[Treatment of isolated fractures of the olecranon: percutaneous double-screw fixation versus conventional tension band wiring]. / Behandlung von isolierten Olekranonfrakturen: Perkutane Doppelschraubenosteosynthese vs. konventionelle Zuggurtung.

BACKGROUND: Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages. PATIENTS AND METHODS: A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring. RESULTS: No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motion was significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001). CONCLUSIONS: The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.

Therapeutic immunomodulation using a virus--the potential of inactivated orf virus.

Viruses can manipulate the immune response against them by various strategies to influence immune cells, i.e. by over-activation leading to functional inactivation, bypassing antigen presentation or even suppression of effector functions. Little is known, however, about how these features of immune regulation and modulation could be used for therapeutic purposes. Reasons for this include the complexity of immune regulatory mechanisms under certain disease conditions and the risks that infections with viruses pose to human beings. The orf virus (ORFV), a member of the Parapoxvirus genus of the poxvirus family, is known as a common pathogen in sheep and goats worldwide. The inactivated ORFV, however, has been used as a preventative as well as therapeutic immunomodulator in veterinary medicine in different species. Here, we review the key results obtained in pre-clinical studies or clinical studies in veterinary medicine to characterise the therapeutic potential of inactivated ORFV. Inactivated ORFV has strong effects on cytokine secretion in mice and human immune cells, leading to an auto-regulated loop of initial up-regulation of inflammatory and Th1-related cytokines, followed by Th2-related cytokines that attenuate immunopathology. The therapeutic potential of inactivated ORFV has been recognised in several difficult-to-treat disease areas, such as chronic viral diseases, liver fibrosis or various forms of cancer. Further research will be required in order to evaluate the full beneficial potential of inactivated ORFV for therapeutic immunomodulation.

[Preparedness of hospital physicians for a mass casualty incident. A German survey amongst 7,700 physicians]. / Wie gut sind Ärzte auf einen Massenanfall von Verletzten vorbereitet?. Ergebnisse einer bundesweiten Umfrage bei 7700 Klinikärzten.

INTRODUCTION: The bomb attacks in Madrid (2004) and London (2005) have increased awareness that terrorist attacks are also a real threat in Germany. Hospitals and health care providers should be prepared. METHODS: We distributed an anonymous online questionnaire to physicians working in trauma centers of different categories. The results were analyzed using descriptive statistical methods. RESULTS: The questionnaire was returned by 1,204 of 7,700 physicians. This reflects a response rate of 15.6%. Of the participants, 53.3% answered that their hospital had a disaster control plan and that they knew the content; 33.9% reported that their hospital had participated in a disaster training scenario. CONCLUSION: As only 53.3% of physicians in hospitals know their disaster control plan and only 33.9% of hospitals have participated in a disaster training scenario we conclude that more action is needed to increase awareness of the problem. Furthermore standardized training programs are needed to disseminate knowledge and skills in order to enable health care providers to face the occurrence of terroristic attacks in Germany.

[The one- and two-stage distally pedicled sural flap : surgical technique and clinical results]. / Der ein- und zweizeitige distal gestielte Suralislappen : Operationstechnik und klinische Ergebnisse.

BACKGROUND: The distally pedicled suralis flap is used to cover local defects of the distal lower leg, ankle and hind foot. It is a local flap with no need for microvascular anastomosis, a constant blood supply and ease of elevation. Disadvantages are lack of sensation, donor site morbidity and venous congestion. METHODS AND MATERIAL: This study includes 25 patients. Apart from the defect extent, cause and location, complications were also determined. RESULTS: The defect site was located in the hind foot in 5 cases and the distal lower leg in 14 cases. In four patients the soft tissue of the lateral calcaneal region and in two cases the sole of the foot were affected. Severe venous congestion, which was only detected in 180° turned flaps, was seen in five cases. In five patients we successfully performed a two-stage flap transposition procedure to avoid venous congestion. CONCLUSION: The sural flap remains a reliable solution for soft tissue defects. Under inappropriate circumstances (small pedicle or severe torque of pedicle) venous congestion or even thrombosis is possible. A two-stage approach with conditioning of venous drainage can have a positive effect on these problems.

[Extended lateral gastrocnemius transposition flap for reconstruction of open knee extensor disruption]. / Rekonstruktion eines offenen Quadrizepssehnendefekts mit dem erweiterten lateralen Gastrocnemiussehnenlappen.

