Positive outcomes following Autologous Matrix-Induced Chondrogenesis (AMIC) in the treatment of retropatellar chondral lesions: a retrospective analysis of a patient registry.

BACKGROUND: The patellofemoral joint is a challenging environment for treating chondral defects. Among the surgical options for the treatment of chondral defects, the single-stage Autologous Matrix-Induced Chondrogenesis (AMIC) procedure uses a porcine collagen I/III membrane to enhance bone-marrow stimulation. However, longer term outcomes data are rare for this specific indication. In order to provide real-world information, an ongoing registry has been established to record patient data and outcomes when AMIC is used to treat chondral and osteochondral lesions. METHODS: Patient data were retrieved from an ongoing, prospective, multisite registry of patients who had undergone AMIC treatment of chondral defects. We identified 64 patients who had undergone AMIC for patellofemoral chondral defects and for whom pre-operative and at least 1 post-operative score were available were included in this retrospective data analysis. Outcomes were assessed via the KOOS, VAS pain, and the Lysholm scores. Outcomes at the post-operative time-points were analysed using a factorial ANOVA with post-hoc testing while linear regression was used to assess associations between the change in the Lysholm score and lesion size. RESULTS: There was a significant improvement in Lysholm, VAS pain, and KOOS scores from pre-operative to the 1st year post-operative (p < 0.001), and this was maintained during the follow-up. CONCLUSIONS: The forces exerted on the patellofemoral joint make this a challenging scenario for chondral repair. Our data demonstrates that the AMIC procedure with a collagen I/III membrane is an effective treatment for retropatellar cartilage lesions, and provides reliable results, with decreased pain and improved function. Importantly, these improvements were maintained through the follow-up period.

Gross and ultrasonic morphology of the equine conceptus on days 10 to 40.

The gross and ultrasonic equine embryo morphology are described with emphasis on specific days after ovulation. Included are labeled colored photographs and detailed descriptions of the embryo proper (future fetus and foal) and of the entire embryonic vesicle on Days 21, 24, 30, 35/36, and 40. A few related aspects are included for the early fetus on Days 45 and 50. Regression lines for growth in the length of the embryo proper and diameter of the embryonic vesicle along with the mean days of the morphological event are included. Ultrasonograms of the embryonic vesicle are shown and discussed from Days 10 to 45. Major morphological changes in the embryo proper include: (1) appearance of forelimb and hindlimb buds, (2) appearance of the pontine flexure, (3) appearance of the genital tubercle, (4) closure of the pontine flexure, and (5) tapering of limbs toward the midline with hoof-shaped tips. Major changes in the embryonic vesicle are: (1) vascularization of mesoderm, (2) appearance of sinus terminalis, (3) emergence of allantoic sac, (4) formation of embryonic circulatory system, (5) formation and maturation of chorionic girdle, and (6) transition from yolk sac to allantoic sac.

Correlation of the Histological ICRS II Score and the 3D MOCART Score for the Analysis of Aged Osteochondral Regenerates in a Large Animal Model.

OBJECTIVE: Reliable outcome measures are essential to predict the success of cartilage repair techniques. Histology is probably the gold standard, but magnetic resonance imaging (MRI) has the potential to decrease the need for invasive histological biopsies. The 3D magnetic resonance observation of cartilage repair tissue (MOCART) score is a reliable yet elaborate tool. Moreover, literature is controversial concerning the correlation of histology and MRI. DESIGN: To test the applicability of the International Cartilage Regeneration and Joint Preservation Society (ICRS) II and MOCART 3D score for the evaluation of aged osteochondral regenerates in a large animal model, and to identify correlating histological and MRI parameters. Osteochondral defects in medial femoral condyles of n = 12 adult sheep were reconstructed with biodegradable bilayer implants. About 19.5 months postoperation, n = 10 joints were analyzed with MRI (3D MOCART score). Histological samples were analyzed using the ICRS II score; both pre- and post-training. The intraclass correlation coefficient, the inter-rater reliability, and the 95% confidence interval were calculated. Matching histological and MRI parameters were tested for correlation. RESULTS: We found a statistically significant correlation of all histological parameters. MRI parameters reflecting "overall" assessments had very strong inter-rater correlations. Statistically significant strong correlations were found for the MRI parameters defect filling, cartilage interface, bone interface, and surface. For defect overall (MRI) and overall assessment (ICRS II), we found a significant yet mild correlation. CONCLUSIONS: The ICRS II and the 3D MOCART score are applicable to aged osteochondral regenerates. Prior training on the scoring systems is essential. Select MRI and histological parameters correlate; however, the only statistically significant correlation was found for overall assessment.

