Fracture treatment in the elderly

With an ever increasing percentage of elderly people among the population fracture management in the aged is of increasing importance in the field of traumatology, since people between the ages of 60 and 80 will constitute the largest subpopulation by 2030. Due to relevant interindividual differences concerning physical constitution and comorbidity this group resembles an extremely inhomogenic population of patients. Discrepancies between biologic and chronologic age make a careful selection of suitable therapeutic strategies individually adapted to a single patient's situation necessary. For the biologically younger patient with good compliance conservative treatment or minimal osteosynthetic procedures requiring partial weight bearing might constitute a reasonable and appropriate therapeutic option whereas for biologically older patients with relevant co-morbidity early mobilisation with short hospitalisation periods is of the highest priority. This is why in these cases osteosynthetic procedures with implants that allow full weight bearing initially after surgery should be preferred. Even though in advanced age there is an increasing risk of fractures in general -- due to increasing incidence of falls and decreasing bone mineral density -- the majority of fractures in elderly is located in the proximal femur, the proximal humerus and the distal radius. Therefore, therapy of fractures in these typical locations shall in recognition of the particular characteristics of the advanced age be displayed in this article.     

Acquired fibrotic atresia of the external auditory canal

BACKGROUND: There are very few communications on this pathologic entity, which is also called "postinflammatory medial meatal fibrosis" (PIMMF), its etiology and the adequate therapy. Apparently the cause is a chronic inflammation (or chronic ekzema) of the medial part of the external meatus or also a long-lasting otorrhea in chronic otitis media. The stratified epithelium of the eardrum and of the adjacent bony meatus is destroyed and replaced by fibrotic tissue. The lateral part of the auditory canal remains open and has the form of the finger of a glove, it may contain granulations, but often it is lined with a smooth stratified epithelium. A severe conductive hearing loss is the result of this anomaly. PATIENTS: During the last 10 years we operated on 46 patients (52 ears) for this pathology: after retroauricular opening, which allows the best control of the anterior tympanomeatal angle, the fibrotic tissue was removed keeping the lamina propria intact. The bony canal was widened, if necessary. The eardrum and the bony canal were covered with split skin graft from the retroauricular region, then the canal filled with an antibiotic package for 3 weeks. RESULTS: Underneath the fibrotic tissue we detected 3 cholesteatomata of the annular region, so it is important to remember, that the atresia may also cover a dangerous pathology. 6 times a second operation was necessary, besides that, we observed 14 recurrencies. All other patients had a wide epithelialized ear canal, their conductive hearing loss disappeared, and the results were stable over several years. Bacteriological and histological examinations were not helpful to clear up the etiology of this disease. CONCLUSIONS: Surgery is the treatment of choice of the acquired atresia of the external meatus. We suppose that in these patients a individual disposition causes the formation of this excessive fibrosis, which has some similarity with keloid formation.     

Ossiculum terminale (Bergmann) Differentialdiagnose einer Densfraktur vom Typ Anderson?I

Anhand einer Kasuistik wird das Ossiculum terminale (Bergmann) beschrieben, welches dem seltenen, ins Erwachsenenalter persistierenden Knochenkern des Apex dentis axis entspricht. In der unfallchirurgischen Praxis spielt dieses Ossikel als Differentialdiagnose zu einer frischen Fraktur der Densspitze (nach der Klassifikation von Anderson/DAlonzo Typ I) eine Rolle. Zur Diagnose ist das konventionelle Röntgen meist nicht ausreichend, die ergänzende Durchführung einer Computertomographie und/oder Kernspintomographie wird angeraten. Eine Instabilität aufgrund eines Ossiculum terminale liegt nicht vor, beim Ausschluss einer frischen Fraktur oder einer verletzungsbedingten ligamentären Instabilität ist keine weitere Therapie erforderlich.     

