Can elderly patients regain their preoperative functional level after distal radius fracture type A? Results from a fracture register study using PROM.

Introduction: Although distal radius fractures (DRFs) are the most common fractures of the human body, there are still ongoing debates concerning the treatment for type A fractures, especially in elderly patients. In spite of good clinical outcomes, it remains unclear whether elderly patients, especially, could regain the preoperative functional level of the wrist. Therefore, we have quantified wrist function within a retrospective study design using patient-reported outcome measures (PROM) and we have analyzed the influence of age between control and patient collective and young vs. old, respectively. Patients and methods: The retrospective study included all patients with a surgically treated DRF type A and a control group of healthy patients, age and gender matched. The function of the wrist was examined by using a self-assessment questionnaire called the Munich Wrist Questionnaire (MWQ) according to the patient-related outcome measurements PROM. Results: We could enroll 110 patients and controls, and the average follow-up was 66 months. Subgroup matching induced similar age group distribution: in both groups, 7 individuals <30 years, 67 between 31 and 64 years, 29 between 65 and 79 years, and 7 individuals >80 years, were enrolled, respectively. In the fracture group, women were significantly older than men (59 ± 15 vs. 47 ± 17 (M ± SD). There was no significant difference between the control and the patient groups (96 ± 6 vs. 95 ± 7). The function was significantly different between controls and patients <30 years (100 ± 1 vs. 98 ± 2). In the control group, there was a functional difference in the age group <30 compared with 65-79 and >80 and in the age group 30-64 compared with 65-79 and >80. In the control group, the function was found to be significantly decreasing with advancing age, whereas in the patient group, this influence was absent. A correlation analysis showed a worse function with increasing age in the control group and therefore a negative correlation. In the fracture group, a similar result could not be obtained. Discussion: Age has a relevant influence on wrist function. Although the wrist function decreases significantly with aging, in the patient group, this influence is absent, and the functional results after surgery are excellent. Even elderly patients can regain their preoperative functional level.

Patient satisfaction after hook plate treatment of bony avulsion fracture of the distal phalanges.

BACKGROUND: Bony avulsion fractures of the distal phalanges can result in mallet finger deformity if not treated appropriately. Therefore, only minimally displaced fractures can be treated conservatively with a good outcome, as dislocation occurs very often. Several surgical treatment options have been developed during the past decades. Data concerning the recently developed hook plate are promising. So far, no data concerning the subjective satisfaction with this method have been published. Therefore, we have analyzed the outcome after hook plate implantation using a self-assessment score, which focuses also on subjective parameters and satisfaction. METHODS: Standardized questionnaires (self-assessment scores and SF-36 questionnaire) were sent to each patient treated with a hook plate due to fracture of the distal phalanx, type Doyle IVb and IVc. Clinical data were evaluated according to the medical record. Scores given per question range from 0 to 10, 10 is the worst and 0 the best outcome. RESULTS: From 69 patients treated, 38 (58%) were enrolled. The whole collective (n = 38) reached a score of 39.7 ± 28.7 points, while men had slightly better results. Men (n = 24) achieved 37.3 ± 27.9 points, women (n = 14) 43.9 ± 30.7 points. Women had significantly better results when analyzed later than 12 months after surgery (52.1 ± 27.9 vs. 29.1 ± 32.8), whereas no changes could be detected in the male group (37.1 ± 29.9 vs. 37.4 ± 27.6). Overall, men were slightly more satisfied than women. Most satisfaction was found regarding pain and fine motor skills (0-0.46 points). Esthetic aspect and nail deformities (3.65 points average) led to the highest dissatisfaction. No differences in the SF 36 score could be detected. CONCLUSIONS: The hook plate is not only a convenient method but it also results in high patient satisfaction. Nail deformities are challenging; however, with increasing experience of the surgeon they decrease. SF 36 score is not an appropriate testing tool for this problem.

[General principles of wound management in emergency departments]. / Grundlegende Techniken des Wundverschlusses in der Notaufnahme.

