artery and for avoidance of extensive intestinal necrosis. The diagnosis can be made without delay in more than 80 % of cases. When the findings are inconclusive the diagnosis must be rapidly confirmed by computed tomography angiography.

Conclusion

The possibilities of duplex sonography as a universally deployable method (e.g. lack of side effects and spatially flexible) in the time-efficient diagnostics of acute and chronic mesenteric artery ischemia have so far been underestimated in the clinical routine.     

Die präoperative computertomographische Abklärung bei Tibiakopffrakturen

Within the last decade computed tomography has become an important instrument for skeletal diagnosis. In this study the value of helical CT-scan was compared with plan X-rays and conventional tomography in 45 patients having sustained an intraarticular tibia plateau fracture. Between plan roentgenogramms and CT-scan the fracture classification according to the AO-classification was changed in 40% of all patients, in 39 cases the amount of impression or dislocation increased with a mean of 4.2 mm. Especially tiny fragments were better visible and therefore responsible for the shift of many B1 fractures to group B3. The difference between conventional tomography and computed tomography was less impressive, a change of fracture classification could be observed in only 6.7% of all cases.     

Präoperative Schmerzen bei urologisch operativen Patienten

Background

The genesis of chronic pain in urology has so far been insufficiently investigated. No investigations have focused on the occurrence of preoperative pain. We developed an epidemiological questionnaire to analyze preoperative pain.

Methods

In this questionnaire, preoperative pain in all patients scheduled for urologic surgery (n=165) was analyzed. Acute and chronic pain was analyzed as main or adjoint pain, with the registration of severity, chronification states, and duration. We registered depression and anxiety, well-being, and somatic and psychological efficiency.

Results

Eighty percent of the patients reported pain within the previous 12 months. Acute preoperative pain was reported by 17% of the patients and chronic pain by 64%. Significant differences in quality of life were detected between patients with or without preoperative pain. Well-being was also significantly affected in patients having pain.

Conclusion

The pain severity and states of chronification not only explain a reduction in somatic and psychological well-being but also emphasize that preoperative pain should be identified thoroughly prior to surgery.     

Radiolunäre und radioskapholunäre Arthrodese bei chronischer Polyarthritis

INTRODUCTION: In 75% of all cases of rheumatoid arthritis the wrist is affected and in 12% is the region of initial manifestation of this chronic inflammatory joint disease. To prevent destruction of the wrist through carpal dislocation, radiolunate and radioscapholunate arthrodeses have increased in importance. METHODS: During a 6.5-year period, 28 radiolunate and 4 radioscapholunate arthrodeses were performed in 30 patients. The indication for operation was progressive carpal translation and increasing subluxation of the wrist in which existent radiological damage had not reached more than grade III according to the classification of Larsen and co-workers. RESULTS: The results obtained during the follow-up study (median: 17.3 months) showed in most treated patients after partial arthrodesis of the wrist no or fewer complaints concerning swelling and pain and an acceptable remaining range of motion of the wrist in everyday life. In patients with preoperatively existing ulnar deviation less than 15 degrees progressive carpal collapse and dislocation could be mostly prevented. CONCLUSION: All told radiolunate and radioscapholunate arthrodeses successfully stabilized the wrist in patients suffering from rheumatoid arthritis.     

Ohrakupunktur bei Detrusorhyperaktivität

Background

Patients suffering from overactive bladder/detrusor overactivity (OAB/DO) seem to benefit from body acupuncture. The study was carried out to test if auricular acupuncture (AAP), which is supposed to show an immediate effect, can also cause urodynamic changes.

Patients and methods

The OAB/DO condition was verified by means of cystometry in 14 patients. These patients were subjected to bilateral AAP after cystometry, a second cystometry was performed 20-30 min later and data were analyzed using the Wilcoxon rank-sum test.