We describe a modified technique to reconstruct a damaged knee extensor mechanism after infected patellar fracture. After resection of infected soft tissue and quadriceps tendon a compound suprapatellar defect existed. Due to compromised tissue on the medial aspect of the calf, we used this flap, which consists of the lateral gastrocnemius muscle with parts of the adjacent Achilles tendon. After a follow-up period of several months the range of movement is 0-0-120°.

[Evaluation of a 2D fluoroscopy-based navigation system for insertion of femoral neck screws. An experimental study]. / Evaluation eines 2-D-fluoroskopiebasierten Navigationssystems zur Implantation von Schenkelhalsschrauben. Eine experimentelle Studie.

INTRODUCTION: The aim of this study was the evaluation of a new computer-assisted planning and navigation system based on 2D-fluoroscopy for guidewire insertion in order to perform cannulated screw placement into the femoral neck. The image acquisition process was supported by a radiation-saving procedure called Zero-dose C-arm navigation. MATERIAL AND METHODS: In the context of a sawbone study, we performed insertion of 3 cannulated screws positioned under navigation control as well as using the conventional technique in 12 sawbones. Both procedures were performed using open and closed techniques. RESULTS: The computer-assisted technique significantly reduced the amount of intraoperative fluoroscopic images (open technique: -14±3 images, closed technique: -29.4±6 images). Drilling attempts were reduced in the computer-assisted groups (open technique: -1.2±1 attempts, closed technique: -1.7±1.5 attempts) and the femoral neck area covered by the screws was greater in the navigation-assisted groups (open technique: +32.1±16.3 mm(2), closed technique: +32.6±14.9 mm(2)), There was no difference concerning parallelism of the screws or perforation of femoral neck or head. The operation time was significantly longer in the navigation-assisted groups (open technique: +24.2±2.1 min, closed technique: +22.8±5.8 min). CONCLUSION: The addition of computer-assisted planning and surgical guidance supported by Zero-dose C-arm navigation can be useful for the fixation of medial femoral neck fractures with cannulated screws. Further studies with the goal of reducing the operation time are indispensable before integrating this navigation system into the clinical workflow.

Evaluation of a new computer-assisted surgical planning and navigation system based on two-dimensional fluoroscopy for insertion of a proximal femoral nail: an experimental study.

Pertrochanteric femoral fractures are common and intramedullary nailing is an accepted method for their surgical treatment. Accurate placement of the implant is essential to ensure fixation. The conventional technique can require multiple guide wire passes, and relies heavily on fluoroscopy. A computer-assisted planning and navigation system based on two-dimensional fluoroscopy for guide wire placement in the femoral neck has been developed, in order to perform intramedullary pertrochanteric fracture fixation using the proximal femoral nail (PFNA). The planning process was supported by a 'zero-dose C-arm navigation' system. The PFNA was inserted into 12, intact, femoral sawbones guided by the computer-based navigation, and into 12, intact, femoral sawbones using a conventional fluoroscopic-assisted technique. Guide wire and subsequent blade placement in the femoral neck was evaluated. The computer-assisted technique achieved a significant decrease in the number of required fluoroscopic images and in the number of guide wire passes. The obtained average blade placement accuracy in the femoral neck was equivalent to the conventional technique. The operation time was significantly longer in the navigation-assisted group. The addition of computer-assisted planning and surgical guidance to the intramedullary nailing of pertrochanteric femoral fractures offers a number of clinical benefits based on the results of this sawbone study. Further studies including fractured sawbones and cadaver models with extension of the navigation process to all steps of PFNA introduction and with the goal of reducing operation time are indispensable before integration of this navigation system into clinical practice.

[Diagnosis and treatment of radiocarpal fracture dislocations]. / Diagnostik und Therapie von radiokarpalen Luxationsfrakturen.

In contrast to the common intra- or extra-articular fractures of the distal radius, radiocarpal fracture dislocations are rare injuries. Concerning this issue, only a small number of publications can be found. Nevertheless, it is important to be informed about this injury since prompt operative treatment is often required and immobilization alone will not be sufficient. Sometimes, radiocarpal fracture dislocations are combined with carpal injuries. In such cases, both the radiocarpal dislocation and carpal injury have to be treated. Diagnostic difficulties can lead to misinterpretation or underdiagnosis. Insufficient reduction and fixation may result in joint incongruity and subsequent osteoarthritis. Reconstruction of the radiocarpal ligaments is a substantial part of operative treatment.

