Operative Versorgung von Achillessehnenverletzungen

Rupture of the Achilles tendon is typically associated with sportive activities with increasing tendency; it occurs most commonly in the third to fourth decade of life with a male-to-female ratio of 5–10:1. Ruptures are caused predominantly by a sudden, unexpected overextension of the tendon while direct trauma is less frequent. The recommended treatment of the injury remains controversial. In Germany, due to the good functional results, the open surgical repair represents the standard therapy since many years. The open suture technique offers the advantage of a lower re-rupture rate but is associated with the risk of wound-related complications including infection. By percutaneous suture techniques a significant decrease in the rate of infections and complications in wound healing could be achieved by minimal-access with reduced soft tissue trauma; on the other hand an increased rate of lesions of the sural nerve is reported. Dynamic imaging assessment of ultrasound or MRI allows a more accurate localisation of the ruptured ends of the tendons which is the prerequisite for the non-operative primary functional treatment of Achilles tendon ruptures. This conservative treatment regime is recommended when adaptation of the ends of the ruptured tendon is possible in 20° plantar flexion of the foot. Moreover, the desired level of daily activity and the patients’ degree of compliance has to be considered. Operative management should be avoided in the elderly patient or patients with risk factors like immunosuppressive therapy, diabetes mellitus, steroid use or failure to comply.     

Intraoperative Echokardiographie

Since the introduction of intraoperative echocardiography into clinical practice in the 1970’s its use and utility in the perioperative period has become increasingly more evident. Especially in patients undergoing cardiac surgical procedures intraoperative echocardiography has gained great diagnostic importance. Intraoperative transesophageal echocardiography (TEE) and epiaortic ultrasound are two important and complementing diagnostic modalities in this patient population. The clinical information obtained with intraoperative TEE in certain cases might have a direct impact on surgical decision-making and therefore may positively influence patient outcome. In patients undergoing non-cardiac surgical procedures, TEE can be a valuable tool in high-risk patients, in patients experiencing hemodynamic instability or in those suffering intraoperative cardiac arrest. Intraoperative TEE might allow a primary diagnosis of the underlying etiology and facilitate the institution of further therapeutic interventions. In addition TEE can be performed during ongoing cardiopulmonary resuscitation and does not interfere with patient management. This review introduces the clinician to the current evidence of the impact of intraoperative echocardiography on intraoperative surgical decisions during surgical procedures. It helps the clinician to identify indications and realize the potential applications of intraoperative echocardiography.     

Verteilungsplanung von Verletzten beim MANV oder Katastrophenfall

Relevant changes have occurred in disaster management in Germany due to legal alterations and the introduction of the diagnosis-related groups (DRG) system. This has resulted in a reduction in bed capacities and an increase in bed utilization. In addition to the preclinical deployment strategy the provisional aspects of disaster medicine with the problem of the emergency service/hospital interface will be described. A suggestion for a solution for optimization of patient allocation in mass disasters or catastrophes will be demonstrated with the catastrophe network of the German Society for Trauma Surgery (DGU).     

Bedeutung von Phosphodiesteraseisoenzymen in der Kontrolle der humanen Detrusormuskulatur

Objectives

The use of inhibitors of phosphodiesterase (PDE) isoenzymes 1 and 5 to treat overactive bladder has been suggested. To further evaluate the significance of PDE isoenzymes in detrusor smooth muscle relaxation, we investigated the effects of selective PDE inhibitors on the tension induced by carbachol of isolated human detrusor tissue. Using immunohistochemical methods, the expression of PDE1, PDE4, and PDE5 in human detrusor was also investigated.

Material and Methods

The expression of PDE1, PDE4, and PDE5 was evaluated by means of conventional immunohistochemistry (IHC). Using the organ bath technique, the effects of the PDE inhibitors vinpocetine, rolipram, sildenafil, tadalafil, and vardenafil on the tension induced by the muscarinic agonist carbachol (1 µM) were investigated.

Results

The tension induced by carbachol was dose-dependently reversed by the PDE inhibitors; the maximum reversal of tension ranged from 7% (tadalafil) to 34% (vardenafil). IHC revealed that the expression of PDE isoenzymes was limited to the smooth musculature of the detrusor. While there was prominent expression of PDE4 and PDE5, immunoreactions indicating the presence of PDE1 were less abundant.