Comparison of hamstring and quadriceps tendon autografts in anterior cruciate ligament reconstruction with gait analysis and surface electromyography.

BACKGROUND: Anterior cruciate ligament (ACL) tear is the most frequent ligamentous injury of the knee joint. Autografts of hamstring (HS) or quadriceps tendons (QT) are used for primary ACL reconstruction. In this study, we planned to examine whether harvesting an HS graft is related to a deficit in dynamic knee stabilisation and strength revealed by dynamic valgus as compared with QT graft or the uninjured leg. Furthermore, if this deficit exists, is it compensated by higher neuromuscular activity of the quadriceps muscle? MATERIALS AND METHODS: Adult patients who had undergone ACL reconstruction with QT or HS autografts were included in this two-armed cohort study. Clinical outcome was assessed by clinical data analysis, physical examination and the Lysholm Score and Knee Injury and Osteoarthritis Score (KOOS). In addition, gait analysis and non-invasive surface electromyography were performed. RESULTS: A complete data set of 25 patients (QT: N = 8, HS: N = 17) was analysed. There was no significant demographic difference between the groups. Time between surgery and follow-up was significantly longer for the QT group. Significant differences regarding clinical outcome were not found between the treated and untreated leg or between the two groups, with excellent scores at the time of follow-up. Gait analysis revealed no significant differences of varus-valgus angles. Significant differences in surface electromyography were only found in the QT group with increased vastus medialis obliquus activity of the treated legs (p < 0.01). CONCLUSIONS: Our results suggest that harvesting of HS grafts for primary ACL reconstruction will not lead to a medial collapse and consequently impaired medial stabilisation of the knee when compared with QT grafts. LEVEL OF EVIDENCE: IV.

TP53 germline mutation testing in early-onset breast cancer: findings from a nationwide cohort.

Early-onset breast cancer may be due to Li-Fraumeni Syndrome (LFS). Current national and international guidelines recommend that TP53 genetic testing should be considered for women with breast cancer diagnosed before the age of 31 years. However, large studies investigating TP53 mutation prevalence in this population are scarce. We collected nationwide laboratory records for all young breast cancer patients tested for TP53 mutations in the Netherlands. Between 2005 and 2016, 370 women diagnosed with breast cancer younger than 30 years of age were tested for TP53 germline mutations, and eight (2.2%) were found to carry a (likely) pathogenic TP53 sequence variant. Among BRCA1/BRCA2 mutation negative women without a family history suggestive of LFS or a personal history of multiple LFS-related tumours, the TP53 mutation frequency was < 1% (2/233). Taking into consideration that TP53 mutation prevalence was comparable or even higher in some studies selecting patients with breast cancer onset at older ages or HER2-positive breast cancers, raises the question of whether a very early age of onset is an appropriate single TP53 genetic testing criterion.

Mid-term outcome of arthroscopic AMIC for the treatment of articular cartilage defects in the knee joint is equivalent to mini-open procedures.

