Is there a role for percutaneous pelvic and acetabular reconstruction?

The primary goal in the treatment of pelvic fractures is the restoration of haemodynamic stability. The secondary goal is the reconstruction of stability and symmetry of the pelvic ring. Percutaneous reconstruction can only be accepted if these goals are met. The type of definitive surgery is dependent of the degree of instability of the anterior and posterior pelvic ring. Retrograde transpubic screw fixation of pubic rami fractures is a good alternative to external fixation or plate and screw osteosynthesis. The technique of screw placement and image intensifier control is explained. Internal fixation of pure sacroiliac dislocations, fracture-dislocations of the sacroiliac joint and sacral fractures can be fixed with sacroiliac screws, placed percutaneously. Reduction of the fracture or dislocation is performed closed, or open if anatomy cannot be restored in a closed manner. The primary goal in the treatment of acetabular fractures is to restore anatomy. Reduction comes before fixation. The goal of minimising approaches cannot be more important. In most cases open reduction will be necessary to achieve anatomical reconstruction. Only the experienced acetabular surgeon will be able to decide when and how he can restore anatomy through a less invasive approach or with a percutaneous procedure. The anterior column screw can be inserted through a separate incision in addition to a Kocher-Langenbeck approach. It is the same screw as the retrograde transpubic screw but placed in the opposite direction. The posterior column screw is placed percutaneously from the lateral cortex of the ilium in the direction of the posterior column. Techniques of placement of both screws are demonstrated. Open reduction and internal fixation remains the standard of care in stabilisation of pelvic and acetabular fractures. Only the experienced surgeon will be able to judge if percutaneous procedures can be an alternative or a useful additive to conventional techniques.     

Congenital proximal bulbar stricture in adults.

Congenital proximal bulbar stricture in adults is a definite clinical entity and should be looked for in adults with obscure urinary symptoms. The stricture is usually short and can be demonstrated with a voiding cystogram, urethrogram, and urethroscopy. The condition is thought to be due to incomplete rupture of the cloacal membrane at its junction with the urogenital sinus. The stricture can be treated easily by internal urethrotomy and/or urethral dilatation.     

Atemwegsmanagement in der Kinderanästhesie

Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.     

Evaluation of female urinary incontinence

The use of urodynamic testing must be selective and based on the particular patient's complaints. In today's cost-conscious health care environment, a diagnosis based on one or two tests is preferable to exposing each patient to the full battery of available tests. For most patients, a cystometrogram and voiding cystourethrogram can confirm a variety of clinical suspicions. A cystometrogram best indicates how the bladder is behaving during filling. The voiding cystourethrogram allows the physician to observe the bladder and urethra during voiding and offers an excellent view of the anatomic relations of the urologic organs in the pelvis. The other important benefit of urodynamics is the objective data made available in hardcopy as a baseline study to be utilized for comparison in the future. The normal sequence of testing is a noninvasive uroflow study to determine the baseline flow rate. The postvoiding residual volume of urine is then determined. A cystometrogram and electromyography can then be done, the latter if there is a suggestion of neurologic disease or if otherwise indicated to determine bladder behavior on filling. Variations that are helpful when a patient fails to have a bladder contraction include having the patient in an upright or seated position during the test. A bethanechol supersensitivity test may be indicated as well. The urethral pressure profile may be done as the catheter is withdrawn and the bladder is already filled. The filled invasive flow rate can then be compared with the free flow rate. Sometimes, one of these rates is abnormal, and there is a question about whether the abnormality is real. The residual urine volume can be determined by subtracting the volume the patient voids from the filling volume. In the end, the key to urodynamic evaluation is the interpretation of the test, which should be made only by the individual actually performing the test. It truly is necessary for the physician to be there in person. Selective use of urodynamics can target an appropriate treatment for most patients. The female patient who complains of incontinence in whom the history suggests detrusor instability may benefit from a trial of cholinolytic therapy if no anatomic defect is present. In this type of patient, a surgical procedure may not be of benefit, whereas the cholinolytic therapy probably will work. This is a good reason for always choosing the appropriate urodynamic tests for evaluating and planning treatment for patients with urinary incontinence.     

Brachytherapy--an example of a urological minimally invasive robotic procedure

A review of the application of urological robots to the prostate is given, together with an examination of the conventional brachytherapy procedure for insertion of radioactive seeds to treat prostate cancer. The specification and design of a robotic system is provided, which can position a series of needles and radioactive pellets in accordance with a pre-operative plan. The needles can be withdrawn automatically, leaving the seeds in position.A separate motorised system is used to position a trans-rectal ultrasound (U/S) probe, which can be used to continually monitor the seed placement. The robot program can be updated intra-operatively if the U/S image shows this to be necessary. The demonstrator system has been demonstrated in-vitro using a variety of gel and animal tissue phantoms. The resulting robot performance shows this to be a viable approach.     