Wound management is one of the major tasks in emergency departments. The surrounding intact skin but not the wound itself should be disinfected before starting definitive wound treatment. Hair should first be removed by clipping to 1-2 mm above the skin with scissors or clippers as shaving the area with a razor damages the hair follicles and increases the risk of wound infections. Administration of local anesthetics should be performed directly through the exposed edges of the wound. After wound examination, irrigation is performed with Ringer's solution, normal saline or distilled water. The next step is débridement of contaminated and devitalized tissue. There are several wound closure techniques available, including adhesive tapes, staples, tissue adhesives and numerous forms of sutures. Management of specific wounds requires particular strategies. A bleeding control problem frequently occurs with scalp lacerations. Superficial scalp lacerations can be closed by alternative wound closure methods, for example by twisting and fixing hair and the use of tissue adhesives, i.e. hair apposition technique (HAT). For strongly bleeding lacerations of the scalp, the epicranial aponeurosis should be incorporated into the hemostasis. Aftercare varies depending on both the characteristics of the wound and those of the patient and includes adequate analgesia as well as minimizing the risk of infection. Sufficient wound aftercare starts with the treating physician informing the patient about the course of events, potential complications and providing relevant instructions.

[Osteosynthesis after periprosthetic fractures of the knee joint]. / Osteosynthese nach periprothetischen Frakturen am Kniegelenk.

Periprosthetic fractures around the knee joint are of increasing relevance due to increasing numbers of total knee replacements and increasing life expectations. These fractures can be a real challenge due to an often limited patient compliance, reduced bone quality and impaired bone perfusion of potential intramedullary shafts resulting in poor healing and lack of fixation options for screws. These fractures necessitate special knowledge and approaches, which are systematically dealt with in this article, beginning with the correct diagnostics through to the most recent developments in the field of osteosynthetic techniques. The trends of minimally invasive techniques are presented and the options and limitations are described.

[Cardiac post-resuscitation care. An indication for trauma whole-body CT?]. / Zustand nach Reanimation. Eine Indikation für die "Traumaspirale"?

We report the case of a 51-year-old male patient who sustained a liver rupture following mechanical cardiopulmonary resuscitation (CPR) with the LUCAS® system. The patient was under anticoagulation and developed an abdominal compartment syndrome. Although the use of mechanical CPR devices, such as the LUCAS® system and the load distributing band (Autopulse®), is becoming more common, there are specific complications described in the literature, which are associated with mechanical CPR. It is important to differentiate between general complications associated with CPR and those which can be attributed to the application of mechanical CPR devices. Using the example of the presented case, this article outlines and discusses these points based on the currently available literature. It should also be noted that mechanical CPR can act in a similar way to chest trauma and can necessitate an investigation with contrast enhanced computed tomography.

Reference ranges for thromboelastography (TEG(®) ) and traditional coagulation tests in term parturients undergoing caesarean section under spinal anaesthesia*.

There has been little published work defining 'normal' thromboelastography (TEG(®) ) values in healthy parturients, and few large studies defining reference ranges for traditional coagulation tests in this patient group. Our aim was to establish peri-operative reference ranges for TEG and for standard laboratory coagulation tests in our pregnant population. Fifty healthy term parturients presenting for elective caesarean section under spinal anaesthesia had blood samples taken pre-operatively, on arrival in the recovery room and, in a subset of 33 women, 4 h after routine thromboprophylaxis with enoxaparin 40 mg. All three samples had TEG analysis, the first and second having standard laboratory coagulation tests in addition. Reference ranges for our pregnant population were established, demonstrating a hypercoagulable state in term parturients and a significant effect of enoxaparin. The standard coagulation reference ranges were within 98% of the local non-pregnant ranges. These reference ranges provide a useful comparator for peri-operative TEG and routine coagulation analysis in term parturients.

British Society for Haematology, Slide session, Annual Scientific Meeting, Bournemouth, 2007.

Eight cases discussed by experts at the 2007 Annual Scientific Meeting of the British Society of Haematology are presented as at the meeting, with a discussion of the morphological features, digital information and differential diagnosis being followed by further information and a final diagnosis. Additionally, digital slides of two of the cases were available to be viewed by the internet with the opportunity for delegates to suggest diagnoses.

Intravenous immunoglobulin given to lymphoma patients with recurrent haemolytic transfusion reactions after transfusion of compatible blood.

