The haemodynamic instability score: Development and internal validation of a new rating method of intra-operative haemodynamic instability.

BACKGROUND: There is no consensus on how to define haemodynamic instability during general anaesthesia. Patients are often classified as stable or unstable based solely on blood pressure thresholds, disregarding the degree of instability. Vasoactive agents and volume therapy can directly influence classification but are usually not considered. OBJECTIVE: To develop and validate a scoring tool to quantify the overall degree of haemodynamic instability. DESIGN: Retrospective observational study. SETTING: University hospital. PATIENTS: The development cohort consisted of 50 patients undergoing high-risk surgery with a control group of 50 undergoing video-assisted thoracoscopic surgery. In the validation cohort, there were 153 high-risk surgery patients and 78 controls. INTERVENTION: None. MAIN OUTCOME MEASURES: The haemodynamic instability score (HI-score) was calculated as a weighted continuous measure ranging from 0 to 160 points, intended to reflect deviations of blood pressure and heart rate from predefined thresholds, and infusion rates of vasoactive agents and fluids. Thresholds were first determined in a development cohort and subsequently tested in a validation cohort. Results are presented as median [interquartile range]. RESULTS: In the validation cohort the HI-score was 59 [37 to 96] in the high-risk surgery group compared with 44 [24 to 58] in the control group (P < 0.001). The score of the haemodynamic domain did not differ (P = 0.69) between groups: 10 [8 to 16] vs. 10 [8 to 16]. However, scores for volume therapy and vasoactive medication were significantly higher in the high-risk surgery group compared with the control group: 14 [6 to 30] vs. 6 [2 to 18], P = 0.003 and 35 [15 to 75] vs. 15 [5 to 35], P < 0.001, respectively. CONCLUSION: We developed the HI-score and demonstrated that it can appropriately quantify the degree of intra-operative haemodynamic instability. The HI-score provides a clinical tool which, after further external validation, may have future applications in both patient management and clinical research.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Ankle cartilage repair : Therapeutic options, results and technical aspects]. / Knorpelreparative Eingriffe am oberen Sprunggelenk : Therapieoptionen, Ergebnisse und technische Aspekte.

BACKGROUND: Therapeutic strategies for cartilage repair of the talus are varied. With the use of biologic scaffolds and biologic agents new cell-based therapies have become the focus of attention. OBJECTIVES: Ankle cartilage repair techniques are presented and assessed by current data. In addition, technical notes for each technique are given. MATERIAL AND METHODS: Currently, the following established ankle cartilage repair procedures exist: microfracturing, AMIC (autologous matrix-induced chondrogenesis), OCT (osteochondral transplantation, mosaicplasty), allograft transplantation. DISCUSSION: The success of each repair technique is dependent on the proper indication, addressing of co-morbidities like axis deviation or ligament instabilities, the experience of the surgeon and the appropriate rehabilitation. Mid- and long-term results are often good or excellent. Best results are seen in isolated cartilage defects without co-morbidities in patients younger than 40 years of age and non-smokers with normal BMI and early intervention. New cell-based therapies utilize scaffolds and biologic agents. They offer promising perspectives, although current data is inconsistent.

[Hallux valgus : Etiology, diagnosis, and therapeutic principles]. / Hallux valgus : Ätiologie, diagnostische und therapeutische Prinzipien.

Hallux valgus-the most common forefoot deformity-can cause both pain and decreased mobility. The development and progress of the hallux valgus is a multifactorial process. Different intrinsic and extrinsic causes are responsible. Various conservative and operative treatment options exist and have to been chosen regarding the stage of the disease. Conservative orthopedic measures may prevent a deterioration of hallux valgus only at an early stage of the disease. Concerning operative techniques, more than 150 different surgical procedures are described in the literature, which can be reduced to some common procedures. These are dependent on the manifestation of the bunion as well as on associated foot and ankle pathologies. Patients should be informed that postoperative follow-up treatment until complete recovery is time-consuming.

[Orthoses and assistive devices in rheumatology : Prevention of disability, support of residual function]. / Hilfsmittel in der Rheumatologie : Einschränkungen vorbeugen, Restfunktionen unterstützen.

