Bildgebung und präoperative Planung der Tibiakopfosteotomie

Zusammenfassung Tibiale Umstellungsosteotomien sind zur Behandlung einer medialen Gonarthrose weit verbreitet. Der ideale Patient ist aktiv, jünger als 55 Jahre und weist eine unikompartimentäre Arthrose bei bandstabiler Varusdeformität <10° auf. Eine sorgfältige präoperative Planung einer hohen tibialen Osteotomie ist für das Erreichen eines gewünschten Korrekturwinkels notwendig. Fujisawa fand dann gute postoperative Ergebnisse, wenn die postoperativ erreichte Traglinie durch die 2/3-Koordinate des lateralen Tibiaplateaus verlief. Hernigou beschrieb gute Langzeitergebnisse nach aufklappender Osteotomie, wenn die Varusstellung des Beins exakt korrigiert wurde. Coventry beobachtete schlechtere klinische Langzeitergebnisse nach lateral schließender Osteotomie, wenn der postoperative femurotibiale Winkel <8° Valgus betrug.Die empfohlenen Methoden der präoperativen Planung variieren zwischen simpler Schätzung des notwendigen Korrekturwinkels, Planungszeichnungen auf Röntgenbildern und der Verwendung von digitalen radiologischen Messapparaten. Unabhängig von der Planungsmethode sollte die reproduzierbare und exakte Korrektur der Beinachse Ziel der Umstellungsoperation sein. Dieses Kapitel beschreibt verschiedene Planungsmethoden, die die Zuverlässigkeit einer tibialen Umstellungsosteotomie erhöhen sollen.     

Entscheidungsfindung und Prioritäten der operativen Behandlungsstrategie während und nach der Schockraumversorgung

OBJECTIVE: Concepts for optimal surgical treatment of the patient with blunt multiple injuries are being evaluated on the basis of the current literature. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: The posttraumatic clinical course is divided into four different periods: acute-, primary-, secondary- und tertiary period. The first and second period are important for life saving surgery and the stabilization of major fractures. After the cardiorespiratory systems have been stabilized, the following priorities have been formulated: head, face, spine, abdomen, extremities. To restrict the degree of operative burden on the patient it appears to be necessary to limit the duration of initial surgery to less than 6 hours. In patients at high risk to develop posttraumatic complications-"borderline patients"-it appears safer to perform only temporary fixation of major fractures. CONCLUSIONS: Three different factors determine the clinical course after polytrauma: Trauma represents the first hit, followed by the therapy-induced burden (second hit). In addition, the third hit is represented by the individual response. An evaluation of the clinical status by immunologic monitoring can be performed in order to assess the patient's status.     

Imaging of early stages of osteonecrosis of the knee

Osteonecrosis of the knee can present as a spontaneous and primary or a secondary clinical entity. The natural history of osteonecrosis follows a course of several sequential stages, and the later stages of both entities seem to be irreversible. Early diagnosis of osteonecrosis is crucial: the earlier the stage of the lesion at the time of diagnosis, the better the prognosis.Clinically, early diagnosis and treatment of osteonecrosis might prevent unnecessary surgery in cases with a concomitant degenerative meniscal tear. Early-stage osteonecrosis should be ruled out before surgery, because arthroscopy has lately been associated with osteonecrosis. Not every imaging method is equally suitable for detecting pathognomonic changes in each stage of osteonecrosis. Early-stage osteonecrosis is difficult to diagnose,because various differential diagnoses must be kept in mind. Moreover, there is a diagnostic window between the onset of symptoms and the appearance of pathognomonic changes on plain radiographs and MRI.     