Accelerated destruction of red cells after transfusion of compatible blood has been reported in both sickle cell disease (SCD) and non-SCD patients. We report three patients with lymphoma, all of whom had recurrent haemolytic transfusion reactions after receiving compatible red cell units. The direct antiglobulin test (DAT) was negative and there were no detectable red cell alloantibodies in either pre-transfusion or post-transfusion samples. As there was no evidence of red cell antibody-mediated haemolysis and response to oral steroids, a trial of intravenous immunoglobulin (IVIg) was given. Immediate cessation of haemolysis with sustained haemoglobin level was achieved in all cases. The response to IVIg in these cases suggests that IVIg should be tried when recurrent non-antibody mediated haemolytic transfusion reactions occur in patients with a lymphoid malignancy.

A cost-benefit analysis of initial burn cultures in the management of acute burns.

It is common practice to obtain cultures in the first 24 hours after burn injuries. However, little evidence exists that these tests change clinical practice or clinical outcome. We conducted a retrospective chart review to determine how often the results of wound and other cultures lead to changes in the clinical treatment of patients. A total of 598 charts were reviewed. Four hundred forty-seven patients had a length of stay in the hospital of 1 day or less and were primarily treated in the emergency department and then discharged from the hospital. Wound cultures were obtained for 42 (10%) of these patients. Thirty cultures (71%) had no significant growth. Twelve cultures (29%) grew mixed common skin flora. No patients in this group were "pan-cultured." No patients in this group required antibiotic treatment on the basis of culture results. A total of 151 patients were admitted to the burn center, with an average length of stay of 3.9 days (range, 2-125 days). In this group, 45 patients (30%) had wound cultures and 24 patients (16%) were pan-cultured in the first 24 hours after admission to the hospital. Enterococcus species grew in the initial wound culture of 1 patient, and the patient was treated with antibiotics. Antibiotics were not ordered for any other patients on the basis of cultures. The collection of routine cultures during the first 24 hours after admission to the hospital is not cost-effective and rarely alters or provides therapeutic direction. An estimated $14,000 per year decrease in charges could be achieved by the elimination of cultures taken during the first 24 hours of admission to the hospital.

Intermediate-dose busulphan before autografting for advanced-phase chronic myeloid leukaemia.

Between June 1994 and October 1995 we performed 11 autografts in nine patients with advanced-phase chronic myeloid leukaemia (CML) using an attenuated cytoreductive regimen consisting of busulphan 8 mg/kg given in divided doses over 4 d. Five patients were restored to chronic phase. Four patients survived > 50 weeks and one remains well at 79 weeks. Toxicity was generally mild. Four procedures were managed entirely in the out-patient clinic. Therefore autografting after this 'intermediate' dose busulphan provides good palliation for patients with advanced CML with relatively little toxicity. Attenuated autografting should offer major advantages in terms of quality of life and cost for patients with advanced-phase CML.

Myelodysplasia following aplastic anaemia-paroxysmal nocturnal haemoglobinuria syndrome after treatment with immunosuppression and G-CSF: evidence for the emergence of a separate clone.

Myelodysplasia (MDS) and aplastic anaemia-paroxysmal nocturnal haemoglobinuria (AA/PNH) syndrome developed in a severe aplastic anaemia (AA) patient after treatment with immunosuppressive (IS) therapy. Glycosylphosphatidyl inositol (GPI)-linked proteins were determined, and during the AA/PNH phase, a high proportion of neutrophils were found to be negative, without clinical evidence of haemolysis. However, MDS developed with cytogenetic abnormalities of monosomy 7,9q- and a rearranged chromosome 6; the GPI-linked protein negative cells were completely replaced by positively expressing cells. This represents the emergence of a GPI-linked protein positive myelodysplasia clone arising separately from an AA/PNH clone.

T cell-depleted allogeneic bone marrow transplantation from a partially HLA-mismatched unrelated donor for progressive chronic lymphocytic leukemia and fludarabine-induced bone marrow failure.