INTRODUCTION: We present the first retrospective study that compares two various autologous matrix-induced chondrogenesis (AMIC) surgical interventions to repair grade III-IV cartilage defects in the knee. Patients who underwent minimally invasive (arthroscopy) or open (mini-arthrotomy) AMIC were followed up to 2 years to investigate if minimally invasive AMIC is superior to open procedures. MATERIALS AND METHODS: Overall n = 50 patients with focal and contained grade III-IV articular cartilage defects in the knee joint were followed in a consecutive cohort study. 20 patients were treated arthroscopically (female 7, male 13; age: mean 38.2 years, range 18-70 years; BMI: mean 27.0, range 18.7-34.7; defect size: mean 3.1 cm2, range 1.0-6.0 cm2), and 30 patients via mini-arthrotomy (female 13, male 17; age: mean 34.4 years, range 14-53 years, BMI: mean 23.9, range 18.4-28.7; defect size: mean 3.4 cm2, range 1.5-12.0 cm2). The primary defect localization was the medial femoral condyle. RESULTS: AMIC led to a significant improvement of VAS pain, KOOS and Lysholm scoring for up to 2 years compared to pre-op. Outcome analysis revealed no significant differences between the two different surgical approaches. CONCLUSIONS: Our results suggest that mini-open AMIC is equivalent to the arthroscopic procedure. The anticipatory hypothesis that minimally invasive approaches bring greater patient benefit per se could not be confirmed. Therefore, we recommend to perform AMIC where indicated and suggest that the surgeon's personal skills profile guide the choice of surgical approach. LEVEL OF EVIDENCE: III.

A sirs-based automated alarm system for the diagnosis of sepsis after burn injury.

The present study examined the effectiveness of an automated systemic inflammatory response syndrome (SIRS)-based alarm system for the early detection of sepsis in adult burn patients. In addition, the relevance of the sepsis criteria from the American Burn Association (ABA) and the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) for this patient group was determined. In this prospective observational study, we included 41 consecutive patients who were admitted to our burn ICU within a one-year period. SIRS alarms were calculated for these patients according to predefined criteria using the PREDEC ALARM automated alarm system and alarms generated according to ABA criteria and daily Sequential Organ Failure Assessment (SOFA) results. The alarms were not visible to the treating doctors and nurses. The alarms identified were related to episodes of sepsis with positive blood cultures. Twenty-one sepsis events were recorded in 41 patients. The receiver operating characteristic (ROC) curve revealed an area under the curve (AUC) of 0.72 for alarms using 2 SIRS criteria, 0.77 for 3 SIRS criteria, and 0.61 for 4 SIRS criteria. AUC values of 0.53 and 0.59 were calculated for the ABA criteria and Sepsis-3 definition, respectively. An alarm system using 3 SIRS criteria proved to be suitable for the early detection of sepsis in burn patients. The frequent number of false alarms requires further refinement of the alarm system. Based on the results of our study, the ABA criteria and the Sepsis-3 definition provide no advantages over the SIRS criteria in the early diagnosis of sepsis after burn injury.

Cette étude évalue l'efficacité d'un système automatique fondé sur les paramètres de SIRS pour la détection précoce du sepsis chez des adultes brûlés. En outre, il étudie la pertinence des critères d'infection de l'ABA et des critères de sepsis selon la conférence Sepsis- 3 chez ces patients. Nous avons inclus 41 patients consécutifs, admis dans notre USI pour brûlés, dans cette étude observationnelle rospective. Les alarmes du système automatique PREDEC ALARM ont été calibrées selon les critères de l'ABA et le score SOFA et comparés aux 21 épisodes septiques à hémocultures positives. Elles étaient cachées aux médecins et infirmières. Les aires sous courbes ROC étaient de 0,72 pour les alarmes basées sur 2 critères de SIRS ; 0,77 pour 3 critères et 0,61 pour 4 critères. Elles étaient de 0,53 pour les critères ABA et 0,59 pour les critères Sepsis-3. Une alarme basée sur 3 critères de SIRS semble donc être utilisable pour détecter précocement un sepsis chez les brûlés, mais le nombre élevé de faux positif nécessite un affinement du système. Les critères ABA et Sepsis-3 ne semblent pas plus efficaces dans ce but.