Airway management in pediatric anesthesia

Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.     

Paraneoplastic Cushing's syndrome in prostate cancer: a difficult management problem

Cushing's syndrome associated with small-cell de-differentiation of prostate cancer is rare, but well described. The detection of Cushing's syndrome in a patient with prostate cancer can be problematical, and when occurring in prostate cancer nearly always implies the development of small-cell transformation. Testosterone levels in these patients are likely to be in the normal range, despite previous castration. The features of Cushing's syndrome contribute considerably to patients' morbidity and probably to their mortality. The syndrome is unlikely to be controlled with inhibitors of steroid synthesis, and chemotherapy is likely to be poorly tolerated, resolving the syndrome in only a few patients. We suggest that bilateral adrenalectomy at an early stage should be considered, possibly as a preliminary to anticancer treatments.     

Infektionsschutzrecht

The infection protection act serves to prevent infectious diseases in humans, to recognize infections early and to prevent spreading. An infectious disease is a disease caused by pathogens or their products. An infection is the incorporation of a pathogen and the subsequent development or multiplication in the human body. The infection protection act and further decisions at the Federal and State levels normalize obligatory registration for a suspected disease, the disease and death from officially named infectious diseases. It is obligatory for the physician who determines the disease and also partly members of other healing or nursing professions. The type, extent and time of the registration must be carried out in a specified manner. Registration is not obligatory for personnel of emergency physician and rescue services if the patient is to be immediately taken to a medical institution. The responsible authorities must implement the necessary measures to avoid dangers due to the presence of an infectious disease. The officers of the authorities and the Ministry of Health must be allowed access to areas of land and buildings, to be allowed to carry out appropriate measures and must be provided with any necessary information. Infringements against the infection protection act can be pursued as summary offences.     

Continent ileal urinary reservoir (Kock pouch)

The Kock pouch has three major limitations at the present time: The efferent nipple valve remains by far the weakest link in the procedure. A 10 to 20 per cent failure rate is too high, and it remains to be seen whether further modifications will be successful in the long run. The long-term function is unproven, and it is possible that deleterious effects may be seen as additional follow-up is obtained. Theoretically, the low-pressure system afforded by the Kock pouch may be superior in long-term safety to that provided by reservoirs made from other bowel segments. A stoma is still necessary. In spite of the above, there is a need for this type of procedure. We cannot remain content with the ileal conduit and should continue to search for better functional diversions. It is a debatable issue relative to the superiority of an internal functional reservoir to the urethra, which may lead to night-time incontinence, versus a Kock pouch with a stoma, which must be intubated. Improvement in overall survival from bladder cancer may be hard to come by, unless effective systemic chemotherapy is available; one means is to perform the surgery without delay in patients with potentially lethal cancers. To do this on a large scale, we must make the surgery as safe as possible and provide the least disruption of lifestyle. In some patients an internal intestinal reservoir attached to the urethra will be possible. Other patients may elect for a Kock pouch, whereas others may even be best served by standard ileal conduit. The growth pains of the Kock pouch have been significant but not without a reward.     

Reconstruction of the congenitally deficient thumb.

Hand function in patients with congenitally deficient thumbs can usually be improved by operative procedures. The specific operation depends on the type of hypoplasia present. It is important for the surgeon to determine whether the thumb can be retained and made more functional by various reconstructive procedures, or whether it should be ablated in favor of a single-stage index finger pollicization. This decision is particularly difficult in patients with type III hypoplastic thumbs, in whom both the osseous and musculotendinous structures may be significantly affected. It is nearly impossible to perform pollicization as a salvage procedure after attempts to reconstruct a retained thumb have failed. The principles presented may assist the surgeon in this decision-making process. Pollicization itself is an exacting procedure requiring attention to numerous details. The surgeon and parents must realize that additional operative procedures may be required to enhance the function of the pollicized digit.     

Failed intubation in obstetrics

Failed intubation in obstetrics is rare. However, if the situation is not managed appropriately the consequences for the mother and newborn may be catastrophic. The skill of managing the airway seems to be decreasing, primarily because the skills are not being practised in general or obstetric anaesthesia. Solutions for this decrease in skills may include improved training and the use of manikins, both for role play and for practising skills. The priority of management is to provide oxygen to the mother and to call for assistance. Oxygen can be provided using basic airway, intubation, and, if necessary, surgical airway skills. Such skills need to be practised on manikins and non-obstetric patients. The decreasing incidence of general anaesthetics means that planning and preparation should be meticulous before and during caesarean section. Ideally, the first intubation attempt should be the best. If a failed intubation occurs, initially techniques such as the use of a bougie, McCoy blade or the left molar approach may be considered, provided hypoxia is avoided. If intubation is unsuccessful the mother should be woken and a regional technique or awake fibreoptic intubation from a suitably experienced practitioner should be considered. A simple protocol shown in this article can be used as a training tool to assess skills, decision-making and teamwork in the event of a failed intubation. Extubation after a difficult intubation should be done with care, and the patient warned of the difficulty in case of further anaesthetics.     

