[Oral prevention of thromboembolism with rivaroxaban and dabigatran: are the newly approved drugs innovations in orthopaedic and trauma surgery? ]. / Orale Thromboembolieprophylaxe mit Rivaroxaban und Dabigatran: Sind die Neuzulassungen Innovationen für die operative Orthopädie und Unfallchirurgie?

Today the indication for thrombosis prophylaxis is a relevant and daily concern in orthopaedic surgery. Recently there are some changes concerning the German guidelines, which are approved by 27 German medical societies. For the first time the guidelines give distinct recommendations for the different indications, the kind of thrombosis prophylaxis and its duration. Some of the recommendations will lead to changes of both processes in outpatient and inpatient management. In parallel 2 new oral anticoagulants have been approved for the prevention of thromboembolic events after elective knee and hip replacement. Dabigatran is an oral thrombin inhibitor. Compared to enoxaparin it has a comparable profile of side effects and efficacy. Rivaroxaban is an oral Xa inhibitor which shows a significantly better efficacy compared to enoxaparin and no difference in side effects. The significant reduction of symptomatic thromboembolisms after elective knee and hip replacement was shown for rivaroxaban compared to enoxaparin in a pooled analysis of phase III data. This review discusses the main topics of the new German guideline and impact of the new oral anticoagulants on in- and outpatient treatment procedures.

[Proximal fracture of the femur in elderly patients. The influence of surgical care and patient characteristics on post-operative mortality]. / Die proximale Femurfraktur des älteren Patienten. Einfluss von operativer Versorgung und Patientencharakteristika auf die postoperative Letalität.

In a retrospective study, 1.173 fractures of the proximal femur, which had been treated surgically, were analysed in two periods from 1975 to 1991 and from 1992 to 2000. The influence on mortality of preoperative risk factors and primary treatment with total hip replacement (THR), even in cases of pertrochanteric fractures, was analysed by stepwise logistic regression. In the later period, mortality within 90 days was 13.1%, and within 1 year 22.2%. Rejection of hemiendoprosthesis in high-risk patients with intracapsular fractures increased the mortality rate from 6.3% to 11.8%. The introduction of dynamic hip screws instead of Ender nails led to a reduction of mortality from 16.5 to 7.1%. Higher mortality after THR (27.6%) compared to osteosynthesis (15.5%) in pertrochanteric femur and lateral neck fractures was due to higher age and increased risk factors. Although the influence of some risk factors could be reduced, age, sex and morbidity influenced the outcome more than surgical treatment. THP, even after pertrochanteric fractures, is reasonable if it guarantees a quick and enduring mobilisation of the patient. Bicentric bipolar prostheses are recommended for high risk patients.

Madelung deformity: clinical features, therapy and results.

In a retrospective study, 31 patients with Madelung deformity were reviewed. They were treated at one institution during a period of 15 years. On first presentation, the mean age was 22.5 years with a range from 10 years to 64 years. Twenty-four patients (77%) were female. The main complaints were pain, limited range of motion, and objectionable appearance. A family history of Madelung deformity was present in four patients (13%). The diagnosis of Leri-Weill syndrome could not be confirmed in any case. There was no correlation between the clinical appearance and the extent of radiologic abnormality. Five patients (16%) were operated on because of permanent pain. On postoperative examination, only one patient revealed no restricted range of mobility and no pain, whereas the other four patients improved in terms of pain but showed only limited improvement of function. The vast majority of patients, however, required no surgical therapy.

[Guidelines for prevention of thrombosis in orthopedics]. / Leitlinien zur Thromboseprophylaxe in der Orthopädie.