An electronically instrumented internal fixator for the assessment of bone healing.

OBJECTIVES: The monitoring of fracture healing is a complex process. Typically, successive radiographs are performed and an emerging calcification of the fracture area is evaluated. The aim of this study was to investigate whether different bone healing patterns can be distinguished using a telemetric instrumented femoral internal plate fixator. MATERIALS AND METHODS: An electronic telemetric system was developed to assess bone healing mechanically. The system consists of a telemetry module which is applied to an internal locking plate fixator, an external reader device, a sensor for measuring externally applied load and a laptop computer with processing software. By correlation between externally applied load and load measured in the implant, the elasticity of the osteosynthesis is calculated. The elasticity decreases with ongoing consolidation of a fracture or nonunion and is an appropriate parameter for the course of bone healing. At our centre, clinical application has been performed in 56 patients suffering nonunion or fracture of the femur. RESULTS: A total of 39 cases of clinical application were reviewed for this study. In total, four different types of healing curves were observed: fast healing; slow healing; plateau followed by healing; and non-healing. CONCLUSION: The electronically instrumented internal fixator proved to be valuable for the assessment of bone healing in difficult healing situations. Cost-effective manufacturing is possible because the used electronic components are derived from large-scale production. The incorporation of microelectronics into orthopaedic implants will be an important innovation in future clinical care.Cite this article: B. Kienast, B. Kowald, K. Seide, M. Aljudaibi, M. Faschingbauer, C. Juergens, J. Gille. An electronically instrumented internal fixator for the assessment of bone healing. Bone Joint Res 2016;5:191-197. DOI: 10.1302/2046-3758.55.2000611.

[Management and Outcome of Surgery in Patients with Severe Pulmonary Hypertension--A Single-Center Experience]. / Management und postoperatives Überleben bei chirurgischen Eingriffen an Patienten mit schwerer pulmonaler Hypertonie--etrospektive Analyse eines Zentrums.

BACKGROUND: Patients with pulmonary hypertension (PH) are at high risk when undergoing surgery. Up to one-third of patients suffer complications; recent studies report a mortality rate of 1 to 7%. Frequent events are deterioration of right heart function and infectious or bleeding complications. METHODS: Data of patients (age ≥ 18) with precapillary PH who need to undergo elective surgery between January 2006 and March 2015 were included in this retrospective analysis. All patients who were planned for surgery underwent the same procedure. First, patients were evaluated in the PH center. Thereafter, PH-relevant data were discussed with the surgeon/anesthesiologist team for risk-adapted planning of anesthesia and intervention. The present analysis comprises patient characteristics and information about surgery and post-interventional course. RESULTS: This study analyzes 31 surgical procedures carried out in PH patients (male: n = 8; PH-group I: n = 23, group III: n = 3, group IV: n = 5, mean age: 59.5 ± 15.3 years). Patients were characterized by compromised hemodynamics and exercise capacity: pulmonary vascular resistance: 805.4 ± 328.5 dyn*s*cm(-5), mean pulmonary arterial pressure: 46.3 ± 9.3 mmHg, 6-minute walking distance: 350.3 ± 123.3 m.The majority of interventions were performed under general anesthesia (n = 24). In 25 cases, the intraoperative monitoring was complemented with right heart catheterization.Eight interventions were associated with complications, three of which were serious. One patient died postoperatively owing to sepsis and right heart failure. CONCLUSION: A careful and structured planning of surgical interventions in patients with PH and the choice of surgical procedure and anesthesia adapted to the conditions of PH might help avoid complications. Further multicentric studies are needed.

Arthroscopic-assisted treatment of a reversed hill-sachs lesion: description of a new technique using cerament.