A 49-year-old man with a 3-year history of chronic lymphocytic leukemia (CLL, stage B at diagnosis) responded well to four course of fludarabine, but developed marrow failure and prolonged pancytopenia lasting 9 months following the fifth course. Fludarabine therapy could not be continued due to pancytopenia, eventually resulting in disease progression. Bone marrow transplantation from an unrelated donor mismatched at one DRB1 locus and both DQB1 loci was performed as salvage therapy. The marrow was depleted of T cells with Campath-1G. Pre-transplant immunosuppression was enhanced with 600 cGy total lymphoid irradiation and Campath-1G infusions in addition to 120 mg/kg cyclophosphamide and 1200 cGy fractionated total body irradiation. Cyclosporine alone was used as post-transplant immunosuppression. Neutrophils reached 0.5x10(9)/1 on day 14 and platelets 50 x 10(9)/1 on day 40. No acute graft-versus-host disease was seen. Bulk disease detected on CT scanning prior to BMT was found to have disappeared 10 weeks after BMT. The marrow showed residual disease (5% CD5+/CD19+ cells) 9 weeks after transplantation, which had decreased markedly at 13 (0.5%) and 26 (0.4%) weeks. The patient is currently alive and well 10 months after BMT with no clinically detectable disease. We conclude that BMT from an unrelated donor is a feasible treatment option in advanced CLL.

Autologous bone marrow or peripheral blood stem cell transplantation followed by maintenance chemotherapy for adult acute lymphoblastic leukemia in first remission: 50 cases from a single center.

The aim of this study was to evaluate the use of maintenance chemotherapy after autotransplantation in adult acute lymphoblastic leukemia (ALL), and to compare the relative durability of marrow and peripheral blood stem cell grafts to chemotherapy. Fifty consecutive ALL patients received 200 mg/m2 melphalan alone or 110 mg/m2 melphalan with total-body irradiation in first remission, followed by autologous marrow (ABMT, n = 38) or peripheral blood stem cells (PBSCT, n = 12). After hematologic recovery, 6-mercaptopurine and methotrexate were administered for 2 years. 6-mercaptopurine could be given to 78.9% of ABMT recipients at a median daily dose of 33.5 mg/m2, and to 91.7% of PBSCT recipients at a median daily dose of 44.1 mg/m2. ABMT recipients started 6-mercaptopurine at a median of 58.5 days post-transplant, and PBSCT recipients at 32 days (P = 0.002). 52.6% of ABMT recipients and 75% of PBSCT recipients received weekly methotrexate. No graft failure was seen as a result of chemotherapy. The actuarial 5-year probabilities of overall survival, survival in first remission and relapse were 56.2, 53.2, and 30.6%, respectively. We conclude that administration of maintenance chemotherapy after autografting in adult ALL may reduce relapse. A randomized study is required to evaluate the relative efficacy of PBSCT vs ABMT, and the role of post-transplant maintenance chemotherapy.

Massive abdominal lymphadenopathy in hairy cell leukaemia: a report of 12 cases.

Lymphadenopathy is an uncommon finding in hairy cell leukaemia (HCL). We report 12 HCL patients in whom relapse was associated with massive abdominal lymphadenopathy. All but one had long-standing HCL (range 3-25 years; median 10 years); in one it was discovered at presentation. Nine patients had been splenectomized and seven had previously been treated with 2'deoxycoformycin (DCF) and/or alpha-interferon (alpha IFN): three had achieved complete remission and four a partial response. The computerized tomography (CT) scan appearances were similar in all cases with a primary lymph node mass centred around the coeliac axis and involving upper para-aortic and retropancreatic regions. Histology and/or cytology confirmed nodal involvement by HCL in six patients. Large immature hairy cells were seen in both lymph nodes and bone marrow, suggesting a degree of transformation. Nine patients were treated with DCF: one had complete resolution, six responded with 50-90% reduction of the lymphadenopathy, one did not respond and one is still on treatment; alpha-IFN was used concomitantly or sequentially in two of the responders. One responding patient died of sepsis after four injections of DCF. Three patients received either alpha- or beta-IFN alone with no response. One elderly patient was not treated. Abdominal lymphadenopathy could be part of the natural history of HCL and/or may represent a transformation analogous to that seen in other low-grade lymphoproliferative disorders. Routine abdominal CT scanning should be part of the work up of all patients with HCL.