Die Littler-Tenodese zur Behandlung der rheumatischen Schwanenhalsdeformit?t

Objective

Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL)?=?Littler?II).

Indications

Rheumatoid swan neck deformity Nalebuff stages?I?CIII (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin.

Contraindications

Advanced radiologic changes of the PIP joint (Larsen?3?C4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis.

Surgical technique

Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2?pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed.

Postoperative management

Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12?weeks. The splint must allow full PIP flexion and limit extension over 20?C30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4?C6?weeks and start of mobilization. Passive extension over 20?C30° of flexion only after 12?weeks.

Results

From 2004?C2007, 30?PIP joints in 20?rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2?pulley was not necessary in any of the cases. After a mean of 22?months, 26?PIP joints in 17?patients could be followed up. In 12?PIP joints, the deformity was partially contracted, in two joints contracted. In 10?joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1?patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.     

Die Extension-First-Technik bei der Knie-TEP-Implantation

Objective

Surgical technique in total knee arthroplasty (TKA) to combine the femur first and tibia first techniques in order to reduce surgical mistakes regarding rotation and alignment.

Indications

Symptomatic arthritis of the knee.

Contraindications

General contraindications for TKA.

Surgical technique

Osseous preparation starting with a distal femur cut. Then the proximal tibia cut is accomplished and the knee is balanced in extension after checking for correct alignment. Bone-referenced positioning of the femoral cutting block for further preparation of the femur. Finally, the rotation of the femur is checked in 90° of flexion by means of ligament tension. If required, the rotation is checked and the flexion gap balanced, respectively.

Postoperative management

Mobilization with weight bearing and range of motion as tolerated.

Results

In a prospective study, 267?knees (160 women, 107 men, average age of 69.3 [46?C89]?years) were followed up preoperatively and after 6 weeks. The clinical results were based on the American Knee Society score. The scores were 48.9 (32?C68) preoperatively and 86.5?(75?C100) at follow-up. Radiologically 92.1% of the knees showed a malposition <3°.     

Bauchlage oder R��ckenlage?

Sudden infant death syndrome (SIDS) is now much less frequent than 20 years ago. This is chiefly due to the success of epidemiologic research and preventive medicine. Unfortunately, the prone sleeping position which has now been identified as one of the leading risk factors for SIDS was strongly recommended by pediatricians in the 1970s. This was the case in most industrialized countries despite the fact that previous publications had pointed to the inherent risk of the prone sleeping position. Even during the campaigns for the prone sleeping positionin parts of Europe, the United States, Australia and New Zealand, there were tendencies towards the opposite direction in other parts of the world, for example in the former German Democratic Republic (GDR). Worldwide, many babies died of SIDS whose deaths could have been avoided if the mistaken recommendation had only been corrected earlier. The current recommendation that babies should sleep in the supine position has been scientifically verified. In retrospect modern medicine lost much credibility with the population because of the prone sleeping recommendation and reestablishing faith took a long time.     

Composite- und Chimärenlappen in der Traumaversorgung

In the recent years, the variety of plastic surgical methods for defect closure among the different reconstructive strategies has been expanded by simultaneous multi-tissue transfer options. Both free microvascular and pedicled flaps may be used for optimized functional and aesthetic defect closure by simultaneous tissue transfer in a single operation. According to their vascular connection and spatial relationship of the different tissue types (skin, fat, bone, muscle, nerve, fascia, vessels etc.) there are various different tissue transplants ranging from simple axial pattern flap to microsurgically constructed sequential chimeric free flaps. The goal with these flaps is to achieve an optimal and overall time-saving treatment with the first reconstructive procedure. Though the initial operative time might be slightly longer, the number and complexity of subsequent procedures are reduced.     

Ranibizumab bei diabetischem Makulaödem

Background

Intravitreal anti-VEGF (vascular endothelial growth factor) therapy with ranibizumab has been shown to be an effective therapeutic option for foveal diabetic macular edema (DME). This prospective study evaluated the functional and morphological retinal changes after intravitreal ranibizumab treatment.

Material and methods

A consecutive prospective series of DME patients treated with intravitreal ranibizumab were examined before and after 3 and 6 months of intravitreal ranibizumab therapy. Best-corrected visual acuity (BCVA) according to the ETDRS protocol, retinal thickness in the macular area and central retinal thickness (CRT) measured with spectral-domain optical coherence tomography (SD-OCT) was determined. In addition, microperimetric functional macular mapping was determined before therapy and 4 weeks after the third injection.