Purpose. Impaction fractures of the anterior aspect of the humeral head, the reversed Hill-Sachs lesion, are common in posterior shoulder dislocation. We present a new technique to address these lesions arthroscopic-assisted with the use of a bone substitute. Methods. We report the case of a 45-year-old male with a reversed Hill-Sachs lesion after posterior shoulder dislocation. Initially a glenohumeral arthroscopy is performed to address concomitant intra-articular injuries. Guided by the k-wire a cannulated sizer was inserted for reduction of the fracture under arthroscopic visualization. For reduction of the impacted part of the humeral head the subcortical defect was filled with an injectable bone substitute (Cerament) to prevent secondary dislocation. Results. X-ray at follow-up 6 months after the index procedure documents the bony remodeling of the bone substitute. At that time the patient was pain-free (VAS 0) and satisfied with the outcome (Constant score: 78, Rand-36 score: 84, Rowe score: 81) with a good ROM. Conclusions. In conclusion, arthroscopic-assisted reconstruction of reversed Hill-Sachs lesions with an injectable bone substitute is feasible and may provide patients with all the benefits of an anatomic reconstruction with decreased risks related to open surgery.

Multimodal evoked potential monitoring in asleep patients versus neurological evaluation in awake patients during carotid endarterectomy: a single-centre retrospective trial of 651 patients.

BACKGROUND: A controversy exists regarding which monitoring technique is superior in cases in which general anesthesia (GA) is necessary for carotid endarterectomy (CEA). Multimodal evoked potential (mEP) monitoring was investigated under GA during CEA and compared with a historical control group undergoing neurological evaluations awake under loco-regional anesthesia (LA). METHODS: We retrospectively studied 651 patients undergoing elective CEA. In groupHISTORY (N.=349; 1997-1999) LA was provided using superficial or deep/superficial cervical plexus blocks. In groupmEP, (N.=302; 2009-2013) GA was performed by administering remifentanil/propofol infusion. The multimodal EPs included the median-nerve-somatosensory and motor evoked potentials. The primary outcome was the rate of technical failure. The arterio-arterial shunt rate and immediate postoperative motor outcomes were also compared. RESULTS: GroupmEP showed a significantly lower rate of technical failure (OR 0.17; CI 0.03-0.6; P=0.002). Because the groups differed systematically, logistic regression analysis was used to compare shunt rates and motor outcomes. Since shunt rates were 8.3% (groupmEP) versus 8.2% (groupHISTORY), but logistic regression model showed significant differences (OR 3.77; CI 1.67-8.95; P=0.001) correct comparison was impossible. Immediate postoperative deficits were 4.3% (groupmEP) and 4.9% (groupHISTORY); logistic regression analysis: transient OR 0.77, CI 0.28 to 0.22, P=0.61 and permanent OR 0.37, CI 0.02-7.74, P=0.49. CONCLUSION: Monitoring mEPs was associated with less technical failure than awake evaluation and showed similar motor outcomes. Because the groups differed systematically, the interpretation of shunt rates was impossible. Monitoring mEP should be considered to detect intraoperative ischemia in cases in which patients undergo CEA under GA.

Transcranial motor evoked potentials during anesthesia with desflurane versus propofol--A prospective randomized trial.

