Hemikolektomie bei Kolonischämie

Pandemic influenza A (H1N1) virus infection is rapidly spreading and has also become a common problem in Germany. Many cases with severe clinical presentation and death have been documented, especially in persons with underlying medical conditions. As of December 15, 2009, Germany has reported 119 H1N1-associated deaths. We report here the first H1N1-associated death in Germany, a 36-year-old woman with morbid obesity. The patient underwent a laparotomy with colon resection due to colon ischemia, a rare visceral complication in such cases. In this article an attempt has been made to reflect the state of requirements in terms of safety, occupational health, hygiene and working conditions with respect to activities involving logistics in the diagnostics, treatment (also surgical) and handling of such patients. Given the rapidly evolving nature the outbreak of human infection with the novel influenza A (H1N1) virus, influenza vaccination is recommended as the only way to prevent the infection of health care workers and patients with underlying medical conditions.     

Ergebnisse und Komplikationen der Behandlung periprothetischer Femurfrakturen mit einem winkelstabilen Plattensystem

Background

Locked plate devices offer advantages in the treatment of periprosthetic femur fractures associated with fixed total hip or total knee arthroplasty. The purpose of this study was to evaluate the early results and complications with a locked plate system (NCB-DF®).

Patients and methods

A total of 31 patients (mean age 76 years, 7 males, 24 females) with a femur fracture above a fixed total knee arthroplasty (TKA, n=12) or a total hip arthroplasty (THA, n=19) were treated with a locked plate.

Results

There were 11 complications necessitating revision: 6 implant failures, 2 in patients with a THA and 4 in patients with a TKA, 4 hematomas and 1 infection and 2 patients died. After 6 months all fractures had healed securely but a secondary correction was necessary in one patient.

Conclusion

Fixation of periprosthetic femur fractures with a locked plate system provided satisfactory results in patients with a THA, however, the relatively high implant failure rate in fractures above a stable TKA is a cause for concern.     

Erste Ergebnisse der multidirektional-winkelstabilen palmaren Osteosynthese der distalen Radiusfraktur

Background

The management of fractures of the distal radius continues to evolve. New operative strategies have recently been developed including the use of fixed-angle plates. This study reviews the results of 20 patients with fractures of the distal radius treated with a new multidirectional fixed angle plate.

Method and materials

A total of 20 patients with closed Colles type fractures of the distal radius were treated with Medartis (Aptus 2.5) palmar fixed-angle plates. Surgery was performed under plexus anesthesia using the standard or extended flexor carpi radialis (FCR) approach. Patients were evaluated prospectively with a mean follow-up of 26 weeks (range 23–28 weeks). Pain, range of motion, grip strength, DASH score, modified Mayo wrist score and radiographs were obtained. The level of significance was set at 95% and the χ² and ANOVA tests in combination with a post hoc Tukey test were used for statistical analysis.

Results

The average range of motion (ROM) in extension-flexion was 87° (76% of the contralateral side) and in ulnar-radial deviation 42° (88% of the contralateral side). Pain values (visual analogue scale 0–100) at follow-up were 3 (without stress) and 24 (with stress). Grip strength improved to 84% of the contralateral side, the mean DASH score was 13 points and the modified Mayo wrist score confirmed the excellent results with a mean value of 83±27 points. Radiological examination showed a satisfactory result with an ulna variance of 0.9±0.4 mm, radio-ulnar inclination of 21±5° and palmar inclination of 4±6°.

Conclusions

Our data show that treating unstable distal radius fractures with multidirectional palmar fixed-angle plates is reliable and effective and produces good early functional and radiological results. However, long-term results with a larger number of patients and randomized prospective studies comparing this technique with other established procedures are required.     

Bildgebende Verfahren bei Primärdiagnose und Staging des Prostatakarzinoms

The new S3 guideline on prostate cancer includes imaging modalities applied for early detection, primary diagnosis, and staging of prostate cancer. Detection and primary diagnosis are based on digital rectal examination, serum PSA levels, and prostate biopsy. Among the imaging modalities, MRI shows the highest test quality parameters. Although MRI cannot replace biopsy to prove prostate cancer, its high negative predictive value can help to reduce the number of subsequent biopsies after negative prostate biopsy. For T-staging, MRI also demonstrates the highest test quality parameters. Its clinical application is limited, since therapeutic consequences are restricted. Due to its high specificity, MRI can save unnecessary pelvic lymph node dissections in patients at high risk for lymph node metastasis (N-staging). Risk-adjusted bone scans, complemented by additional radiological examinations if necessary, remain the standard to assess hematogenous metastasis (M staging).     

Chemotherapie beim Harnblasenkarzinom

This review summarizes results of neoadjuvant and adjuvant trials for locally advanced bladder cancer as well as data on systemic chemotherapy for metastatic urothelial cancer. Increasing attention has been drawn to targeted cancer therapies in the treatment of urothelial cancer in recent years. In future, molecular profiling will play a major role as a means to tailor individual therapy.     

Die Bedeutung der SYNTAX-Studie für die moderne Koronarchirurgie

Coronary artery bypass graft surgery (CABG) is still considered to be the standard of care for patients with a prognostically relevant pattern of coronary artery disease. New stent designs, including drug-eluting stents (DES) and improvements in percutaneous coronary intervention (PCI) technologies during recent years, challenge CABG in the treatment of coronary three-vessel disease and/or left main stem stenosis. To date, randomized trials have demonstrated significantly higher repeat revascularization rates in PCI patients but comparable results regarding procedural and mid-term survival as well as adverse events like myocardial infarction. In contrast, real world registry data demonstrated a survival benefit of CABG over PCI as the primary treatment option. Recently, 2-year results of the largest comparative randomized trial to date, the SYNTAX trial, were made available. These data demonstrated the superiority of CABG over PCI regarding the combined endpoint of death and major adverse cardiac and cerebrovascular events, including repeat revascularization. There were comparable results in patients with less complex coronary artery disease between PCI and CABG, while patients with more complex coronary pathologies had significantly better results after surgical intervention. These results have led to controversies in all major medical societies and have resulted in intensive and ongoing guideline discussions.     

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.