[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]. / Integrale interventie ter voorkoming van functieverlies bij ouderen tijdens ziekenhuisopname: het Zorgprogramma voor Preventie en Herstel.

BACKGROUND: Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age. METHODS/DESIGN: To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline. DISCUSSION: This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

Spondylolysis in osteopetrosis.

We report the occurrence of spondylolysis and/or spondylolisthesis of the lumbar vertebrae in five patients with osteopetrosis, four of them having multiple lesions. The case histories indicate that spondylolysis had developed in the pathological bone as a result of increased stress and that it is an acquired lesion.

The most severe forms of Perthes' disease associated with the homozygous Factor V Leiden mutation.

It has recently been postulated that thrombophilia may have a role in the aetiology of Perthes' disease. The published reports, however, remain conflicting. In this study a retrospective analysis of the coagulation parameters was made in 47 patients with Perthes' disease and the results compared with the clinical data. Five patients with Factor V Leiden mutation were found (10.6%) and surprisingly four of them had a homozygous pattern. These four patients showed the most severe form of the disease, Catterall group IV, with flattening of the entire epiphysis, involvement of the metaphysis, shortening and broadening of the femoral neck, trochanteric overgrowth and developed mushroom-shaped aspherical laterally displaced femoral heads in dysplastic acetabula. We would like to suggest that the homozygous form of Factor V Leiden mutation has some role in the clinical course of Perthes' disease and particularly its most severe form.

Contradictions of derotation in scoliosis surgery using the CD principle.

Current literature has increasingly emphasized the problem of derotation in scoliotic deformities. The Cotrel-Dubousset (CD) principle as a means of correcting rotation has been questioned by various authors. This paper aims to draw attention, using algebraic methods, to the importance of the remaining rotational deformities, and to suggest the introduction of the notion 'rotational balance'.

The 'rotational preconstraint'.

This model provides a novel view of the etiology of some scolioses and can answer some of the biomechanical questions regarding pathogenesis of dorsal curves. According to our findings, paravertebral muscular imbalance is likely to favour such a pathological condition which, with the interference of the postural reflexes and the body weight-related vertical loading, might lead to the formation of a true scoliotic curve. Review of earlier research studies in the light of our findings reveals controversy in some authors' reported results and their own interpretations and seems to generally support our theory.

Multilevel callus distraction: a novel idea to shorten the lengthening time.

Lower extremity inequality is a common problem in everyday orthopaedic practice. The leg discrepancy can lead to variety of other problems, i.e., spinal problems. Surgical intervention is very demanding and requires patient compliance. Wagner's and Ilizarov's elongation technique are most commonly used worldwide, but it gives satisfactory results only in a long period of time and as we know there could be several inconvenient outcomes. Our idea aims at shortening this time period, and avoiding some of the inconvenient outcomes. Unfortunately we do not have the opportunity to go further in our investigations, but we hope that someone interested in this field will have an idea which would make continuation possible.

Preliminary results of early open reduction by an anterior approach for congenital dislocation of the hip.

We report the results of 113 early open reductions of congenitally dislocated hips using a technique we have developed. Surgery is followed by functional postoperative treatment with a Pavlik harness or abduction splint. The age of the patients and the follow-up period ranged from 6 to 24 months and 2 to 12 years, respectively. Radiologic results corresponded to Severin grades I and II in 98%. Severe ischemic necrosis was not observed. Secondary surgery (femoral derotation osteotomy and/or Pemberton's operation) was performed in 21% of the cases. Reduction at a young age resulted in fewer secondary procedures. Good results were attributed to postoperative treatment: Abandoning rigid fixation prevented soft tissue stretching, which may endanger blood supply to the joint. This treatment ensures concentric reduction and allows early and spontaneous joint mobilization in a functional position. These factors stimulate further joint development.

Pemberton's pericapsular osteotomy for the treatment of acetabular dysplasia.

We present the results of 80 Pemberton procedures carried out between 1977 and 1990. The patient age at the time of operation ranged between 2 and 12 years, and follow-up was between 1 and 15 years. Before Pemberton's operation, conservative treatment, closed and open reduction, and derotation femoral osteotomy were used. Pemberton's operation was combined with intertrochanteric femoral osteotomy in 30 cases. The mean values of the acetabular and center edge angle of Wiberg showed postoperative improvement of 19 and 17 degrees, respectively; whereas at follow-up, improvement was 20 and 23 degrees, respectively. Radiologically, 79% of the cases met Severin's classification grade I-II criteria. Clinically, 81% were classified as excellent and good. The results were closely correlated with ischemic necrosis due to preoperative treatment. Only patients belonging to groups II-IV of Kalamchi and MacEwen, plus one patient operated on at relatively old age (12 years), were found radiologically to be in Severin's groups III and IV. The results among patients operated on before age 7 were more favorable than those of patients operated on at an older age.

Results of surgical treatment of knee instabilities.

Between January 1, 1981 and January 5, 1987, 146 reconstructive operations for acute (39) and chronic (107) knee instabilities were performed. THe majority of the acute cases were anteromedial (24), and of the chronic instabilities, 33 were anteromedial, 14 anterolateral, and 53 combined anteromedial-anterolateral. In terms of suture, replacement, and reinforcement of the damaged structures of the acute cases, 32 were good, 6 fair, and 1 poor, while the reconstruction, according to Müller, for chronic instabilities produced good results in 34, fair in 59, and poor in 14. It is essential that such operations be performed by a trained surgical team. For success, precise knowledge of anatomy, exact examination, accurate diagnosis, adequate surgical techniques, and careful postoperative treatment are essential.