Damage control orthopaedics in unstable pelvic ring injuries

Pelvic ring injuries are often associated with other system injuries and require a multidisciplinary approach for their treatment. Early mortality is usually secondary to uncontrolled haemorrhage whereas late mortality is due to associated injuries and sepsis-induced multiple organ failure. The management of the pelvic fracture should be conceived as part of the resuscitative effort as errors in early management may lead to significant increases in mortality. In severely multiple injured patients who are in an 'unstable' or 'in extremis' clinical condition damage control orthopedics is the current treatment of choice. By performing limited surgical interventions the subsequent reduction in blood loss and transfusion requirements can only be beneficial in these critically ill patients, reducing the risk of developing systemic complications and early mortality.     

L-selectin shows time and gender dependency in association with MODS

BACKGROUND: Recent investigations have demonstrated gender related immunologic alterations after trauma. These complications arise due to polymorphonuclear granulocytes (PMN) interacting with endothelium via L-selectin. Therefore, the purpose of this study was to investigate gender related differences in the expression of L-selectin in relation to posttraumatic multiple organ dysfunction syndrome (MODS). METHODS: Multiply injured patients were prospectively entered in the study. MODS was determined using the Denver score. The concentration of L-selectin on the surface of PMN was determined using flow cytometry during a 14 days' period. RESULTS: 48 patients were included in the study. The kinetics of L-selectin were different comparing male and female patients. Male patients with MODS initially showed a rapid decrease of surface L-selectin from 80 to 20 ng/ml. A return to admission levels was related to MODS. Male patients without MODS displayed elevated L-selectin levels up to 140 ng/ml. Female patients, however, all showed an initial rapid decrease of L-selectin to 20 ng/ml. Women who developed posttraumatic MODS had significantly increased levels up to 110 ng/ml before development of MODS developed. CONCLUSIONS: We feel that a gender related dimorphism in the initial L-selectin expression following trauma exists and is associated with MODS. These findings indicate new therapeutic means for the treatment of MODS. Therapies should be timely and gender dependently coordinated.     

Renal allograft function in matched pediatric and adult recipient pairs of the same donor

BACKGROUND: To study the effect of donor age on kidney function, the authors investigated matched pairs from the same kidney donor given to a pediatric or an adult recipient. METHODS: Fifteen matched pairs of an adult and a pediatric patient, selected from the Eurotransplant registry, receiving the renal graft from the same cadaveric donor were selected for analysis of graft function over 7 years. Nine matched pairs were from adult donors (mean age, 40 years; range, 23-60 years) and six from pediatric donors (mean age, 11 years; range, 4-15 years). All recipients had comparable immunosuppression with cyclosporine A, prednisolone, and azathioprine and comparable numbers of acute rejection, cytomegalovirus reactivation, and antihypertensive therapy. Mean age of pediatric and adult recipients at transplantation was 5 years (range, 1-9 years) and 38 years (range, 25-60 years), respectively. RESULTS: The calculated glomerular filtration rate (GFR) corrected to body surface area was not different in adult and pediatric recipients. Initial absolute GFR was significantly lower in pediatric recipients (27 mL/ min; range, 17-38 mL/min) than in adult recipients (54 mL/min; range, 25-74 mL/min) (P <0.05) and remained lower in the following years. Initially, pediatric donor kidneys transplanted into pediatric recipients showed a lower absolute GFR than those transplanted into adults, however, approaching the GFR in adult recipients later. Adult donor kidneys transplanted into pediatric recipients showed a persistently lower absolute GFR in children compared with those transplanted into adult recipients. CONCLUSIONS: The authors conclude that adult donor kidneys in pediatric recipients decrease GFR in the early stages and lack an increase in GFR with growth of the child.     

