Neue Entwicklungen der endovenösen Lasertherapie

Endovenous laser therapy (ELT) has been applied in clinical practice as a therapy for truncal vein insufficiency for about 10 years now. One characteristic of ELT is the broad spectrum of different treatment protocols using a variety of laser systems and forms of endovenous application. Despite good clinical results with effective and relatively pain-free occlusion of insufficient truncal veins, undesired side effects such as ecchymoses, phlebitis, and recanalization have been observed. These can be traced mainly to thermal lesions in the vein wall and are focused in spots with perforations and transmural ablations of the tissue. In recent years, systematic experimental investigations and the analysis of clinical results have increased understanding of the connection between endovenous laser application and clinical results. This has led to continuous development and optimization of ELT. In particular, the use of longer wavelengths, radially irradiating fiber optic cables, and endovenous laser irradiation with continuous pull-back of the optical fiber seem to have a positive influence on occlusion rate and side effects. As a result, ELT treatment is coming closer to the goal of a standardized effective method for treating varicose veins. Further controlled studies are required to compare optimized ELT with other endovenous modes of treatment and open surgery.     

Klassifikation und Therapie von ellengelenknahen Verletzungen

Fractures and luxations in the range of the upper arm and forearm close to the elbow are rare in adults. The early diagnosis and correct therapy is very important to restore the function of the complex elbow joint. Distal humeral fractures AO type B and C often go along with neurological lesions. The therapy as a rule is open reduction and internal fixation. The most common classification of olecranon fractures is named after Schatzker. The classification considers the type of osteosynthesis, which is needed subject to the number of fracture fragments. Fractures of the processus coronoideus are often associated with luxation of the elbow and are classified according to Regan and Morrey. Depending on fracture type and level of stability of the elbow joint, conservative or operative therapy is recommended. The Mason classification is widely accepted for fractures of the radial head. The simple type of fracture is treated conservatively, while dislocated fractures and more fragmented fractures necessitate osteosynthesis or resection. In cases of joint instability after resection, a radial head prosthesis should be implanted. Separately the Monteggia injury, the Essex-Lopresti injury and “terrible triad” injury as severe combined lesions of the elbow joint are reviewed. All types of injuries are frequently under-diagnosed at first visitation and result in poor functional outcome. Luxation of the elbow joint requires a rapid reposition after analgesic sedation.     

Die Auswirkung definierter Varusdeformitäten am proximalen Humerus auf die Elevationskräfte des Armes

Objectives

This study investigated the hypothesis that different varus deformities of the humeral head decrease the efficiency of the M. supraspinatus (SSP) and increase the deltoid elevation forces.

Methods

A varus deformity model of the proximal humerus was developed with an intact rotator cuff and deltoid muscle in human specimens. Three groups were differentiated per random distribution: group I (n=8): 45° varus deformity, group II (n=8): 20° varus deformity, and a control group (n=8). The effect of different varus malunions (20° and 45° varus) on the SSP efficiency and on the arm elevation forces was analyzed with a robot-assisted shoulder simulator and a force-controlled hydraulic system in three defined phases of elevation: 0–30°, 30–60°, and 60–90°.

Results

The SSP efficiency (i.e., the degree of elevation per unit muscle force) was 0.12±0.03°/N in group I, 0.18±0.05°/N in group II, and 0.24±0.10°/N in the control group and was significantly lesser in group I than in group II (p=0.036) and in the control group (p=0.039). Under physiological loading of the rotator cuff, the deltoid elevation force per elevation angle was significantly greater in groups l and ll compared to the control group in the elevation phases between 0–30° and 60–90°. In case of an unloaded SSP (i.e., simulation of a SSP tear), the elevation forces were significantly greater in group l than in group ll (p=0.040), and in the control group (p=0.004) in the elevation phase between 60° and 90°.

Conclusion

Varus deformities of the humeral head significantly decreased the SSP efficiency (45° varus), and significantly increased the arm elevation forces (≥20° varus in the elevation phases 0–30° and 60–90°). The hypothesis of our study could be confirmed.     

Testikuläre Ischämie

Background

Ischemia and reperfusion (I/R) lead to cellular damage. A disturbance of testicular perfusion occurs during the therapy of cryptorchidism and in cases of testicular torsion. This results in the activation of mediator cells with an increasing synthesis of mediators of infection like TNF-α and the expression of cell adhesion molecules like ICAM (intercellular adhesion molecule) and VCAM (vascular cell adhesion molecule) at the cellular surface.

Methods

The expression of the cytokines IL-10 and TNF-α and the adhesion molecules ICAM and VCAM after defined testicular I/R injury in nine male transsexuals was evaluated with rt-PCR. Furthermore we examined lactate and the diameter of the testicular tubulus under ischemic conditions.

Results

During ischemia ICAM, IL-10, and VCAM do not show significant changes on the side of testicular ischemia and the contralateral side; the same was seen for the tubulus diameter. TNF-α and the testicular lactate values showed a significant change of the expression pattern.

Discussion

The statistical changes of TNF-α and testicular lactate are the expression of leukocyte migration, infectious reaction, and immune response. To what extent the TNF-α expression represents a severe immunological reaction remains undefined. This human study shows primary results for the immunological understanding of and cellular response to testicular ischemia.     

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°.     

Burn-out in der An?sthesie und Intensivmedizin

Background

With the demands faced by anesthetists and intensive care physicians apparently increasing continuously in Germany, the increased risk of burnout in comparison with the general working population is discussed. This debate has previously been merely speculative because of the lack of studies comparing the burn-out risk of the German working population with anesthetists. Accordingly it was not certain whether anesthetists really are at greater risk of developing burnout as has often been suggested. Moreover, age, gender, function, workplace environment, e.g. working at a hospital compared to a general practitioner (GP) surgery, may influence the risk of burnout. Therefore, this study examined whether the risk for anesthetists in Germany suffering from burnout really is greater than in other occupations. In addition, factors influencing the burnout risks of anesthetists were analyzed.