A combined state and state estimate feedback solution to the ship positioning control problem

A stochastic linear quadratic optimal control problem is considered in which some of the plant states may be measured without a measurement noise component. This set of states are assumed to be associated with the plant inputs and force transducers. The optimal controller is shown to include state feedback from this part of the system. The states which cannot be measured are assumed to be combined in noisy output signal. The optimal controller corresponding to this second subsystem is shown to include a Kalman filter and state-estimate feedback. The combination of state and state-estimate feedback has the advantage that the dimension of the Kalman filter is equal to that of the second subsystem mentioned above. In the conventional solution to this problem, no states are assumed measurable, and the dimension of the Kalman filter is equal to the dimension of the complete system. In many industrial control problems, the combined control law enables a significant reduction in the dimension of the filter to be achieved. The technique has been proposed for use in dynamic ship positioning control systems, and this problem is discussed.     

The laryngeal mask airway.

The laryngeal mask airway (LMA) is a new concept in airway management. A miniature inflatable mask is positioned in the hypopharynx, forming a low-pressure seal around the laryngeal inlet. The mask is attached via a tube to the breathing circuit. It is inserted after induction of anesthesia without the need for muscle relaxants or laryngoscopy. The LMA can be used to facilitate both spontaneous and controlled ventilation in adults and children. The LMA has been used for a wide variety of surgical procedures but is probably best suited to short procedures, especially if a light general anesthetic is used in combination with a regional technique. It may be particularly useful in outpatient anesthesia, as it avoids the need for intubation or muscle relaxants. It can be used as an alternative to mask anesthesia or when an endotracheal tube would have been inserted to allow surgical access. It has been used successfully in cases of difficult or failed intubation, although its role here needs further appraisal. It does not protect against aspiration of stomach contents and should not be used when aspiration is a risk. Controversy exists regarding its use to facilitate positive-pressure ventilation (PPV) due to concern that gases under pressure may be forced into the stomach and predispose the patient to regurgitation. It may be more difficult to use in children. It is now widely used in the United Kingdom; however, it is not yet available for sale in the U.S. It has already had a major effect on practice in Britain and has the potential to do the same in the United States.     

Ureteral obstruction after abdominal aortic surgery

Obstructive uropathy following abdominal aortic surgery can no longer be considered a rarity. Early hydronephrosis, developing in the first postoperative year, occurs in 10% to 20% of patients; it usually runs a benign, self-limiting course. The incidence of delayed ureteral obstruction, which develops or persists after the first postoperative year, is unknown because it is asymptomatic in most cases. Although spontaneous resolution is possible, it seems that this late form is more likely to persist. The diagnosis of postoperative hydronephrosis is not an indication for urologic intervention. This should seldom be necessary; it should be reserved only for patients with evidence of worsening obstruction or deteriorating renal function. Early and particularly, delayed hydronephrosis seems to be a marker for present or impending graft complications, such as infection or false aneurysms. A prolonged follow-up is therefore mandatory whenever the diagnosis is established as it may improve long-term survival and limb salvage. The need for routine screening for this condition remains to be established. With the availability of noninvasive methods, such a task could be easily accomplished.     

Diagnostik kindlicher Frakturen

During the diagnostic phase children need to be treated differently from adults. Neither the history taking nor the physical examination is so important as in adults. The history can be elicited from relatives accompanying the patient, but should not be allowed to delay further diagnostic procedures and treatment. Fast and accurate diagnosis is needed so that treatment can be selected and implemented, and also to reassure the parents. It is important that inspection and examination should not be painful for a child. Fracture treatment in children needs special experience and should be performed in trauma centers. In addition to accidents that have to be treated privately, accidents for which patients are insured by the German employer’s liability insurance associations are common and need to be treated in qualified trauma centers. The localization of fracture lines depends on the maturity of the physis. This is why the mechanism of the accident is not so important as in an adult and the physical examination has to be reduced to a minimum. A sufficient diagnosis is yielded by two X-rays in perpendicular planes. X-rays in an oblique plane or of the contralateral side are recommended in special situations, e.g. triplane fractures, as are CT and MRT. The maturity of different ossification centers has to be taken in account to avoid false diagnoses. The use of ultrasound is not recommended for the diagnosis of fractures in children.     