Total hip arthroplasty in young patients using the thrust plate prosthesis: clinical and radiological results

Introduction The standard treatment for patients who require total hip replacement is the implantation of an intramedullary diaphyseal anchored hip prosthesis. A bone-sparing thrust plate hip prosthesis (TPP) can be used as an alternative device for young patients. The TPP relies on proximal femoral metaphyseal fixation. The theoretical advantage of leaving diaphyseal bone intact is easier conversion to a stemmed prosthesis. This retrospective study evaluated the medium- and short-term results after total joint replacement using the third generation TPP.Materials and methods Between 1997 and 2001, 58 TPPs were used for 52 patients. Clinical and demographic data were obtained from the patients charts and our electronic database. Their average age at time of surgery was 40.9±11.4 years. At follow-up, the Harris hip score, residual pain, required pain medication, and the ability to lie on the operated side were documented. Radiographic evaluation included standardized radiographs of the hip joint and the pelvis.Results Four patients required revision surgery (6.9%). For 51 of the remaining 54 TPPs, a postoperative functional and radiological status was obtained. The average follow-up was 26±11.0 months. 88% of the patients experienced some or complete relief of pain. The median Harris hip score at follow-up was 73±20.5 points. A postoperative hip dislocation occurred in 5 patients (8.6%).Conclusion Since many patients experienced some or complete relief of pain, the TPP can be recommended as a feasible implant for the treatment of hip disorders requiring total hip arthroplasty in young patients. Revision surgeries are facilitated by the good bone stock remaining in the proximal femur.     

A single center clinical experience in intensive care management of 104 pediatric renal transplantations between 1998 and 2002

Only a few publications about the treatment in the intensive care unit (ICU) after pediatric renal transplantation have been published yet. As there are no guidelines, we hereby describe the results and recommendations of our transplant unit. A total of 104 renal transplantations have been performed in 96 children at our center since 1998. The age of the children has ranged from 6 months to 18 yr and their body weight from 6 kg to 110 kg. A special fluid management was performed in order to avoid hypotension and hypoperfusion of the graft. Systolic arterial pressure was kept at elevated levels above 100 mmHg during the first day after transplantation. The children remained on the respirator for 4-8 h after transplantation. Anticoagulation was performed using low dose heparin because of the size mismatch of the anastomosed vessels. The mean time in the ICU for the pediatric patients aged <3 yr was 2 days and for children older than 3 yr was 1 day. The main complications after renal transplantation in the ICU were disorders of electrolytes, acute renal failure because of a non-functioning graft (12%), bleeding from the anastomoses (4%), arterial or venous thrombosis (1%), arterial hypertension and pulmonary edema, defined as radiographic evidence (1%). In case of non-function peritoneal- or hemodialysis were performed in the ICU. Young children were more frequently affected than older children. From 1998-2002 one patient died during the ICU time. The 3 yr graft survival rate was 90%. To sum up, children undergoing renal transplantation should be treated in a specialized unit postoperatively to avoid early non-functioning of the graft and extrarenal complications. General guidelines for postoperative care should be established.     

Unresolved legal and ethical issues in research of adults with severe traumatic brain injury: analysis of an ongoing protocol

This paper synthesizes federal and state laws and bioethics literature with observations from an ongoing research protocol to identify, define, and clarify the unresolved legal and ethical issues regarding research involving adults with traumatic brain injury (TBI). Solutions that protect rights and minimize unnecessary impediments to valuable clinical and scientific inquiry are also illustrated using the same protocol. Research was performed at intensive care, inpatient rehabilitation, and long-term acute chronic hospitals. Our research protocol identified five areas of law impacting adults with TBI: advanced directives, healthcare surrogacy acts, probate acts, power of attorney acts, and the Health Insurance Portability and Accountability Act. The published bioethics literature and responses from local human subject institutional review boards (IRBs) suggest that some of the unresolved ethical issues in research include defining vulnerability, defining informed voluntary consent, determining competency and/or decision-making capacity, using caregivers as subjects, and conducting multisite cooperative studies. Collaboration with IRB members and administrators as well as legal and research ethic scholars developed procedures that protect rights while avoiding unnecessary impediments to research. Investigations of persons with TBI and other cognitive impairments are governed by complicated and inconsistent regulations within the Common Rule and federal and state statues. A need for clear and consistent regulatory guidance regarding multisite studies of TBI persists. In lieu of regulatory guidance, carefully researched solutions for critical peer review are needed to guide future multisite investigations of TBI.