OBJECTIVE: This study aimed to evaluate differences in transcranial electrical motor evoked potential (tcMEP) amplitudes between desflurane/remifentanil and propofol/remifentanil anesthesia treatment plans in patients without preexisting motor deficits (PMDs) undergoing carotid endarterectomy (CEA). METHODS: This prospective trial included 21 patients who were randomly assigned to an effect group (Group(DESFLURANE); n=14) or a control group (Group(STANDARD-PROPOFOL); n=7). tcMEP amplitudes were measured 35 min post-induction (T1) either with desflurane or propofol. Treatment was then changed to propofol in Group(DESFLURANE). After an additional 35 min, the tcMEP amplitudes were reevaluated (T2). Differences in amplitudes (DW) between T1 and T2 were calculated for each patient, and the means of these differences were compared between groups. RESULTS: tcMEPs were recorded in all 21 patients. At T1, the mean amplitude was 840.1 (SD 50.3) µV and 358.9 (SD 74) µV for Group(STANDARD-PROPOFOL) and Group(DESFLURANE), respectively. The absolute mean difference (T1-T2) between groups was -496.75 µV (p=0.0006). CONCLUSION: Desflurane reduces the tcMEP amplitude significantly more than propofol in patients without PMDs undergoing CEA. SIGNIFICANCE: TcMEPs were recorded in all patients regardless of the anesthesia regimen. In patients with initially small amplitudes, desflurane may limit tcMEP recording because it produces a remarkable amplitude reduction, even in patients without PMDs.

Cost-effectiveness of newborn screening for cystic fibrosis determined with real-life data.

BACKGROUND: Previous cost-effectiveness studies using data from the literature showed that newborn screening for cystic fibrosis (NBSCF) is a good economic option with positive health effects and longer survival. METHODS: We used primary data to compare cost-effectiveness of four screening strategies for NBSCF, i.e. immunoreactive trypsinogen-testing followed by pancreatitis-associated protein-testing (IRT-PAP), IRT-DNA, IRT-DNA-sequencing, and IRT-PAP-DNA-sequencing, each compared to no-screening. A previously developed decision analysis model for NBSCF was fed with model parameters mainly based on a study evaluating two novel screening strategies among 145,499 newborns in The Netherlands. RESULTS: The four screening strategies had cost-effectiveness ratios varying from €23,600 to €29,200 per life-year gained. IRT-PAP had the most favourable cost-effectiveness ratio. Additional life-years can be gained by IRT-DNA but against higher costs. When treatment costs reduce with 5% due to early diagnosis, screening will lead to financial savings. CONCLUSION: NBSCF is as an economically justifiable public health initiative. Of the four strategies tested IRT-PAP is the most economic and this finding should be included in any decision making model, when considering implementation of newborn screening for CF.

[The clinical outcome after occipitocervical fusion due to metastases of the upper cervical spine: a consecutive case series and a systematic review of the literature]. / Das klinische Outcome okzipitozervikaler Stabilisierungen bei Metastasen der oberen Halswirbelsäule: Eine konsekutive Fallserie mit systematischem Review der Literatur.

BACKGROUND: Increasing incidences of osseous metastatic malignancies and higher life expectancy in patients are resulting in a raise of occipitocervical metastases. Those patients with infaust prognosis have a significantly reduced quality of life. In Germany, between 800 and 1680 new cases per year are expected. Treatment algorithms include the evaluation of the general condition, the operability of visceral metastases, the tumor localization, the sensitivity to chemo-/radiotherapy, the fracture risk and the extent of neurological deficits and myelopathies. MATERIAL/METHODS: A systematic review on clinical studies or case series in posterior occipitocervical fusions due to metastases to the craniocervical transition yielded nine publications with 48 patients without neurological deficit. The mean survival time in the given follow-up was 6.44 months (n = 26; SD: 5,28; 95 % CI: 4.3-8.57). When measured, the clinical outcome was improved towards the VAS, the DENIS Pain Scale and the quality of life through the activities of daily living (ADL). We searched our clinical database for occipitocervical stabilizations in patients with craniocervical metastases. The prospectively collected data included the preoperative Tokuhashi score, SIN score, neurological status, length of hospitalization, perioperative course/loss of blood/complication rate, as well as the Karnofsky- index and pain measured by VAS preoperatively and in follow-up. RESULTS: Six patients were treated in this consecutive case series. The median age was 72 years (min./max.: 65/82), the average BMI 31.75 (min./max.: 19.3/38.1). The mean preoperative Karnofsky-index was 35 % (min./max.: 23.99/46.01; 95 % CI: 8.39) the mean preoperative Tokuhashi-score 7 (min./max.: 4/10), the mean preoperative VAS7 (min./max.: 4.8/9.2; 95 % CI: 1.68). There were no perioperative complications. In the follow-up, one patient showed a loosening of the screws in the osteolytic massae laterales and one patient suffered from a construct failure after fall. DISCUSSION: Metastases of the craniocervical transition are rare. The initial treatment of instability includes the application of a rigid Miami-J-collar or a Halo fixator. The decision for an operative procedure must accurately assess the individual patient characteristics to provide him a balanced concept between operational risk and clinical benefit. The assessment should be based on the life expectation and the expected quality of life in dependency of the respective therapeutic concept and its risks. The sole posterior stabilization of craniocervical instability through occipitocervical fusion leads to a reduction of pain, has a low perioperative risk, and may prevent a hospitalization. It is justified for selected patients to receive this treatment to help alleviate pain and to improve their quality of life. From our experience, rare cases of pain without instability should undergo conservative treatment in the first line. Due to the low availability of data on the manifestation and the clinical course of craniocervical metastases, there is a need for the collection of both the descriptive patient data include the radiographic findings as well as the clinical outcome and socio-economic factors using appropriate scoring systems.