PURPOSE: The necessity of effective prevention of DVT is generally accepted. However, attitudes and beliefs concerning prophylaxis vary greatly in terms of the risk groups receiving prophylaxis and the prophylactic methodology. This paper reviews current research on the subject and seeks to provide recommendations. RESULTS: Known clinical risk factors allow the classification of patients according to high, medium and low risk of developing thromboembolism. Basic forms of prophylaxis are physiotherapy and early mobilisation. However, there are no data on the safety and efficacy of these methods. Mechanical devices used include external intermittent pneumatic compression and graduated compression stockings. Used in isolation, these methods reduce the incidence of deep vein thrombosis in low and moderate risk patients by one half or one third. There is no distinction between mechanical and pharmacological methods in terms of safety and efficacy. Furthermore, secondary effects are extremely rare. Moderate and high risk category patients should receive combined modes of mechanical and pharmacological treatment. A direct comparison of safety in moderate risk patients fixed doses of standard heparin vs. low molecular weight heparin revealed no significant differences. In the case of high risk patients, adjusted dose heparin administered subcutaneously or fixed dose low molecular heparin is recommended. A severe secondary effect of heparin-prophylaxis is heparin-induced thrombocytopenie. The optimum duration of pharmacological prophylaxis is not yet clear. CONCLUSION: The methods and duration of prophylaxis remain subject to an individual medical assessment of the clinically significant benefits in relation to the risk secondary effects of the treatment. On major questions there are significant variations in the specialist literature. This means that standards cannot be formulated, although recommendations can be given.

Thanatophoric dysplasia type II: new entity?

There is some question about whether the two forms of thanatophoric dysplasia (TD), Type II with and Type I without cloverleaf skull, belong to the same entity. Thus, we investigated one 6-day-old TD with cloverleaf skull using examination of the external phenotype, radiology, autopsy, skeleton preparation, large section histology, detailed section histology, and ultrastructure. The loss of the three-phase contours-characteristics for Type I (54)--in certain metaphyses, the absence of the perichondral spurs to some extent, and their substitution by a structure similar to the perichondral "ring of Lacroix" have a suggested origin in normal cartilage-bone tissue. The same mechanism is postulated (a) for the appearance of less bent or normally shaped tubular bones compared with TD Type I, and their corresponding increased mechanical stability, and (b) for the less amount of platyspondyly in Type II than in Type I. We suggest that the malformation of the cloverleaf skull has its origin in the promontory growth of the relatively normal cartilage-bone tissues at the skull base resulting in an early synostosis and a consecutive fusion of the cranial sutures. The ultrastructural analysis of chondrocytes demonstrates the significant contribution of electron microscopy for TD studies. We suggest that pathologically altered light chondrocytes accounts for plump cross-striated collagen fibrils, the reduced cellular proliferation, and the impaired formation of columnar and hypertrophic zones. It is clear that normal cartilage-bone tissue distributed among "thanatophoric" tissue is the reason for the differences between Type I and Type II. Hypotheses are presented that explain this tissue mosaicism. Thus, TD Type I and TD Type II do not represent two different entities but the same entity with varying features due to mutational events occurring at different times.

[Humerus lengthening in a unilateral technique: case report]. / Die Humerusverlängerung in unilateraler Technik: Fallbeschreibung.

Surgical lengthening of the humerus is indicated for cosmetic and functional reasons. The discrepancy should exceed 4 cm. Complications (review of literature) and our own experience regarding lengthening of extremities indicate that surgical lengthening of the humerus is technically feasible and reasonably safe. It appears to have fewer risks and complications than surgical lengthening of the femur or the tibia; even though radial nerve paralysis is an important complication.

[Rare occurrence of villonodular synovitis of both shoulder joints]. / Das seltene Auftreten einer villonodulären Synovialitis an beiden Schultergelenken.

Presentation of the radiological, histological, and clinical findings in one patient with bilateral villonodular synovitis of the shoulder is made. This synovitis is a nonmalignant disease entity of controversial origin and nature.

Mapping of different neuropeptides in the lower brainstem of the rat: with special reference to the ventral surface.

A neuropeptide map of beta-endorphin-, vasoactive intestinal peptide-, substance P-, and somatostatin-like reactive neurons and nerve fibers was made by means of immunohistochemistry. Indirect immunofluorescence was carried out in parallel to peroxidase-antiperoxidase reaction using a modified fixation technique. Special interest was directed to the superficial ventral regions of the medulla oblongata where regulative centers for respiration and circulation have been localized. The atlas presented offers a reliable tool for a precise neuromorphological localization of these neuropeptides in pharmacophysiological experiments.