Rekonstruktive Fußchirurgie bei diabetisch-neuropathischer Osteoarthropathie

ZusammenfassungFragestellung Die neurogene Osteoarthropathie zieht oft eine invalidisierende und konservativ nicht mehr beherrschbare Deformität des Fußes nach sich. Eine Operationsindikation ergibt sich bei rezidivierenden Ulzera, tiefen Infektionen und bei dekompensierter Statik mit progredienter Deformierung. Die Methode der externen Fixation steht dabei auf dem Prüfstand.Methodik 65 zwischen 1997 und 2003 operierte Füße mit Neuroarthropathie bei 21 Frauen und 43 Männern konnten retrospektiv untersucht werden. Bei 56 Patienten lag eine diabetische Polyneuropathie vor. Als Operationsmethode kam in 59 Fällen ein Fixateur externe zur Anwendung, 9-mal erfolgte die Fixation mit Steinmann-Nägeln. Die Nachbehandlung sah die Mobilisation in einer Unterschenkelorthese bis zu 1 Jahr Dauer vor.Ergebnisse Bei den Diabetikern betrug die durchschnittliche Erkrankungsdauer für Typ 1 24,8 und für Typ 2 13,7 Jahre. Alle Füße entsprachen dem Levin-Stadium 3 oder 4, hinsichtlich der Sanders-Klassifikation waren die Typen II bis V vertreten. In 5 Fällen sahen wir reine Luxationen, weitere 9-mal eine Kombination aus ligamentären und ossären Veränderungen. Operative Revisionen infolge von Komplikationen waren in 7 Fällen erforderlich, zum Teil mehrfach. Folgeoperationen im weiteren Krankheitsverlauf waren 13-mal erforderlich, in 6 Fällen wegen eines Korrekturverlustes. Durchschnittlich 752 Tage nach der Fußkorrektur führten 3 Nachamputationen bei 2 Patienten zu einer prothetischen Versorgung. Pin-Infekte und Wundheilungsstörungen waren häufig, aber konservativ beherrschbar und unabhängig von vorbestehenden Ulzerationen oder Infekten. Innerhalb des ersten Jahres nach der Operation kam es bei 13,9% der Füße zu einem Ulkus. Alle Patienten wurden mit Hilfsmitteln mobilisiert, 47 mit einer Unterschenkelorthese und 15 mit Maßschuhen.Schlussfolgerungen Die externe Fixation zur Stellungskorrektur bei Neuroarthropathie stellt ein geeignetes und variables Verfahren mit geringer Komplikationsrate dar. Es können floride wie auch zum Stillstand gekommene Osteoarthropathien behandelt werden. In der Regel wird eine fibröse Ankylose hergestellt, die eine schmerzfreie Mobilisation unter Vollbelastung erlaubt. In geeigneten Fällen—bei gutem Alignement des Fußes und guter Mitarbeit des Patienten—ist nach etwa 12-monatiger Tragedauer der Unterschenkelorthese eine Versorgung mit Maßschuhen möglich.     

Molekulargenetische Analyse und klinische Aspekte bei Patienten mit hereditärer Hämochromatose

Background

The purpose of the study was to perform a molecular genetic analysis and to document clinical aspects in patients with hereditary hemochromatosis.

Patients and methods

The study included 33 outpatients (23 males average age 50.6 years and 10 females average age 60.6 years) with a disorder of iron metabolism (transferrin saturation >?75?%) as confirmation of hemochromatosis who were subjected to molecular genetic and clinical analyses.

Results

A homozygous mutation of the hemochromatosis (HFE) gene (C282YY) was detected in 63.6?%, a compound heterozygous mutation (C282Y/H63D) in 30.3% and no mutation of the HFE gene was detected in 6.1?%. The following organ manifestations could be objectified: arthralgia (78.8?%), liver disease (39.9?%), skin hyperpigmentation (30.3?%), osteoporosis (24.2?%), diabetes mellitus (24.2?%) and cardiomyopathy (12.1?%). Comparison between patients with heterozygous and homozygous hemochromatosis revealed the following differences: compound heterozygote patients presented less frequently with osteoarthritis of the metacarpophalangeal (MCP) joints and hands (85.7?%/71.4?% homozygotes vs. 60?%/60?% heterozygotes). Osteoarthritis of the shoulder joints and osteoporosis as well as hypothyroidism were more frequent in compound heterozygote patients, whereas osteoarthritis of the knee and hip joints as well as liver disease were more common in homozygote patients. No differences between both groups were seen with respect to the clinical manifestations of cardiomyopathy and diabetes mellitus.