Due to the frequent presence of comorbidities in patients suffering from rheumatism with increased perioperative risk factors, conservative treatment is often needed. Besides pharmacological treatment, physiotherapy and occupational therapy, a variety of orthoses are available depending on the individual indications. They can be used to stabilize or support joints, limit the range of motion, prevent unphysiological movements or provide relief for affected limbs. In order to choose the right kind of orthosis, the physician should know the underlying cause of disease. Furthermore, for patients with rheumatism many devices are available for daily living that use ergonomic handles or improved leverage effects to compensate for the often severe limitations and to improve the quality of life.

[Course of pain after operative orthopedic interventions: Characterization exemplified by total knee arthroplasty]. / Schmerzverlauf nach operativer orthopädischer Intervention : Charakterisierung am Beispiel der Knieendoprothetik.

BACKGROUND: The number of cases of orthopedic surgery is still increasing and postoperative pain management is of great importance for the patients. Therefore, in this study factors influencing the pain and the developement of pain in general in the first 7 days after total knee arthroplasty were examined. MATERIAL AND METHODS: A total of 28 patients were included in this prospectively designed trial and underwent total knee arthroplasty with psoas compartment and sciatic nerve regional anesthesia and additionally propofol sedation. Postoperative pain scores were documented using a numerical rating scale (NRS) and anthropometric data and perioperative parameters were correlated with the postoperative pain score. RESULTS: Evaluation of the pain values per interval showed that the maximum and the mean postoperative pain levels decreased up to day 4 after surgery and then increased. No significant effects of the analyzed parameters age, body mass index (BMI), duration of surgery and catheter indwelling time could be found. Female patients had significantly more pain than males in this collective. CONCLUSION: The results show that there were no factors which have a significant influence on the degree of postoperative pain. Female patients suffered from more pain than males. There was an increase in pain after postoperative day 4 which might be the effect of more extensive mobilization and reduced effects of regional anesthesia. It is important that pain is treated in the early postoperative period.

[Hindfoot deformities in adults. Conservative and surgical treatment]. / Adulte Rückfußdeformitäten. Konservative und operative Therapie.

The term hindfoot deformity denotes many different disease patterns that are associated with malformations of the axis. Destruction of the hindfoot caused by chronic polyarthritis or diabetic diseases are complex examples. This article aims to qualify the reader to diagnose the most important and most common hindfoot deformities in adults and to make decisions about stage-adjusted conservative and surgical therapeutic options.

[Achilles tendon rupture : Current diagnostic and therapeutic standards]. / Achillessehnenruptur : Aktuelle Standards in Diagnostik und Therapie.

A superior life expectancy and an increased activity in the population result in an increase in degenerative diseases, such as Achilles tendon ruptures. The medical history and physical examinations are the methods of choice to diagnose Achilles tendon ruptures. Ultrasound and radiography represent reasonable extended diagnostic procedures. In order to decide on the medical indications for the therapy concept, the advantages and disadvantages of conservative and surgical treatment options have to be weighed up on an indivdual basis. There are explicit contraindications for both treatment options. For the surgical treatment concept open suture techniques, minimally invasive methods and reconstructive procedures are available. The postoperative management of the patient is as important as the choice of surgical technique. With the correct medical indications and supervision of the patient it is possible to achieve extremely satisfying results for the patient with both conservative and surgical treatment options.

[Operative therapy for rheumatoid arthritis of the hand]. / Operative Therapie bei rheumatoider Arthritis der Hand.

The need for operative treatment of severe rheumatic deformities of the hand and wrist is decreasing due to the increased use of disease-modifying drugs; however, some patients do not tolerate or do not sufficiently respond to these drugs, which often results in the hands being affected and in advanced stages to severe deformity and loss of function. In these cases operative surgery can help to slow the progression of rheumatic destruction and restore the function of the patient's hand. This article describes the principles of surgery for rheumatoid arthritis of the hand. A meticulous synovectomy or tenosynovectomy is the first stage of treatment. With progression of rheumatic destruction various salvage procedures are necessary to preserve the best possible functional state.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Wrist arthroscopy : challenging procedure of modern hand surgery]. / Handgelenksarthroskopie : Herausforderndes Verfahren der modernen Handchirurgie.