Validation and reproducibility of computerised cell-viability analysis of tissue slices

Background

The identification of live cells using membrane integrity dyes has become a frequently used technique, especially with articular cartilage and chondrocytes in situ where tissue slices are used to assess cell recovery as a function of location. The development of a reproducible computerised method of cell evaluation would eliminate many variables associated with manual counting and significantly reduce the amount of time required to evaluate experimental results.

Methods

To validate a custom computerised counting program, intra-person and inter-person cell counts of nine human evaluators (three groups – unskilled, novice, and experienced) were compared with repeated pixel counts of the custom program on 15 digitised images (in triplicate) of chondrocytes in situ stained with fluorescent dyes.

Results

Results indicated increased reproducibility with increased experience within evaluators [Intraclass Correlation Coefficient (ICC) range = 0.67 (unskilled) to 0.99 (experienced)] and between evaluators [ICC = 0.47 (unskilled), 0.85 (novice), 0.93 (experienced)]. The computer program had perfect reproducibility (ICC = 1.0). There was a significant relationship between the average of the experienced evaluators results and the custom program results (ICC = 0.77).

Conclusions

This study demonstrated that increased experience in cell counting resulted in increased reproducibility both within and between human evaluators but confirmed that the computer program was the most reproducible. There was a good correlation between the intact cell recovery determined by the computer program and the experienced human evaluators. The results of this study showed that the computer counting program was a reproducible tool to evaluate intact cell recovery after use of membrane integrity dyes on chondrocytes in situ. This and the significant decrease in the time used to count the cells by the computer program advocate its use in future studies because it has significant advantages.

     

Epidermal cyst of the breast: Detection in a screening programme

Two cases of epidermal cyst of the breast, a rare benign condition, were detected during a 3-year period in a mammographic screening programme, from 57 954 screening examinations. It is not uncommon for epidermal cysts to be initially misdiagnosed. The mammographic, ultrasound and histological features are presented. It is recommended that these lesions be resected because they possibly have malignant potential.     

TRACHEOSTOMY COMPLICATIONS AND THEIR MANAGEMENT

The word tracheostomy derived from two greek words meaning ‘I cut the trachea’ has been known for about 3500 yrs. The process has evolved over the years and has undergone revolutionary changes in the methodology, instrumentation and indications. Although tracheostomy is now commonly used the complication rate remains high. In our series it was 48% which is comparable with other series. The purpose of this paper is to discuss the complications of tracheostomy with special attention to their management and prevention.KEY WORDS: Complications, Tracheostomy     

A bone marrow transplant with an acquired anti-Le(a): a case study

A patient with aplastic anemia received an ABO incompatible bone marrow transplant (BMT) from an HLA identical sibling. Weekly HLA antibody screens were performed as part of the BMT protocol. At the time of transplant, a hemolytic anti-Le(a) was detected in the Le (a-b-) donor. The Le (a-b+) recipient had no red cell or LCT antibody. A hemolytic anti-Le(a) was detected in the recipient on day 8, but no LCT reactivity was noted at this time. On day 15, the LCT panel demonstrated reactivity with 9 of 50 panel cells without apparent HLA specificity. Graft vs. host disease (GVHD) was present on the skin at this time. The dose of cyclosporin A was increased, but by day 20 the GVHD worsened and the LCT titers increased to 8. This strong reactivity was noted only in the Le (a+) panel members (12/50) and was neutralized with commercial Lewis substance. On day 34 there was no evidence of GVHD, but the lymphocytotoxic anti-Lea continued to be present. The patient began experiencing renal and gastrointestinal difficulties by day 48, and expired on day 60. In renal transplants the kidneys retain their Lewis type and secrete Lewis substance in the urine. In our experience BMT patients retain their Lewis type regardless of the type of the donor. The Lewis system has been linked to renal allograft rejection, and Lewis antigens may function as transplantation antigens in BMT patients as well. In addition, lymphocytotoxic Lewis antibodies can mask other significant HLA antibodies and must be identified when screening patients in need of plateletpheresis products.