Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial.

Pertrochanteric fractures are a rising major health-care problem in the elderly and their operative stabilisation techniques are still under discussion. Furthermore, complications like cut-out are reported to be high and implant failure often is associated with poor bone quality. The PFNA(®) with perforated blade offers a possibility for standardised cement augmentation using a polymethylmethacrylate (PMMA) cement which is injected through the perforated blade to enlarge the load-bearing surface and to diminish the stresses on the trabecular bone. The current prospective multicentre study was undertaken to evaluate the technical performance and the early clinical results of this new device. In nine European clinics, 59 patients (45 female, mean age 84.5 years) suffering from an osteoporotic pertrochanteric fracture (Arbeitsgemeinschaft für Osteosynthesefragen, AO-31) were treated with the augmented PFNA(®). Primary objectives were assessment of operative and postoperative complications, whereas activities of daily living, pain, mobility and radiologic parameters, such as cement distribution around the blade and the cortical thickness index, were secondary objectives. The mean follow-up time was 4 months where we observed callus healing in all cases. The surgical complication rate was 3.4% with no complication related to the cement augmentation. More than one-half of the patients reached their prefracture mobility level within the study period. A mean volume of 4.2ml of cement was injected. We did not find any cut-out, cut through, unexpected blade migration, implant loosening or implant breakage within the study period. Our findings lead us to conclude that the standardised cement augmentation using the perforated blade for pertrochanteric fracture fixation enhances the implant anchorage within the head-neck fragment and leads to good functional results.

[The interdisciplinary approach in reconstructive surgery of the extremities]. / Operative Interdisziplinarität-Extremitäten. Aus der Sicht des plastischen Chirurgen.

In cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits will inevitably produce new imperatives for interdisciplinary cooperation in the future.

[Can costs be lowered by post-hospital patient management with telecare]. / Kann man durch poststationäre Patienten-Betreuung mittels Televisite Kosten senken?

The idea of Televisite is to equip the patients with a camera and a communication panel at the time of their discharge from the hospital. In that way patients and physicians are able to continue the treatment and the rehabilitation program. An easy to handle interface helps the patient to answer simple questions or to send voice recordings, pictures or videos via a service centre to the doctor in attendance. This concept has the great advantage that the patients has to visit the physician in the office or in the hospital only when absolute required. Routine checks can be done by telecommunication. Thus the efficiency of the system may significantly contribute to lower costs in the health care system.

[Femoral neck fracture. Osteosynthesis or which endoprosthesis is indicated?]. / Schenkelhalsbruch. Osteosynthese oder welche Endoprothese ist indiziert?

Femoral neck fractures are frequent fractures of the elderly. They can be treated by the use of dynamic hip screws, lag screws, bipolar hemi-protheses or total hip replacement. The results are markedly influenced by the timing of the operation and the choice of the implant. Using the Garden classification of femoral neck fracture we demonstrate a different therapeutic approach according to Garden stadium I-IV.

Major injury induces increased production of interleukin-10 in human granulocyte fractions.

Patients with severe trauma or polytrauma frequently acquire alterations in immune functions which are correlated to dysbalanced cytokine synthesis. In these settings the role of polymorphonuclear neutrophil granulocytes (PMN) as cytokine-producing cells is less well characterized. The immunosuppressive role of interleukin (IL)-10 is well known, and increased systemic IL-10 levels are related to the severity of injury and to posttraumatic complications. We determined concentrations of IL-10 in culture supernatants of 30 individual PMN fractions isolated from 18 severely traumatized patients (15 polytraumata, Injury Severity Score: 18-41, 3 severely burned patients) admitted to intensive care units. IL-10 was analyzed by ELISA (R&D Systems, Wiesbaden, Germany). PMN were isolated from EDTA-anticoagulated peripheral blood employing a one-step procedure based on a discontinuous double Ficoll gradient. The cells [1 x 10(6)/ml RPMI 1640 supplemented with 10% fetal calf serum and 25 mM N-(2-hydroxyethyl)-piperazine-N'-(2-ethanesulfonic acid] were stimulated with 0.05% heat-killed Staphylococcus aureus (Pansorbin, Calbiochem-Novabiochem, Bad Soden, Germany) for 24 h using cell culture conditions. Our results show that PMN fractions of traumatized patients produce significantly (P<0.008) higher amounts of IL-10 (354+/-95 pg/ml, n = 30) than normal healthy donor cells (125+/-95 pg/ml, n = 7). IL-10 release from PMN fractions exceeded the release from isolated patients' peripheral blood mononuclear cells induced by similar stimulation or by stimulation with toxic shock syndrome toxin-1 (10 ng) and concanavalin A (2 microg). Our results provide evidence that PMN fractions play an active role in the development of posttraumatic immunosuppression by autocrine or paracrine mechanisms, for example, by suppressing one's own antimicrobial activities or determining the development of T-cell responses via their ability to release IL-10.

[Sports fitness after functional conservative versus surgical treatment of acute Achilles tendon ruptures]. / Sportfähigkeit nach konservativ-funktioneller versus operativer Behandlung von akuten Achillessehnenrupturen.

Acute Achilles tendon ruptures are mostly related to recreational activities. Therefore, these patients intend to return to sports as soon as possible with no functional deficiency. This is the first study, comparing functional results after functional treatment to those after surgery. According to sonographic examinations of the tendon gap, primary functional treatment with heel supported shoes or surgery were suggested. Between 2/1991 and 12/1992, 22 patients with acute Achilles tendon rupture were treated without operation (group 1) and in 10 patient the rupture was sutured (group 2). 6 months later, 27 patients underwent standardized clinical examination: one leg standing for one minute, measurement of the circumference of the calf. The actual activities were assigned to Tegner Activity Score. 19 patients had isokinetic cybex testing with 60 degrees/s. There were 3 re-ruptures in group 1 and no comparable complications in group 2. At this time, clinical examination and Tegner Activity Score showed no relevant differences. Force of flexion was 30.4% lowered in group 1 and 2.4% in group 2. Additional training of the calf muscles improved the results after 6 weeks in group 1. We concluded that individual management of acute Achilles tendon rupture is possible according to sonographic tendon gap. Functional treatment is effective, but the rate of re-ruptures has to be reduced by careful selection of patients (rupture gap < or = 2 mm, high cooperation).