Arthroscopy of the wrist has developed in the shadow of arthroscopy of the large joints. Nowadays, wrist arthroscopy has a relevant importance in the diagnostics and therapy in hand surgery and is indispensable for serious surgery of the wrist. Special equipment and extensive knowledge of the surgeon are necessary for carrying out the procedure.

[Endoprosthetic treatment of the ankle]. / Endoprothetische Versorgung des oberen Sprunggelenks.

BACKGROUND: Chronic polyarthritis is the second most common cause regarding the etiology of upper ankle osteoarthritis after posttraumatic degenerative changes. Patient mobility is limited by this painful disease. Besides conservative treatment options, replacement of the upper ankle joint is an operative therapeutic option in eligible candidates which provides very good results. OBJECTIVES: Besides epidemiological data, clinic presentation, diagnostic tools, treatment options and management of postoperative complications for patients with ankle osteoarthritis, this article presents the results of midterm outcome after total ankle replacement. MATERIAL AND METHODS: The retrospective results of 44 patients after total ankle arthroplasty are presented. RESULTS: After an average follow-up of 53 months (range 20-98 months) the majority of results were good or excellent with respect to pain relief. CONCLUSION: Total ankle replacement is a good option for treating osteoarthritis of the ankle joint in rheumatoid arthritis when attention is paid to the eligibility of the patients.

[Arthrodesis for patients with rheumatic arthritis of the ankle and hindfoot. A reasonable option?]. / Arthrodesen bei Patienten mit rheumatisch bedingten Sprunggelenks- und Rückfußarthrosen. Eine sinnvolle Option?

BACKGROUND: Ankle and hindfoot deformities as well as degenerative changes are often found in patients with rheumatological diseases. They often suffer from severe pain and complain of increasing immobility. Corrective procedures with ankle or hindfoot arthrodesis are promising options. OBJECTIVES: This article presents epidemiological data and describes the clinical aspects, diagnostics and treatment options for patients with ankle and hindfoot osteoarthritis. MATERIALS AND METHODS: The retrospective results of 56 patients after ankle or hindfoot arthrodesis are presented. RESULTS: After an average follow-up of 52 months the majority of results were good or excellent with relief of pain and reconstruction of the function of the foot. CONCLUSION: Ankle or hindfoot arthrodesis represents a promising option for patients with severe osteoarthritis and can safeguard patients from increasing immobility.

[Injection treatment for cervical and lumbar syndromes : Special infiltration techniques]. / Injektionstherapie bei Zervikal- und Lumbalsyndromen : Spezielle Infiltrationstechniken.

Minimally invasive injection treatment is indicated particularly in cases of treatment-resistant, painful degenerative alterations of the cervical and lumbar spine, intervertebral disc displacement and radicular syndrome. Through the injections and the supplementation with further conservative, e.g., physical therapy and activating measures, the vicious circle of neural irritation and muscle tension and sympathetic nerve reactions can be interrupted.

Patterns of Medical Residents' Preferences for Organizational Socialization Strategies to Facilitate Their Transitions: A Q-study.

Introduction: To facilitate various transitions of medical residents, healthcare team members and departments may employ various organizational socialization strategies, including formal and informal onboarding methods. However, residents' preferences for these organizational socialization strategies to ease their transition can vary. This study identifies patterns (viewpoints) in these preferences. Methods: Using Q-methodology, we asked a purposeful sample of early-career residents to rank a set of statements into a quasi-normal distributed grid. Statements were based on previous qualitative interviews and organizational socialization theory. Participants responded to the question, 'What are your preferences regarding strategies other health care professionals, departments, or hospitals should use to optimize your next transition?' Participants then explained their sorting choices in a post-sort questionnaire. We identified different viewpoints based on by-person (inverted) factor analysis and Varimax rotation. We interpreted the viewpoints using distinguishing and consensus statements, enriched by residents' comments. Results: Fifty-one residents ranked 42 statements, among whom 36 residents displayed four distinct viewpoints: Dependent residents (n = 10) favored a task-oriented approach, clear guidance, and formal colleague relationships; Social Capitalizing residents (n = 9) preferred structure in the onboarding period and informal workplace social interactions; Autonomous residents (n = 12) prioritized a loosely structured onboarding period, independence, responsibility, and informal social interactions; and Development-oriented residents (n = 5) desired a balanced onboarding period that allowed independence, exploration, and development. Discussion: This identification of four viewpoints highlights the inadequacy of one-size-fits-all approaches to resident transition. Healthcare professionals and departments should tailor their socialization strategies to residents' preferences for support, structure, and formal/informal social interaction.