Conclusion

Despite the fact that inhibitors of PDE1, PDE4, and PDE5 exerted only a weak relaxant response on detrusor strips precontracted by carbachol, our findings indicate that both the cAMP and cGMP pathways might be involved in the relaxation mechanism of human detrusor smooth muscle.     

MR-Kolonographie: Technik, Indikationen und Befunde

Magnetic resonance imaging (MRI) has evolved as a powerful tool that has been applied more and more in recent years for the assessment of gastrointestinal structures, owing to its unsurpassed soft tissue contrast, lack of radiation exposure, and implementation of fast scanning techniques. As a virtual endoscopic technique, MR colography (MRC) makes it possible to image inflammatory processes and tumor disease of the large intestine with a high degree of accuracy. In this article we describe current techniques and applications of MRC and give an overview of clinical studies comparing MRC with other diagnostic procedures.     

Autologe Chondrozytentransplantation am oberen Sprunggelenk

Ankle sprains are one the most common injuries of the lower limb. Fractures, ligamentous lesions, and cartilaginous damage are often associated. Nevertheless the injury is often misjudged and concomitant chondral lesions are assessed late. In the case of a symptomatic osteocartilaginous lesion of the talus, which can be illustrated by MRI or X-ray, operative intervention is indicated. Methods such as microfracturing, mosaicplasty, and autologous chondrocyte transplantation (ACT) are in clinical use. The latter is well known and being established as the treatment of choice for large cartilage defects in the knee. Due to the good results in the knee and the technological improvements (three-dimensional tissue constructs seeded with autologous chondrocytes) this method is being increasingly applied for cartilage lesions of the talus. In contrast to the mosaicplasty donor site morbidity is low and the size of the defect is not a limiting factor. The current studies about ACT of the talus show a stable repair of the defect with mostly hyaline-like cartilage and high patient satisfaction. Therefore, the procedure can be recommended for lesions >1 cm². Concomitant treatment of posttraumatic deformities (malalignment), ligamentous instabilities, and especially the reconstruction of bony defects are compulsory.     

Sinnvolle bildgebende Diagnostik des lokal fortgeschrittenen Prostatakarzinoms

Prostate cancer is one of the principal medical problems facing the male population in developed countries with an increasing need for sophisticated imaging techniques and risk-adapted treatment options. This article presents an overview of the current imaging procedures in the diagnosis of locally advanced prostate cancer. Apart from conventional gray-scale transrectal ultrasound (TRUS) as the most frequently used primary imaging modality we describe computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). CT and MRI not only allow assessment of prostate anatomy but also a specific evaluation of the pelvic region. Color-coded and contrast-enhanced ultrasound, real-time elastography, dynamic contrast enhancement in MR imaging, diffusion imaging, and MR spectroscopy may lead to a clinically relevant improvement in the diagnosis of prostate cancer. While bone scintigraphy with (99m)Tc-bisphosphonates is still the method of choice in the evaluation of bone metastasis, whole-body MRI and PET using (18)F-NaF, (18)F-FDG, (11)C-choline, (11)C-acetate, and (18)F-choline as tracers achieve higher sensitivities.     

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.     

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.     

Heparininduzierte Thrombozytopenie

Heparin-induced thrombocytopenia (HIT) represents a serious side effect caused by an atypical immune response to platelet factor 4 leading to platelet activation and thrombin formation. These patients are at high risk of thromboembolism, with a rapid drop in platelet count between days 5 and 14 after the initiation of heparin treatment. In single cases, especially after major surgery, platelet count reduction might be absent or hidden by preceding thrombocytosis. Different clinical manifestations of HIT include unspecific skin reactions with potential necrosis at the site of heparin injection, mostly after the application of unfractionated heparin but also with low molecular weight heparin. In heparin-induced skin necrosis, administration of unfractionated or low molecular weight heparin is contraindicated and heparin therapy should be stopped immediately. Instead, an alternative anticoagulant in the form of a direct thrombin inhibitor such as argatroban, and respectively lepirudin, or danaparoid sodium must be administered. Due to frequent misinterpretations of heparin-induced unspecific skin reactions, especially in the absence of thrombocytopenia, we present two case reports which should increase the awareness of HIT’s various clinical pictures.