Schmerztherapeutische Möglichkeiten in der Unfallchirurgie

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.     

Skapulaosteotomie nach Benjamin bei liegender Humeruskopfprothese

In 1994 a 47-year-old female patient with primary osteoarthritis of the shoulder joint was implanted with a humeral head endoprosthesis. Secondary glenoid erosion developed 2.5 years later which was not treated by glenoid implantation but by means of scapular neck osteotomy according to Benjamin. After surgery the situation substantially improved and the patient is currently free of pain and exhibits a nearly free active and passive mobility. The patient returned to the clinic 18 years after the primary surgery and approximately 15 years following the scapular neck osteotomy to discuss the implantation of a total shoulder endoprosthesis on the opposite side. In view of this exceptionally favorable course this possibility should be considered in severe cases where secondary glenoid implantation is not possible for various reasons.     

Urinmarkersysteme zur Diagnostik des Urothelkarzinoms

Cystoscopy and urinary cytology are standard tools in the diagnostics of urothelial cancer of the urinary bladder; however, cystoscopy is invasive and urinary cytology lacks accuracy for the diagnosis of low grade tumors. More recently several alternative urinary test systems were developed with the aim to make the diagnostics of urothelial tumors more reliable; however, in general all protein-based point of care test systems have a high rate of false positive test results, especially in patients with benign disorders. Fluorescence in situ hybridization, which is highly sensitive and specific, may be a reasonable supplement to the diagnostic spectrum in patients after instillation therapy or bladder replacement. Additionally, there are several new test systems which still need to be tested in large clinical studies with respect to diagnostic accuracy.     

Ungeplante Zweiteingriffe nach Frakturen des oberen Sprunggelenks

The purpose of the present study was to analyze the risk factors associated with unexpected second procedures and strategies of revision surgery. Within a 5 year period 647 patients with closed ankle fractures AO type 44 were identified of which 77 (11.9%) needed revision surgery. Complications were addressed to 4 main groups: deep infections (IG) were seen in 29 patients (4.5%), problems with primary wound closure (WG) in 22 patients (3.4%), insufficient reduction (KG) in 22 patients (3.4%) and other causes (RG) included 4 patients (0.6%). Significant predictive factors for soft tissue complications were higher age, comorbidities with peripheral arteriosclerosis, high American Society of Anesthesiologists (ASA) score and diabetes mellitus. AO 44 type B2 and B3 fractures were often associated with soft tissue problems. The more complex fracture types AO 44 C1-C3 and A2-A3 were significantly associated with problems of insufficient congruency post-surgery. The distribution of the mean revision rate was significantly different (p<0.01) for all groups: IG 4.59, WG 3.5, KG 1.55, RG 1.25. In summary, we strongly recommend immediate reduction of displaced fractures and to consider a more detailed fracture classification. To reduce the amount of unexpected ankle procedures individual risk factors should be weighed against the advantages of optimal open reduction and internal fixation.     

Herz und Diabetes

Antidiabetic therapies have to prove cardiovascular safety and efficacy in addition to blood glucose lowering potential. In recent studies metformin administration and dipeptidyl peptidase-4 (DPP-4) inhibition both reduced hypoglycemic and cardiovascular events in comparison to sulfonylurea. High-density lipoprotein (HDL) cholesterol has recently received much attention as a modulator of cardiovascular risk; however, drug-induced increase of HDL cholesterol was unable to reduce cardiovascular events in patients on optimal statin therapy. Therefore, HDL cholesterol levels remain an important risk predictor without being a therapeutic target. In the field of interventional cardiology the FREEDOM trial demonstrated bypass operations to be superior to drug-eluting stent implantation in patients with diabetes and advanced coronary heart disease.     

Kosten und Nutzen eines Qualitätsmanagements

The establishment of quality management (QM) has been mandatory for health care providers of the national health insurance since 2004; however, certification is so far only compulsory for rehabilitation clinics. The costs have so far only been quantified in a few medical studies, while they are widely known in business administration with a basic distinction made between planning, steering, auditing, and declaration costs. Another business economics approach differentiates between prevention, appraisal, and non-conformance costs. The benefits of QM relates to customers, employees, external service providers, and health insurance providers. Also important in our consideration of the patient as a customer is that they should not be considered a customer in the usual business sense because the patient is in an emergency situation and can not freely decide. Improvements in treatment quality and in reducing the rate of adverse events make up the largest portion of the benefits of QM. Furthermore, QM can have a positive influence on motivation and employee recruitment. In addition, the cost savings that result despite costs for QM must not be forgotten.     

Operation hämatogener Metastasen

Urological malignancies represent approximately 40?% of all solid tumors. Synchronous or metachronous organ metastases develop in 30?% of patients. Depending on the tumor entity and tumor characteristics, resection of metastases can improve patient survival. Surgical resection of residual tumors is an integral part of the multimodal therapy concept of patients with nonseminomatous metastatic germ-cell cancer. Surgical inoperability is the only reason not to resect. Resection of hematogenous metastases from renal cell carcinoma has been postulated as a standard therapy for decades. Appropriate patient selection is the key for a survival benefit. Prognosticators such as patient’s general condition as well as number, location, and size of metastases help to counsel and select patients accordingly. Metastases of transitional cell or penile carcinoma should only be resected when a response to systemic treatment is evident in the individual case. There is no evidence in favor of resecting organ-metastases of prostate cancer in the current guidelines and the literature. In this article, arguments against resection of metastases following the current literature and guidelines are described.