[Treatment of pediatric flat feet by shoe insoles : a scientific-based therapy?]. / Die Behandlung des kindlichen Knick-Senk-Fußes durch Schuheinlagen : Eine wissenschaftlich fundierte Therapie?

The differentiation of physiological pediatric flat feet and the pathological course as well as adequate initiation of therapeutic options represents a challenge the importance of which should not be underestimated. Fears and worries of parents and their insistence on inducement of therapeutic measures take center stage in the physician-patient relationship. The problem is that there are insufficient data from scientific studies dealing with the conservative treatment of flat feet in children. This paper intends to give a survey of the current status in the literature concerning indications and therapeutic success using insoles in the treatment of flat feet in children.

[Bone marrow edema syndrome (BMES)]. / Das Knochenmarködemsyndrom (KMÖS).

Bone marrow edema (BME) syndrome represents a pathologic accumulation of interstitial fluid in bone - with a traumatic BME being differentiated from a non-traumatic, often ischemic, and a reactive as well as a mechanical BME. Atraumatic/ischemic BME is inconsistently described as a separate entity or as a reversible preliminary stage of osteonecrosis (ON). However, there is always the risk of transformation of BME into ON and subsequent joint destruction. The most common sites of BME are the hip, knee, and ankle. Magnetic resonance imaging is the diagnostic gold standard. Differential diagnoses of the transient BME as osteonecrosis, osteochondrosis dissecans, and a reflex dystrophy should be considered. Conservative or surgical treatment is considered, depending on the etiology of BME. BME syndrome is generally treated conservatively. Infusion of prostacycline or bisphosphonates is a promising option. Ischemic BME and early stages of ON can be successfully treated by core decompression. A combination of both treatment options may also offer advantages.

[Injection treatment for cervical and lumbar syndromes: principles, indications and general performance]. / Injektionstherapie bei Zervikal- und Lumbalsyndromen: Grundlagen, Indikationen und allgemeine Durchführung.

An intensive conservative treatment that exhausts all treatment options should fundamentally be carried out before every surgical intervention in the region of the spinal column. The therapeutic measures are determined by the extent of the cervical or lumbar syndrome. As a rule, in cases of local complaints symptomatic measures with physiotherapy or digital healthcare applications are indicated. In cases of referred cervical and lumbar syndromes targeted injections can be employed. Before targeted injection treatment a detailed orthopedic clarification with respect to the intensity of local, radicular or pseudoradicular complaints must be carried out. When carrying out minimally invasive injection treatment specific prerequisites with respect to spatial, personnel and technical conditions must be fulfilled. The indications and contraindications must be strictly controlled.

[Postoperative treatment strategies after rheumatic orthopedic operations of the shoulder. A suggestion]. / Nachbehandlungsstrategien nach rheumaorthopädischen Operationen an der Schulter. Ein Vorschlag.

Although surgical treatment of rheumatoid patients is quite common for disorders of the shoulder, less is known about the efficacy of the postoperative regimens. Clear therapeutic standards are still missing; however, without systematic and intensive postoperative physical therapy, a good postoperative outcome cannot be achieved. This article shows our postoperative treatment regimens and describes our preferred techniques in physical therapy.

[Orthopedic operations and postoperative treatment of rheumatic elbows]. / Orthopädische Operationen und Nachbehandlungsregimes am rheumatischen Ellenbogen.

This article gives an overview of the indications for operative treatment and the respective post-treatment of rheumatic elbows. The goal should be to preserve the function of the elbow joint and freedom from symptoms to prevent joint destruction which unfortunately can still be seen nowadays.