Refixation of osteochondral fractures by ultrasound-activated, resorbable pins: An ovine in vivo study.

OBJECTIVES: Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions. METHODS: In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months. RESULTS: The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown. CONCLUSION: As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures.

Fungal infections in burns: a comprehensive review.

Burn wound infections remain the most important factor limiting survival in burn intensive care units. Large wound surface, impaired immune systems, and broad-spectrum antibiotic therapy contribute to the growth of opportunistic fungal species. Faced with challenging fluid resuscitation, wound excision and cardiopulmonary stabilization, mycosis in burns are likely to be underestimated. Diagnostic performance can sometimes be delayed because clinical signs are unspecific and differentiation between colonization and infection is difficult. Therapeutic measures range from infection prophylaxis over treatment with antifungal agents towards radical amputation of infected limbs. New methods of early and reliable detection of fungal organisms, as well as the use of novel antifungal substances, are promising but require wider establishment to confirm the beneficial effects in burn patients. This review aims to highlight the main important aspects of fungal infections in burns including incidence, infection control, diagnostic and therapeutic approaches, prognosis and outcomes.

Les infections de plaies des brûlures restent le facteur le plus important qui limite la survie dans des unités de soins intensifs des brûlures. Une plaie grande, une immunodépression, et une antibiothérapie à large spectre contribuent à la croissance des espèces fongiques opportunistes. Face à la réanimation liquidienne difficile, l'excision de la plaie et la stabilisation cardiorespiratoire, les mycoses des brûlures sont susceptibles d'être sous-estimées. Le rendement diagnostic peut parfois être retardé car des signes cliniques ne sont pas spécifiques et la différenciation entre la colonization et l'infection est difficile. Les mesures thérapeutiques vont de la prévention des infections au traitement avec des agents antifongiques vers amputation radicale des branches infectées. De nouvelles méthodes de détection précoce et fiable d'organismes fongiques, ainsi que l'utilisation de nouvelles substances antifongiques, sont prometteuses mais on a besoin de plus exemples pour confirmer les effets bénéfiques chez les patients brûlés. Cette revue a pour but de mettre en évidence les principaux aspects importants des infections fongiques chez les brûlures, y compris l'incidence, la lutte contre les infections, les approches diagnostiques et thérapeutiques, le pronostic et les résultats.

[Medical appraisal of anterior cruciate ligament ruptures]. / Begutachtung der vorderen Kreuzbandruptur.