Arthroscopic implantation of a three dimensional scaffold for autologous chondrocyte transplantation

The arthroscopic M-ACT technique is applicable for defects at the femoral condyle up to 5 cm2. The size of the defect has to be assessed with a specific scaled, percutaneously inserted needle. Then an 8 mm water-stop-cannula is positioned in a suprameniscal portal. The chondrocyte seeded matrix is trimmed to size the defect. The scaffold is introduced in the joint through the cannula and placed into the defect with a blunt arthroscopic grasp instrument to prevent damage of the scaffold. Then a specific drill guide is inserted through an additional anteromedial portal to place it on the scaffold in a perpendicular angle. The position of the drill guide should not be changed during the next two steps. It may be helpful to hold the matrix in place with a probe inserted through the cannula. A 1.5 mm K-wire is drilled at least 16 mm into the subchondral bone. Then the biodegradable pin (length 16 mm) is placed in the drill guide and carefully hammered into the subchondral bone. The joint is flexed so that the drill guide can be placed on the posterior end of the scaffold. Another hole is drilled with the K-wire and a second pin is inserted. Finally the stability of the matrix is tested with a probe and the joint is mobilized.     

Restricted structure control of multiple model systems with Series 2 DOF tracking and feedforward action

The solution of a scalar optimal control problem is discussed where the feedback, series tracking and feedforward controllers are chosen to have a very simple. Each controller term may be chosen to be of reduced order, lead/lag, or PID forms, and the controller is required to minimize an LQG cost‐index. The optimization is based upon a cost‐function which also allows separate costing of the terms due to the feedback, tracking and feedforward controllers. The system model can be uncertain and can be represented by a set of models over which the optimization is performed. This provides a form of robust optimal control that might even be applied to non‐linear systems that can be approximated by a set of linearized models. The theoretical problem considered is to obtain the causal, stabilizing, feedback, series‐tracking and feedforward controllers, of a prespecified form, that minimize an LQG criterion over the set of possible linear plant models. The underlying practical problem of importance is to obtain a simple method of tuning low‐order controllers, given only an approximate model of the process. The results are illustrated in a power generation control problem for a system represented by 12 different linearized plant models. The single feedback controller that is obtained has a simple form and stabilizes the full set of models. Copyright © 2001 John Wiley & Sons, Ltd.     

Battered child syndrome simulating myositis

The battered child syndrome is not an unusual problem to be encountered in a clinical orthopedic practice. The manifestations in abused children may be varied and many, necessitating that orthopedists be familiar with the ways in which affected children present to reduce the unfortunate consequences that occur when abuse is not initially recognized. Our purpose in reporting the case of an abused child is to attract the attention of the orthopedic surgeon, who may be the initial physician to see a battered child, to an unusual presentation of this syndrome which simulated myositis. The association of myositis with battered child syndrome has not been previously encountered in the orthopedic literature.     

The Hanger Reflex: An Inexpensive and Non-invasive Therapeutic Modality for Dystonia and Neurological Disorders

The hanger reflex is a phenomenon characterized by the involuntary rotation of the head when a wire hanger is worn around the head such that a force is applied to the frontal temporal area by the longer side of the hanger. The application of a shearing force on the skin is thought to be the cause of this phenomenon. Attempts have been made to treat cervical dystonia using equipment designed to induce the hanger reflex. This reflex may have implications in the treatment of headaches, cervical pain, and adhesive capsulitis. The hanger reflex is seen not only in the head region but is also in other parts of the body. Thus, it could be used in the treatment of systemic dystonias. The hanger reflex may help develop inexpensive and non-invasive treatment for dystonia or other neurological diseases and is expected to be the focus of research in the future.     

Melanoma anorrectal. Revisión de conjunto

Anorectal melanoma is an uncommon and aggressive disease. Because the patients often present with non specific complaints, a high clinical suspicion is important to avoid a delayed diagnosis. Patients undergoing radical surgery have no significant survival difference compared to those undergoing wide local excision. Abdominoperineal resection should be reserved for selected patients in whom local excision is not technically possible or cannot obtain a clear margin. The indiscriminate use of groin dissection is not advisable in anorectal melanoma and should be use in selected cases. Systemic chemotherapy is generally a non effective treatment and continues be studied. Radiation therapy can be used as hypofractionated radiation therapy combined with local excision or in a palliative setting. The oncological outcomes in anorectal melanoma are very poor. The aim of the present study is to review clinicopathology features and management of anorectal melanoma.