Surgical treatment of pathologic fractures from metastatic tumors of long bones.

Surgical treatment of 74 cases of impending and established metastatic pathologic fractures were analyzed. On the basis of various reports, the incidence of bone lesions, bone-seeking primary tumors, lesion sites, diagnostic techniques and possibilities, as well as indications for and methods of surgical treatment, are surveyed. Surgical intervention is only one aspect of the different components of general treatment in bone metastases. An aggressive surgical procedure yields very satisfactory results in most cases, compared with those of conservative treatment.

The effect of early anterior approach open reduction with functional postoperative treatment on the early development of the acetabulum in CDH.

Between 1980 and 1983, 30 anterior approach open reductions were performed on congenitally dislocated hips of 29 patients after unsuccessful conservative treatment; patients were between 6 and 18 months old. After the removal of the obstruction from the acetabulum, the reduction was performed with preservation of the limbus. Some part of the capsule was removed to constrict and tighten it and to prevent redislocation. This capsuloplasty demonstrates the success of a Pavlik harness and abduction splint postoperatively, without plaster fixation. The accelerated development of the acetabulum could be observed on radiograph by this functional treatment, compared to the control group treated with the usual hip spica postoperatively. The development of the acetabulum on the operated side almost equals the sound side within a year. If the operation was performed earlier, joint development would be quicker.

[Reoperations in the management of clubfoot]. / Reoperációk a dongaláb kezelésében.

The results of 118 operations for club-foot are assessed, of these 57 were reoperations. It is stated that the relapse is most often the consequence of the insufficient primary operation and the relapse and the residual deformity are the more serious the more insufficient was the primary operation. The severity of the deformation is defined first of all by the position of the calcaneus. In milder cases the soft tissue operation only may be successful, in the more severe cases bony operation (Evans' operation in this series of the authors) has also to be performed. After their own primary operations reoperation was in 24 per cent necessary. The number of the bony operations was half of the soft tissue operations. The second and rarer case of the relapses was that the foot proved to be even originally rigid, not redressable, "rebel". First of all in these cases may multiple reoperations be necessary and the transposition of the anterior tibial muscle is also useful. The club-foot with a major dominant adduction deformity of the tarsometatarsal joint is thought to be a separate entity and it is corrected with tarsometatarsal capsulotomies or serial metatarsal osteotomies.

Reoperation in treatment of clubfoot.

We evaluated 118 operations (including 57 reoperations) on clubfeet. We concluded that relapse is most often the consequence of insufficient primary surgery, and the less sufficient the intervention, the more severe the relapse or residual deformity. The severity of deformity is determined and shown, first of all, by the position of calcaneum. In milder cases, soft tissue operation can prove useful, whereas more severe cases require bony intervention as well. The second, rarer cause of relapse was the fact that the foot was originally stiff and nonreducible. These feet may need multiple reoperations.

[Experience with the implantation of porous coated hip endoprostheses and primary stability of implantation]. / Tapaztalataink porosus bevonatú csípöprothesis beültetési technikájával és a beültetés primer stabilitásával.

The use of porous coated cementless prosthesis, shows a worldwide spread in consequence of the advantages given by the "live" connection between the implant and the bone. Based on 40 implantations of prostheses of this type (Duraloc 1200 acetabulum, AML shaft) authors report on the technique of the implantation and the primary stability reached. In consequence of the formation, the variety of size and the properly usable instruments for implantation, the prostheses could be used for every kind of deformed, dysplastic hips and good primary stability was reached in every case operated.

[Surgical reposition in the management of epiphysiolysis of the femoral head]. / A mütéti repositio az epiphyseolysis capitis femoris kezelésében.

In major slipped femoral capital epiphysis the hip function can be restored with a possibly adequate correction of the deformity. Previously authors have performed various inter- and subtrochanteric femoral osteotomies with this aim, in 4 recent cases however the slipped femoral head was reduced operatively according to Dunn and Angel. 2-4 years after the operation good results were found. The blood supply of the epiphysis was not damaged in either case, and the hip motion was restricted in one case only, in which previously 2 other operations were already performed. The operative reduction with the technique described is suggested where the conditions of this considerable operation are given.

[Suture of the meniscus in acute instability of the knee joint]. / Shov meniska v usloviiakh ostroi neustoichivosti kolennogo sustava.

The authors describe a multiform function of the menisci and the causes of frequently occurring simultaneous injuries of the meniscus and of the ligament. In 26 cases of acute instability of the knee the authors put sutures over the meniscus. In all the cases the results were good, there were no complications and there was no need to make a repeated operation in any of the cases. Making use of the suture over the meniscus, it is possible to improve the results of the surgical treatment of instability of the knee to a greater extent.

[Results in Miacalcic therapy in the analgesic treatment of patients with bone metastases]. / Miacalcic kezeléssel elért eredményeink a csontmetastasisos betegek fájdalomcsillapításában.

Authors have administered between 1984--87 in 30 patients with bone metastasis weekly 3 X 100 iu Miacalcic injections to relieve pain. The literature dealing with the pain relieving effect of calcitonin is summarized and their own results are assessed from more viewpoints. The use of Miacalcic injection is suggested as it was found a modern and very effective palliative medicine for pain relieving.