Results

A total of 41 eyes from 33 patients were evaluated. During the 6-month observational period patients received a mean number of 5.2 injections. The mean BCVA increased significantly from 26?±?14 to 33?±?13 letters 4 weeks after the third injection and to 34?±?14 letters 6 months after starting the treatment. The mean CRT decreased significantly from 509?±?147 µm to 385?±?121 µm after the third injection and to 383?±?110 µm after 6 months. After 3 injections, the thickness of the most prominent central retinal area was less than 445 µm in 68.3% of patients and after a further 3 months of treatment in 78.0%.

Conclusion

The presented data demonstrate that intravitreal ranibizumab is effective for DME in everyday clinical practice and results are comparable to those of registration trials. After three initial injections significant structural and functional improvements were observed in a considerable number of patients.     

Hypertone Veränderungen des Fundus

Systemic hypertension affects approximately 25?% of the population worldwide and is the most important preventable risk factor for cardiovascular diseases. Hypertension-related fundus abnormalities can be classified into hypertensive retinopathy, choroidopathy, and optic neuropathy. Hypertensive retinopathy causes vascular constriction of retinal arterioles and typical fundus findings, such as blot hemorrhages, hard exudates and cotton wool spots resulting from ischemia within the nerve fiber layer. The use of a detailed grading system based on the severity of vascular constriction is not practicable as arteriosclerotic changes are common among elderly people. Therefore, early stages with pure vascular pathology should be differentiated from severe forms of hypertensive retinopathy with parenchymal changes of the fundus. Screening the retina for hypertensive changes is essential in cases of severe systemic hypertension, acute visual impairment, diabetes mellitus and pregnancy.     

Eintrübung einer Intraokularlinse

A patient with endothelial dystrophy was treated with Descemet stripping automated endothelial keratoplasty (DSAEK) combined with cataract extraction and implantation of a hydrophilic intraocular lens (IOL, Lentis-L312, Oculentis) but visual acuity dropped from 0.15 logMAR to 0.52 logMAR 18 months later due to calcification of the IOL. With new methods of lamellar corneal transplantation being used more frequently the number of necessary anterior chamber tamponades with air/gas are increasing. In cataract cases in which a gas tamponade and transplantation might be necessary later on (cornea guttata), hydrophilic IOLs should be avoided.     

Progressionsverlangsamung am Beispiel der diabetischen Nephropathie

Zusammenfassung  Die diabetische Nephropathie geht mit einer exzessiven Erhöhung der kardiovaskulären Morbidität und Mortalität betroffener Patienten einher. Der Prävention beziehungsweise der Progressionsverzögerung kommt daher eine enorme klinische Bedeutung zu. Neben der intensiven Hyperglykämiekontrolle ist vor allem die antihypertensive Therapie mit Zielblutdruckwerten <130/80 mmHg entscheidend. Im Mittelpunkt der Pathogenese steht die Aktivierung gewebeständiger Renin-Angiotensin-Systeme. Eine Blockade durch ACE-Hemmer und AT₁-Rezeptor-Antagonisten ist hinsichtlich der nephroprotektiven wie auch kardioprotektiven Wirkung in einer Vielzahl von Studien belegt. Eine Kombinationstherapie wäre aus pathophysiologischen Überlegungen sinnvoll, valide klinische Daten fehlen jedoch noch. Die intensive Behandlung von Diabetespatienten muss frühzeitig erfolgen, nur ein multimodaler Ansatz mit Patientenschulung und Pharmakotherapie bietet die Chance, die diabetische Nephropathie mit ihren assoziierten kardiovaskulären Risiken zu verhindern oder zumindest in ihrer Progression zu verzögern.     

Evidenzbasierte Therapie des Raynaud-Syndroms

Raynaud's syndrome has a prevalence of 3-5% in the general population. Despite its high frequency, the majority of available therapies have not been validated in randomized controlled trials. Effective therapies with a high level of evidence include the calcium channel blocker nifedipine. As analyzed by meta-analyses, nifedipine showed improvement of the peripheral circulation, as well as reduction of both the intensity and frequency of attacks in patients with primary and secondary Raynaud's syndrome as compared to placebo. Similar results in a metaanalysis were obtained for intravenous infusions of iloprost in patients with secondary Raynaud's phenomenon associated with systemic sclerosis. In addition, intravenous infusions of iloprost improved healing of fingertip ulcers in patients with systemic sclerosis. Therapies with significant effects in single randomized controlled trials include angiotensin II-receptor type 1 antagonists (losartan), the calcium channel blockers felodipine und amlodipine, serotonin-reuptake-inhibitors (fluoxetine) und phosphodiesterase-V-inhibitors (sildenafil, vardenafil). However, the results for these promising substances have to be confirmed in long-term trials with larger patient numbers.