Systemic thrombolysis with rt-PA in patients under 40 years of age: a subgroup analysis of the Cologne Stroke Experience.

BACKGROUND: While the application of intravenous systemic thrombolysis (IVT) with rt-PA (recombinant tissue plasminogen activator) in older patients is currently moving into the focus of epidemiological studies, only few data are available regarding the application in young patients ≤40 years. Single-center data of a thrombolysis register were analyzed with respect to safety and efficacy of the treatment of young patients. METHODS: In a retrospective subgroup analysis of 450 patients treated by IVT within a 3-hour time window, patients ≤40 years were identified (n = 20). Clinical data [age, pretherapeutic stroke severity (National Institute of Health Stroke Scale, NIHSS), OTT (onset to-treatment time), rt-PA-dose, DNT (door[-]to[-]needle time), rate of symptomatic intracranial hemorrhages] and medical history were determined. The clinical outcome was assessed by the mRS (modified Rankin Scale). The results were compared to those of patients >40 years (n = 430). RESULTS: Twenty patients ≤40 years (mean age 32 years) out of 450 patients (4%) were treated by IVT. The percentage of predisposing diseases and vascular risk factors was significantly lower when compared to patients >40 years (p < 0.05). In contrast, the percentage of smokers was significantly higher (55 vs. 24%; p < 0.05). In comparison to patients >40 years, OTT, DNT and NIHSS at admission were not significantly different. After 3 months, 11 of 20 young patients (55%) showed a favorable outcome (mRS 0-1) and 80% were functionally independent (mRS 0-2). In the group of patients >40 years (n = 430), the respective percentages were significantly lower [p < 0.05; 34% (mRS 0-1) and 52% (mRS 0-2), respectively]. Symptomatic intracranial hemorrhages were not observed (in patients >40 years: 4%, p < 0.05). CONCLUSIONS: In comparison to the cohort of patients >40 years, IVT in young patients is safe and leads to a significantly better outcome after 3 months. Our data therefore encourage the use of IVT in young patients.

[Total elbow joint arthroplasty. Surgical approaches]. / Ellenbogengelenk-totalendoprothese. Zugänge.

The dorsal approach to the elbow joint is commonly used for arthroplasty of the joint and consists of different steps. The superficial approach including the incision of the skin and the preparation of subcutaneous tissue precedes the deep approach. The latter contains preparation and transposition of the ulnar nerve, relief of extensors and ligaments radiating into the articular capsule. Concerning the preparation of the extensors three important techniques are differentiated, triceps splitting, triceps reflecting and triceps preserving.

[Endoprosthetics of the radial column after trauma]. / Endoprothetischer ersatz des radialen pfeilers nach trauma.

Non-displaced fractures of the radius head are in most cases treated conservatively. Open reduction and anatomical internal fixation of displaced radius head fractures is the method of choice. In comminuted fractures of the radius head (Mason type III and type IV) replacement with a radius head prosthesis achieves joint stability and prevents secondary complications, such as valgus elbow deformity and proximal radial migration. Modern anatomically formed prostheses show promising results in the medium-term view. Typical complications after radius head replacement are limited range of motion in the elbow joint, arthritis of the capitulum and heterotopic ossifications. In cases of capitulum arthritis, capitulum prostheses were developed to resurface the lateral compartment of the elbow joint. Short-term results are encouraging with improvements in pain and range of movement.

[Salvage procedures of the elbow. Alternatives to elbow arthroplasty]. / Salvage procedures am ellenbogen. Alternativen zur ellenbogenendoprothetik.