Results

None of the patients showed local or systemic complications but DO persisted in all patients and urge urinary incontinence (UUI) persisted in 85 % (11/13) of patients. Intravesical pressure decreased after AAP but without reaching statistical significance. In 22 % (2/9) of patients residual volume (RV) disappeared completely while 78 % (7/9) of patients showed significant reduction of RV.

Conclusions

This study could not prove a significant influence of AAP on DO or UUI; therefore an immediate effect of AAP in patients suffering from OAB/DO seems to be unlikely. Further studies are necessary to evaluate the effect of repeated AAP sessions on urodynamic changes.     

Präoperative Psychoedukation bei einem schwer traumatisierten Kind

N., an 8-year-old girl with a long term history of severe sexual abuse and maltreatment with consecutive mental disorders, was scheduled for surgery of clubfeet. The team consisting of an anesthesiologist, a psychologist and a pediatrician decided to prepare the girl for surgery without time pressure. In a first step we applied psychoeducation to obtain a certain degree of confidence. Psychoeducation is a special form of psychological treatment aiming to define cause and goal of surgery together with the patient and relatives. In a further step the anesthesiologist familiarized her with the surgical procedure and the operating theatre. Finally a careful anesthesia with a pain-free postoperative period was applied. Even extremely traumatized children can be prepared for surgery by the help of psychoeducative methods, without time pressure, a careful and pain-free anesthesia and an experienced team of doctors.     

Befundadaptierte operative Versorgungsmöglichkeiten bei Wirbelsäulenmetastasen

The current operative approaches and technical possibilities in the operative treatment of spinal metastases are manifold which enables an individual operative strategy adapted to the patient’s condition. Maintaining quality of life is the primary goal in the treatment of these patients. The therapeutic goals, such as pain control, avoidance of neurological deficits and the achievement of spinal stability have to be attained with as little morbidity as possible. From this perspective the available operative techniques ranging from minimally invasive approaches to complex reconstructive surgery will be addressed and discussed in this article.     

Das präoperative EKG als Routineuntersuchung bei Kindern

Objective: The aim of this study is to examine whether a routine preoperative ECG is necessary in children to assess the risks in anaesthesia and surgery. Methods: We examined the records of 3030 children anaesthetized in our hospital in 1990 and compared records of complications with preoperative ECGs. We also evaluated questionnaires on this subject which we had sent to 51 large pediatric hospitals in Germany in 1991. Results: During 3030 anaesthetic procedures there were 93 complications, 67 of which were not of cardiac origin. Of the 26 cardiac complications only 4 needed therapy (AV-Block 2°, fall in blood pressure). Preoperative ECGs were recorded in 180 cases: 152 were normal, 8 showed harmless deviations from normal and 16 were recorded because of known cardiac defects. None of the 180 children developed complications during anaesthesia. Our questionnaire was returned completed carefully by 36 of the 51 hospitals. In most hospitals a preoperative ECG is only recorded when heart disease is known or suspected. Conclusion: Routine preoperative ECGs are unnecessary in children unless there are clinical symptoms of heart disease or heart disease is suspected.     

Intraartikuläre operative Maßnahmen bei Arthrose

The reconstruction of weight-bearing joint surfaces has long been a challenge for the orthopedic surgeon. The statistical rise in life expectancy, the spread of high-risk sports and leisure-time activities combined with high demands for painfree joint function even in older age as a factor for contemporary quality of life are the demographic factors of the bone and joint decade announced by the WHO. Osteoarthritis represents a multifactorial, irreversible, often heterogeneous joint disease with joint destruction as the inevitable consequence. Conventional and innovative intra-articular operative methods for the treatment of osteoarthritis are presented and discussed. Tissue engineering stands for vitalizing tissue modification by modification of cellular and humoral mechanisms. Thus, new therapy options for curing degenerative joint diseases will arise in the future. Autologous chondrocyte transplantation (ACT) represents one of the first clinically established methods. The paradigm of treating osteoarthritis by the orthopedic surgeon will be multimodal in the future. Innovative techniques in the biotechnological sector provide a promising horizon.