Conclusion

Prevalent causes of death in hereditary hemochromatosis are heart failure, liver disease (cirrhosis and hepatocellular carcinoma) and portal hypertension. Therefore, an early diagnosis, adequate therapy and genetic screening of family members are of great importance. Medicinal treatment will only effectively prevent deleterious organ involvement and subsequent complications if initiated at an early stage. Furthermore, an overview of the current data is given.     

Der spastische Knick-Plattfuß bei Patienten mit Infantiler Zerebralparese

BackgroundSpastic flatfoot is a common problem in patients with cerebral palsy. The neurological deficit represents the primary damage, the musculoskeletal deformities the secondary damage.Diagnostics and surgeryIn addition to the physical examination, the X-ray of the foot with full weight bearing is the diagnostic standard. Different surgical techniques, extra-articular arthrodesis (Grice), Evans’ calcaneus lengthening osteotomy, optionally in combination with a sliding calcaneous osteotomy, or more stable procedures, such as TN arthrodesis or triple arthrodesis, are available as therapy options.ResultsThe procedures and the postoperative therapy are described, the present results are discussed. The individual procedure must be decided on the extent of the deformity and the activity of the individual patient.ConclusionFlexion or torsional contractures of the proximal joints requires a different therapy regime in the sense of a multilevel surgery therapy concept and may have to be additionally planned.     

Die subkutane Milzzerreißung und ihre Behandlung

Ohne Zusammenfassung     

Die einreihige Innennaht der End-zu-End-Anastomose bei dringlichen Dünndarmresektionen,ihre klinische und pathologische Bedeutung

Ohne Zusammenfassung     

Präklinische Notfallsonographie bei traumatologischen Patienten

Besides severe cerebral trauma, abdominal bleeding is the most frequent cause of death after multiple trauma. Abdominal bleeding is difficult to diagnose because initially at the scene a multiply injured patient with a stable circulation is often encountered. Ultrasound diagnostics have played a central role in the diagnostics of emergency patients for many years. This technique is used both in the emergency room and in the intensive care unit, in the operation center and to an increasing extent in emergency diagnostics during the pre-hospital setting. The following article deals with the ultrasound investigation of injured patients, the indications and examination technique are described, as well as the specific characteristics of using ultrasound at the scene. Finally, device-specific characteristics and the state of development in Germany are presented.     

Die zirkulierenden Adhäsionsmoleküle sICAM-1 und sE-Selectin bei Patienten mit Sepsis

Aim: The aim of this study was to investigate whether the plasma levels of the circulating adhesion molecules sICAM-1 and sE-selectin could serve as early predictors of developing sepsis and its severity. Methods: Twenty-four patients admitted to an intensive care unit with a high risk of developing septic complications were enrolled in this study. Patients were divided into three groups: group I, with infection without systemic sepsis, n = 8; group II, surviving patients with severe sepsis and multi-organ failure (MOF), n = 8; and group III, nonsurviving patients with severe sepsis and MOF, n = 8. Classification of patients was performed according to the clinical criteria defined by the Sepsis Consensus Conference in 1992. Blood samples were taken at 7 a.m. starting from the day of admission until the 7th day after diagnosis of sepsis. Plasma levels of sICAM-1 and sE-selectin were determined in all samples taken between the 3rd pre-septic day and the 7th day after the diagnosis of sepsis was made. Results: In group I, both sICAM-1 (354.21 ± 128.60 ng/ml, 86 samples) and sE-selectin (30.41 ± 7.20 ng/ml, 86 samples) levels remained within the reference range over the whole period of observation. The sICAM-1 levels of group II (between 550.82 ± 275.67 ng/ml and 445.08 ± 243.63 ng/ml) tended to show values above the reference range without being significant. Mean sICAM-1 levels in group II did not differ from those of group I. From the 2nd pre-septic day onwards the sICAM-1 levels of group III increased, but not significantly. Significant differences in sICAM-1 levels between group I and group III were observed, with peaks at the samples of the 2nd pre-septic day and after the 3rd day of sepsis, respectively (P < 0.05). The sE-selectin levels in group II were elevated from the 3rd pre-septic day onwards, with a peak value on the 2nd day of sepsis (P < 0.05). Afterwards, levels decreased to initial values despite ongoing sepsis. Mean values of sE-selectin levels of group I and II were significantly different with the onset of sepsis (P < 0.05). Plasma levels of sE-selectin in group III were significantly elevated (66.30 ± 9.00 ng/ml on the 3rd pre-septic day), reaching their maximal values of 106.67 ± 21.66 ng/ml at the end of the observation period. Significant differences between sE-selectin levels of groups I and III existed from the 3rd pre-septic day onwards, and between group II and III on the 7th and 8th day of sepsis. Conclusion: Our results show that sICAM-1 is a relatively non-specific indicator for sepsis. In contrast, sE-selectin seems to be a good and early predictor of the beginning of severe sepsis with MOF. Furthermore, sE-selectin levels seem to have a prognostic value for the severity, possible course, and outcome of developing sepsis.     