Destructive changes of the elbow joint represent a challenge for both patient and surgeon. Resection arthroplasty is associated with postoperative instability and loss of power and is a rarely performed procedure. Interpositional arthroplasty remains a useful option for healthy active patients with severe post-traumatic elbow arthrosis and is one of the oldest methods used to reconstruct the elbow. The principle of interpositional arthroplasty is based on a sparing resection of the destroyed joint surface and on creating a congruent elbow joint with human tissue. Nowadays, autogenous dermis, fascia lata or Achilles allograft are used. A preoperatively stable elbow is required to prevent instability following interpositional arthroplasty. The use of total elbow arthroplasty is limited due to the contraindications and in such cases the only remaining options are salvage procedures of the elbow. In general, arthrodesis should be performed in patients with painful osteoarthritis of the elbow with high demands on the upper extremities. Historically, tuberculosis was the most common indication for elbow arthrodesis and various methods of elbow arthrodesis have been described. However, most attention has been given to the position in which the elbow joint should be fixed and should be decided depending on the individual characteristics of the patient. Sufficient bone stock is crucial for a successful elbow arthrodesis and in cases with massive bone loss reconstruction of the elbow using an allograft can be performed to restore bone quality. However, the high complication rate of this procedure limits the scope of its use. Nevertheless, allograft procedures can restore pain-free joint function for several years.

[Endoprosthesis for the fractured elbow: uni- and bicompartmental alloarthroplasty of the humero-ulnar joint]. / Frakturendoprothetik am ellenbogen: uni- und bikompartimentelle alloarthroplastik am humeroulnaren gelenk.

Posttraumatic arthrosis or rheumatoid arthritis located at the elbow, in particular at the humero-ulnar joint will probably not occur in increasing numbers in the future due to new antirheumatic medications and modern implants. However, the demographic development with an increase of the geriatric population and the typical physical changes is evident. Due to osteoporosis with a resulting poor bone quality severe fracture patterns may occur at the site of the distal humerus after a simple collapse. The usual surgical aim consisting of an exact anatomic reduction may be impossible to achieve by applying the standard operative treatment. Several studies have proven that a prosthetic replacement of such a severely damaged elbow is a viable solution for elderly people. A mobile, pain-free and stable elbow joint promotes a fast recovery of the patient with a quick return to former activities. Nevertheless, elbow prostheses cannot withstand great strains and the surgeon has to identify those fractures which require a prosthetic replacement. The surgical implantation procedure requires an adequate knowledge of both elbow anatomy and prosthetic options.

[Sociolinguistics and liaison psychiatry: a particular aspect]. / La sociolinguistique en psychiatrie de liaison: un certain regard.

Verbal language is a major tool of medical communication. However, its use can be problematic, namely because the speakers of a given language do not necessarily agree on the meaning of the words they exchange. This phenomenon is usually called linguistic variability. Based on a famous political and legal case and medical examples, we will show how variability is a critical source of misunderstandings and other communicational breakdowns. In addition, we will suggest some strategies which are likely to limit the impact of variability on clinician/patient interaction.

[The community interpreter: a central role in the puzzle of the intercultural consultation]. / L'interprète communautaire: une pièce centrale dans le puzzle de la consultation interculturelle.

As a consequence of growing global migration, physicians in French speaking Switzerland often face communicational difficulties with allophone patients. This paper first discusses advantages and shortcomings of various ways of dealing with this kind of situations. The indication of using professional interpreters will be addressed, as well as some specific therapeutic, linguistic and relational features of triadic consultations involving a physician, a patient and an interpreter. Finally, useful practical information and advices are provided to clinicians in order to help them optimize their consultations with allophone patients.

[Acetabular defect reconstruction in revision surgery of the hip. Autologous, homologous or metal?]. / Azetabuläre Defektrekonstruktion in der Revisionschirurgie der Hüfte. Autolog, homolog, Metall?

The treatment of periprosthetic bone defects of the acetabulum is a therapeutic challenge in hip revision surgery. The aims are the biological reconstruction of osseous acetabular defects and the restoration of a load-bearing acetabular bone stock as well as restoring the physiological joint biomechanics and achieving primary and load-stable fixation of the revision graft in the vital pelvic bone. The biological reconstruction of the acetabular bone stock should include what is referred to as "down-grading" of the acetabular defect situation in case a repeat revision procedure becomes necessary.Nowadays, a large variety of grafts and reconstruction procedures are available for the reconstruction of acetabular defects. The choice of suitable materials (osseous or metallic) for the restoration of a load-bearing acetabular bone stock is currently the subject of controversial discussion.This article reviews the various options for the reconstruction of acetabular bone defects taking into consideration the current findings in the scientific literature.

[Primary endoprosthetic replacement of fractured elbow in elderly patients]. / Primäre Alloarthroplastik des frakturierten Ellenbogens beim hochbetagten Patienten.