Method

A total of 3,541 questionnaires completed by German aaesthetists for a study on work satisfaction by the CBI (Copenhagen Burnout Inventory, part of the Copenhagen Psychosocial Questionnaire, COPSOQ) were analyzed. Apart from calculating the number of participants with a high risk of developing burnout syndrome, the data were used to calculate a generalized burnout score for all participants. The score was compared with data from both a random sample representing a wide variety of occupations from among the general population in Germany (n?=?4,709) and a random sample of German hospital doctors (n?=?616). In addition, subgroups were formed by gender, function (senior consultant, senior physician, specialist, junior doctor) and type and place of work (university hospital, public hospital, private clinic, GP surgery, freelance work) and the proportion of each group with a high risk of burnout syndrome was calculated. In addition, general burnout scores were compared statistically for differences among the various groups.

Results

The proportion of study participants with a high risk of burnout was 40.1%. Differences were found to exist between genders (male 37.2% versus female 46%), qualifications (senior consultant 28.9%, senior physician 38%, specialist 41.5%, junior doctor 46.7%) and working in a hospital (41.3%) compared to a GP surgery (33.2%). The random sample of hospital doctors (n?=?616) showed a burnout score of 49?±?19 (mean?±?standard deviation), compared to 44?±?19 for a random sample of the German population (n?=?4,709) and 42?±?19 for anesthetists (p??0.05). Working in a hospital was found to result in higher burnout scores than in a GP surgery or freelance work (43?±?19.2 versus 38.1?±?20.5; t(3531)?=?5.0, p?Conclusions Despite 40.1% of anesthetists being at high risk of burnout, generally speaking the risk of burnout among anesthetists was not higher than in other occupational groups in Germany. However, burnout risks for specific groups, such as female junior doctors in anesthesia, were higher and the possibility of providing social support in the workplace should be considered.     

Retroperitoneoskopische Nierenchirurgie

Retroperitoneoscopy enables quick, simple, and direct access to the retroperitoneal cavity. We describe our operative technique and discuss the advantages and disadvantages of retroperitoneoscopy. We report on our experience with this operative technique after 360 procedures: nephrectomy, partial nephrectomy, living donor nephrectomy, cryotherapy of renal tumors, pyeloplasty, adrenalectomy, and further operations. In addition, we discuss indications that are suitable for beginners to retroperitoneoscopy and some topics that require special attention.     

Zugangswege zum Oberflächenersatz am Hüftgelenk

A large variety of approaches are described for standard total hip arthroplasty. All of them are technically based on three different approaches: anterior, anterolateral, or posterior. In recent hip resurfacing, the posterior approach is common, due to large instruments used to ream the femur. Better exposure of the acetabulum is achieved by the posterior approach, but this technique puts the important extraosseous blood supply to the femoral head at risk. The anterior approach preserves blood supply and gives better options to treat the femoroacetabular impingement. If specific surgical modifications and instruments designed for minimally invasive surgery are used, hip resurfacing can be performed with an anterolateral technique. Excellent functional and clinical outcomes have been reported after all three approaches.     

Palacos im Herzen

For more than 20 years percutaneous vertebroplasty has been used in the minimally invasive treatment of vertebral fractures. We report on a patient with embolisation of bone cement into the pulmonary artery and the right ventricle, which was perforated. The final diagnosis was delayed due to a combination of complications, previous disorders as well as a second embolisation.     

Valvular heart operation in patients with previous mediastinal radiation therapy

Background. The outcome of valvular heart operations in patients with previous mediastinal radiation therapy was studied.

Methods. This is a single center retrospective study of 60 patients (37 females, 23 males) with a mean age of 62 ± 15 years (28 to 88 years old) operated on from January 1976 to December 1998. Valvular heart operations performed included aortic valve replacements (n = 26), mitral valve procedures (n = 16), tricuspid valve procedures (n = 6), and multiple valve procedures (n = 12). A total of 264 clinical, hemodynamic, electrocardiographic and echocardiographic variables were analyzed.

Results. Total follow-up was 199 patient-years with a mean of 3.3 ± 3.1 years and a range of 0 to 12.4 years old. Early mortality was 7 patients (12%). Early mortality in patients with constrictive pericarditis was 40% (4 of 10) compared with 6% (3 of 50) in patients without constrictive pericarditis. By univariate analysis, early mortality was associated with constrictive pericarditis (p = 0.011), reduced preoperative ejection fraction (p = 0.015), and longer cardiopulmonary bypass times (p = 0.037). A total of 14 patients (23%) required permanent pacemaker placement before (n = 7), during (n = 1), or early (n = 6) after valvular heart operations. There were 19 late deaths (malignancies, 7; heart failures, 5; other cardiac, 4; and other noncardiac, 3). Overall survival and freedom from late cardiac death and cardiac reoperation at 5 years for hospital survivors were 66% ± 8%, 82% ± 7%, and 93% ± 4%, respectively. By univariate analysis, late cardiac death was associated with low ejection fraction (p = 0.002), New York Heart Association (NYHA) functional class IV (p = 0.004), preoperative congestive heart failure (p = 0.02), and preoperative atrial fibrillation (p = 0.038). Eighty-five percent of the discharged patients were in NYHA functional class I or II at follow-up.

Conclusions. Early results of valve replacement after mediastinal radiation therapy were good except in the presence of constrictive pericarditis. Long-term outcome was limited by malignancy and heart failure. Early surgical intervention is recommended before the development of risk factors for late death, namely, severe symptoms, left ventricular dysfunction, and atrial fibrillation.