Hochdosischemotherapie und hämatopoetische Stammzelltransplantation bei Patienten mit Keimzelltumoren

In cases of germ cell tumors, urologists cooperate with oncologists to determine the best timing for high-dose chemotherapy (HDC). In the primary treatment of patients with"intermediate" and"poor" prognosis, HDC conveys no benefit. These patients are treated with four cycles of cisplatin, etoposide, and bleomycin (BEP). After failure of the standard therapy again four cycles of conventional-dose combination chemotherapy are necessary in good prognosis patients: cisplatin, ifosfamide and either etoposide (VIP or PEI), vinblastine (VeIP) or paclitaxel (TIP). HDC should be considered in patients who fail primary treatment, and who show unfavorable prognostic features prior to salvage treatment.     

Die Anwendung der pneumatischen Prothese in Verbindung mit Pectoraliskanälen bei beiderseits Oberarmamputierten und Schulterexartikulierten

Ohne ZusammenfassungMit 9 TextabbildungenHerrn Professor Dr. med. S. Weil zum 80. Geburtstag gewidmet.     

Die präklinische Versorgung des polytraumatisierten Patienten

Zusammenfassung In den entwickelten Industrienationen stellt das Trauma die häufigste Todesursache bei unter 40-jährigen dar. Die präklinische Versorgung dieser Patienten beeinflusst wesentlich die Prognose hinsichtlich der Letalität und der Morbidität. Diese Phase ist gekennzeichnet durch die Notwendigkeit schneller Entscheidungen in kürzester Zeit unter häufig ungünstigen Bedingungen mit eingeschränkten diagnostischen und therapeutischen Mitteln. Damit steht das erstversorgende Team vor besonderen Herausforderungen. Zum präklinischen Management des Polytraumas gehören die Untersuchung des Verletzten, die Stabilisierung der Vitalfunktionen in der speziellen Situation des hämorrhagisch-traumatischen Schocks, die Immobilisation der Wirbelsäule und die Versorgung der Einzelverletzungen. Auch Besonderheiten wie die Bergung des Verletzten, der Anfall mehrerer Verletzter, die Transport- und Zielkoordination und nicht zuletzt die Eigensicherung sind dabei zu berücksichtigen.     

Die Behandlung großer Verbrennungen mit und ohne Tannin

Ohne Zusammenfassung     

Die Beckenringzerreißung beim polytraumatisierten Patienten

Pelvic injuries represent a thorny and stubborn therapeutic challenge. Because major forces are required to fracture the pelvis, pelvic ring disruption, more than any other fracture, can lead to life-threatening associated injuries such as massive bleeding, organ injuries, and open fractures including hemipelvectomy.The rapid diagnosis and effective treatment ("damage control") of those injuries play the key role in the patient's survival, inasmuch as the mortality of multiply injured patients with pelvic ring disruption remains high with 20-35%. Exsanguinating hemorrhage represents the most dreaded acute complication of pelvic injuries.Therefore, diagnostic and therapeutic procedures have to be primarily adapted to the hemodynamics of the patient, secondarily to injuries of the brain and the torso. The time point and the techniques of definitive pelvic ring stabilization may be different in the patient with multiple injuries compared to isolated pelvic ring injuries.     

Offene Stabilisierung und Endoprothetik bei geriatrischen Patienten mit acetabul?ren Frakturen

Fractures of the acetabulum after low-energy trauma in geriatric patients suffering from osteoporosis are increasing in number and significance due to demographic changes. The results of current therapeutic principles though tend to be poor in this population, while risk and treatment-related morbidity of surgical or conservative approaches are substantial.The treatment of geriatric patients can be challenging, not only because of their often complex medical history. They essentially need rapid functional restoration and return to their familiar environment to avoid general decline unlike younger patients for whom rather the long-term perspective is crucial. This article critically discusses the current literature and reports on first experiences with a new surgical concept in six geriatric patients aged 82-91 years: the combination of an anterior minimally invasive approach for open reduction and internal fixation of the acetabulum combined with an anterior minimally invasive (AMIS?) approach to the hip for total hip arthroplasty with promising short-term results.     