AIM OF STUDY: Inadequate treatment of distal intra-articular fractures of the humerus results in painful restriction of movement or malarticulation. Especially in geriatric patients with osteoporosis, stable osteosynthesis can be difficult. Primary total endoprosthetic replacement of the cubital joint could offer an alternative. MATERIAL AND METHODS: In 12 patients with a distal intra-articular fracture of the humerus a cemented semi-constrained Coonrad-Morrey prosthesis was implanted. Patient were followed-up after an average of 13 months and assessed according to the Mayo score. RESULTS: In 6 patients additional computerized tomography was carried out. Minimally invasive Kirschner wire osteosynthesis resulted in immediate postoperative loss of correction due to osteoporosis. As with the external distraction-compression apparatus the ulnar pinholes can form a predetermined breaking point and fixation in a long-arm cast is recommended. The mean Mayo score was 90.5 points and mean range of motion in extension/flexion was 84.5 degrees. CONCLUSION: In elderly patients primary endoprosthetic treatment of a distal intra-articular fracture of the humerus with a semi-constrained cemented prosthesis may offer an alternative to osteosynthesis thus enabling creation of a mobile, painless and stable cubital joint.

[Pseudo tumours in haemophilia patients]. / Pseudotumoren bei hämophilien Patienten.

UNLABELLED: Pseudo tumours are amongst the rare yet pathognomonic complications of haemophilia. They are old, encapsulated haematomas which due to their sometimes enormous size can cause massive complaints. These haematomas are surrounded by a thick fibrous capsule. They are attributed to persistent bleedings. The pathophysiology of pseudo tumors is not conclusively established yet. Some believe that they originate from bone material or the periosteum, while others suggest their development from soft tissue. They spread aggressively, displace the surrounding tissue, and cause secondary periosteal erosion of the bone. This results in bone resorption and destruction of surrounding muscular and soft tissue. Pseudo tumours develop slowly over many years. They occur primarily in adults and are largely unresponsive to conservative treatment. CASE: A 48-year-old man with moderate hemophiliaA (FVIII:C 2%) and no FVIII inhibitor. Due to recurrent bleeding into the muscle of the right thigh diagnosis of two pseudo tumours (psoas, adductor magnus). In 2004 tumour extirpation with subsequent relapse; because of high local bleeding tendency (despite permanent prophylaxis with FVIII concentrate and adjusted lifestyle) surgical revision in 02/2008. Postoperatively, no recurrent bleeding; the patient is fully fit for work three months later. CONCLUSION: In order to reduce the complication rate when a pseudo tumor is suspected, patients should be treated in a specially equipped interdisciplinary center with adequately trained and experienced surgeons and haemostaseologists.

[Action research and clinical governance: the example of the project "psychiatry and migrants" at the Vaudois University Medical Center]. / Recherche-action et gouvernance clinique: l'exemple du projet "psychiatrie et migrants" du CHUV.

Action research is a useful instrument for the organization health care and the clinical governance of psychiatric institutions. What this type of research offers can be illustrated by the cohort study of migrant patients without health insurance who consulted the Department of Psychiatry of the Vaudois university medical center (CHUV) in 2008. While giving greater visibilty to the psychological suffering and social distress of these patients, the study also enabled the authors to determine which clinical procedures were actually offered to these patients and the amount these procedures cost the department. The small number of cases that were identified as well as their uneven distribution amongst the different services of the department suggest that considerable efforts must still be made to improve access for this population to public psychiatric services.

Human-sized magnetic particle imaging for brain applications.

Determining the brain perfusion is an important task for diagnosis of vascular diseases such as occlusions and intracerebral haemorrhage. Even after successful diagnosis, there is a high risk of restenosis or rebleeding such that patients need intense attention in the days after treatment. Within this work, we present a diagnostic tomographic imager that allows access to brain perfusion quantitatively in short intervals. The device is based on the magnetic particle imaging technology and is designed for human scale. It is highly sensitive and allows the detection of an iron concentration of 263 pmolFe ml-1, which is one of the lowest iron concentrations imaged by MPI so far. The imager is self-shielded and can be used in unshielded environments such as intensive care units. In combination with the low technical requirements this opens up a variety of medical applications and would allow monitoring of stroke on intensive care units.