BACKGROUND: Anterior cruciate ligament tears are one of the most common human ligament ruptures. The assessment of such ruptures is particularly difficult because most ACL injuries involve minimal to no contact. The steps of the assessment are presented with the necessary requirements. METHOD: Criteria for determining the cause of anterior cruciate ligament ruptures are discussed against the background of our experience and the literature. Different definitions of causality apply to German statutory accident insurance (workers' compensation) on the one hand and to private accident insurance on the other. RESULTS: The assessment of disability within the scope of workers' compensation in most cases results in "under 10 to 30%", while in private accident insurance it is rated as 1/10 to 1/20 degree of disablement.

Outcome of Autologous Matrix Induced Chondrogenesis (AMIC) in cartilage knee surgery: data of the AMIC Registry.

INTRODUCTION: Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment for localized full-thickness cartilage defects combining the well-known microfracturing with collagen I/III scaffold. The purpose of this analysis was to evaluate the medium-term results of this enhanced microfracture technique for the treatment of chondral lesions of the knee. METHODS AND MATERIALS: Patients treated with AMIC (Chondro-Gide, Geistlich Pharma, Switzerland) were followed using the AMIC Registry, an internet-based tool to longitudinally track changes in function and symptoms by the Lysholm score and VAS. RESULTS: A series of 57 patients was enrolled. The average age of patients (19 females, 38 males) was 37.3 years (range 17-61 years). The mean defect size of the chondral lesions was 3.4 cm(2) (range 1.0-12.0 cm(2)). All defects were classified as grade III (n = 20) or IV (n = 37) according to the Outerbridge classification. Defects were localized at the medial (n = 32) or lateral (n = 6) condyle, at the trochlea (n = 4) and at the patella (n = 15). The follow-up period was 2 years. The majority of patients were satisfied with the postoperative outcome, reporting a significant decrease of pain (mean VAS preop = 7.0; 1 year postop = 2.7; 2 years postop = 2.0). Significant improvement of the mean Lysholm score was observed as early as 1 year after AMIC and further increased values were noted up to 2 years postoperatively (preop. 50.1, 1 year postop. 79.9, 2 year postop. 85.2). CONCLUSIONS: AMIC is an effective and safe method of treating symptomatic chondral defects of the knee. However, further studies with long-term follow-up are needed to determine if the grafted area will maintain structural and functional integrity over time. LEVEL OF EVIDENCE: Prognostic study, Level IV.

AMIC Cartilage Repair in a Professional Soccer Player.

We report a case of a professional soccer player suffering from a traumatic cartilage lesion grade IV according to the Outerbridge classification at the femoral condyle treated with an enhanced microfracture technique (AMIC). Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment for localized full-thickness cartilage defects combining the well-known microfracturing with collagen scaffold and fibrin glue. Because of the cartilage lesion (3 cm(2)), an AMIC procedure was performed followed by a rehabilitation program according to the protocols in the literature, (Steadman et al.; 2003). After 8 months of rehabilitation, the player returned to team training and after 10 months to competition. Altogether he returned to the same skill level for almost one year after the index operation. He is very satisfied with the clinical results after AMIC, which corresponds with the Lysholm score of 90 points at 12 months.

[Antimicrobial treatment in burn injury patients]. / Antimikrobielle Therapie bei Patienten nach Verbrennungstrauma.

Infections are a great diagnostic and therapeutic challenge in intensive care patients with burn injuries. The major problems are due to bacteria with hospital-acquired multiresistance to antibiotics but fungal and viral infections may also be life-threatening. The main key points addressing pharmacotherapy with antibiotic, antifungal and antiviral agents in this special setting are exact diagnosis, early therapy with suitable drugs, adequate duration of treatment and adequate doses based on pharmacokinetic and pharmacodynamic characteristics of these compounds. The latter parameters are significantly altered in burn patients and show a wide interindividual and intraindividual variation in drug response as a result of the characteristic phases of burn injury. Drug concentration analysis may help to avoid inadequate dosing. In this review the main characteristics of burn injuries and the pharmacology of antibiotics, antifungal and antiviral agents in these patients are presented.