Präoperative Veränderungen des Blutvolumens und der Blutzusammensetzung bei neurochirurgischen Patienten,ihre Bedeutung und ihre Behandlung

Ohne Zusammenfassung     

Anästhesie bei Patienten mit NBIA

Background

Neurodegeneration with brain iron accumulation (NBIA) forms a group of rare hereditary diseases with rapid neurodegenerative progression due to an abnormal accumulation of iron in the basal ganglia. This causes extrapyramidal symptoms as well as dystonia and mental retardation. The most common form of NBIA is pantothenate kinase-associated neurodegeneration (PKAN, formerly Hallervorden-Spatz syndrome). There are multiple anesthesiological challenges with great implications for the clinical routine, particularly regarding the preparation for general anesthesia and the premedication visits. As with other orphan diseases, the available recommendations are mainly based on case reports.

Objective and methods

This article gives a short overview of complications associated with NBIA pertaining to general anesthesia. This includes anesthesia-relevant clinical symptoms and perioperative management. The published literature and case reports (available on PubMed) were reviewed to extract a set of recommendations.

Results

So far only a few reports have included the anesthesia management of NBIA patients. Most of them refer to PKAN as the predominant type (50% of cases). Recommendations were found on www.orphananesthesia.eu and consensus guidelines on PKAN in general. In particular, dystonia-related restrictions in the maxillofacial area can complicate airway management and cause difficulties with respect to intubation. Furthermore, local or regional anesthesia as the sole anesthesia technique is not eligible/viable due to the reduced compliance of the patient. Special attention should be paid to a timely premedication visit and evaluation to ensure sufficient time to safely plan and prepare the anesthetic procedure.

Conclusion

The handling of NBIA patients requires good preparation, including an interdisciplinary team and customized time management. In principle, both general anesthesia as a balanced method and total intravenous anesthesia (TIVA) seem to be possible/viable options. The main focus is on airway management. Even after brief sedation in the context of diagnostic measures, the patient should be monitored for longer than usual.

     

Die 3D-Bewegungsanalyse der oberen Extremität und ihre Anwendung in der Schulterendoprothetik

Background

The aim of this study was to analyze the range of motion of the shoulder and elbow during activities of daily living (ADL). Moreover, proprioception after shoulder arthroplasty was assessed.

Materials and methods

A new, marker-based 3D model for the upper extremities was used. Ranges of motion of the shoulder and elbow in 10 ADL were measured in a standardized fashion in seven subjects. Proprioception was measured in 26 patients with degenerative pathologies of the shoulder joint. A total of 13 patients received total shoulder replacement, 8 hemiarthroplasty, and 5 reverse prosthesis.

Results

A mean shoulder anteversion/retroversion of 100°, an abduction/adduction of 89°, and an external/ internal rotation of 205° were necessary to perform the ADL. The mean elbow extension/flexion was 110° and mean pro-/supination 127°. For the whole cohort, the proprioception value decreased 6 months after implantation of a shoulder prosthesis from 7.0° preoperatively to 8.1° postoperatively (p<0.05). There was a postoperative decrease of proprioception for all movements and for overall proprioception, but this was not significant. With regard to the different implants, a decrease of proprioception was also found, without reaching significance.

Conclusion

Complex, dynamic movements and joint angles of the upper extremity can be recorded using 3D motion analysis at any time. In contrast to other studies, decreased proprioception was found in the short term after shoulder prosthesis implantation.     

Die verzögerte Knochenbruchheilung bei Unterschenkelschaftbrüchen und ihre Behandlung

Ohne ZusammenfassungMit 36 Textabbildungen.     

Die Hautspaltlinien und die Schnittführung bei Fußoperationen

Background

In the constantly evolving, increasingly important field of foot surgery, the question arises as to whether the incision types currently in use are adequate. Whether Langer’s lines should be considered during the operative approach to the foot is examined here. The goal of the current study was to investigate the pattern of skin cleavage lines of cadaveric feet and to establish the optimal incision type for surgical approaches to the foot.

Materials and methods

Twelve feet from older deceased subjects were examined. The samples were fixed. The cleavage lines of the individual skin regions were outlined and evaluated. To emphasize the significance of the investigative findings, the cleavage lines and the current, relevant operative approaches were compared.

Results

Standard current approaches often ignore skin cleavage lines, understandably resulting in cosmetically unsatisfactory scars. A chart with ideal incision types for individual operations was created.

Conclusion

The ideal incision should run parallel to skin cleavage lines. If this is not completely possible due to operative requirements, then at least a large part of the incision should follow these lines.