[Emmert's plastic surgery]. / Emmert-Plastik.

OBJECTIVE: The aim of the surgical intervention is the elimination of infections, ulceration and pain caused by ingrown nails (unguis incarnatus). INDICATIONS: A surgical intervention is recommended for ingrown nails (the large toenail is most frequently affected) in stage III and higher (according to the Mozena classification) as well as in cases of nail plate defects and recurrences. CONTRAINDICATIONS: In cases where a disturbance of wound healing is expected and general contraindications for surgery. SURGICAL TECHNIQUE: The surgical approach incorporates a half-moon-shaped skin incision and a straight longitudinal nail incision. Both incisions extend to the bone. A wedge-shaped piece of tissue is removed and after thorough curettage and rinsing the wound is closed using transungual single-button sutures. POSTOPERATIVE MANAGEMENT: Regular changes of wound dressing, relief of the affected ray by immobilization during wound healing. An antibiotic therapy is only indicated in selected cases. RESULTS: Between 1 January 2013 and 1 January 2023 a total of 50 Emmert's plastic surgery operations (15 women and 35 men) were performed at the Klinikum Vest, Knappschaftskrankenhaus Recklinghausen. The average age of the patients was 50.6 years. The mean follow-up time was 63 months. The outcome and satisfaction of the patients were evaluated according to the self-reported foot and ankle score (SEFAS). The total point count (median value) of the evaluated SEFAS score was 44.

[Distal hand block]. / Distaler Handblock.

OBJECTIVE: Peripheral nerve blocks in hand surgery. INDICATIONS: Short operations on the hand. CONTRAINDICATIONS: Long operations, polyneuropathy, local anesthesia allergy. TECHNIQUE: Identification of landmarks, skin disinfection, local anesthesia injection, surgery. POSTOPERATIVE MANAGEMENT: Postoperative monitoring. RESULTS: We performed 75 hand surgeries using distal nerve blocks over 3 years (between 2015 and 2018) in our department. In all, 60% (n = 45) of cases belong to the innervation region of the median nerve, 28% of cases (n = 21) belong to the innervation area of the radial nerve and about 5% (n = 4) to the innervation area of the ulnar nerve. In 7% (n = 5) of cases, anesthesia of two neighboring innervation areas was necessary. The distal nerve block provides a reliable form of anesthesia in hand surgery with low complication rates.

[Intravenous regional anesthesia]. / Intravenöse Regionalanästhesie.

OBJECTIVE: Intravenous regional anesthesia. INDICATIONS: Short duration hand operations. CONTRAINDICATIONS: Open wounds, lengthy operations, local infections, polyneuropathy, Raynaud syndrome, allergy to local anesthetics. TECHNIQUE: Insertion of an intravenous cannula, attachment of a double lumen cuff, Esmarch's tourniquet, injection of the local anesthetic, stepwise pumping up the tourniquet, surgery, stepwise removal of the tourniquet. POSTOPERATIVE MANAGEMENT: Postoperative monitoring of the patient after the end of anesthesia. RESULTS: Over a time period of 2 years (January 2017-December 2018) 90 operations of the hand were carried out with the patient under intravenous regional anesthesia (IVRA). The average age of the patients was 61 years. After surgery the patients were questioned according to the criteria of the quality of recovery­9 score according to Myles in the German version of Eberhard et al. (2002). The tourniquet could be removed on average 29 min after surgery. No intraoperative or postoperative complications occurred. Therefore, the IVRA represents a reliable and simple form of anesthesia especially for surgery of the hand.

Effects of 8-Prenylnaringenin and Whole-Body Vibration Therapy on a Rat Model of Osteopenia.

Background. 8-Prenylnaringenin (8-PN) is the phytoestrogen with the highest affinity for estrogen receptor-α (ER-α), which is required to maintain BMD. The osteoprotective properties of 8-PN have been demonstrated previously in tibiae. We used a rat osteopenia model to perform the first investigation of 8-PN with whole-body vertical vibration (WBVV). Study Design. Ovariectomy was performed on 52 of 64 Sprague-Dawley rats. Five weeks after ovariectomy, one group received daily injections (sc) of 8-PN (1.77 mg/kg) for 10 weeks; a second group was treated with both 8-PN and WBVV (twice a day, 15 min, 35 Hz, amplitude 0.47 mm). Other groups received either only WBVV or no treatment. Methods. The rats were sacrificed 15 weeks after ovariectomy. Lumbar vertebrae and femora were removed for biomechanical and morphological assessment. Results. 8-PN at a cancer-safe dose did not cause fundamental improvements in osteoporotic bones. Treatment with 8-PN caused a slight increase in uterine wet weight. Combined therapy using WBVV and 8-PN showed no significant improvements in bone structure and biomechanical properties. Conclusion. We cannot confirm the osteoprotective effects of 8-PN at a cancer-safe dose in primary affected osteoporotic bones. Higher concentrations of 8-PN are not advisable for safety reasons. Adjunctive therapy with WBVV demonstrates no convincing effects on bones.

Effect of Urocortin on strength and microarchitecture of osteopenic rat femur.

As yet there is no evidence of the potential antiosteoporotic effect of Urocortin-1 (UCN), a corticotropin releasing factor related peptide, in vivo. In this study, and for the first time, we investigated the effect of UCN in a rat osteopenia model. Sixty female Sprague-Dawley rats were divided into 5 groups: (1) sham-operated, (2) untreated ovariectomized (OVX) rats, (3) and (4) OVX animals treated for 5 weeks with daily subcutaneous low-dose UCN (3 µg/kg of BW) or high-dose UCN (30 µg/kg of BW) 8 weeks after ovariectomy, and (5) OVX rats treated with daily estrogen (0.2 mg/kg of BW p.o) 8 weeks after ovariectomy for 5 weeks (E). After sacrifice, the femurs were reserved for biomechanical, histomorphometric and ash testing. In the biomechanical test, the high-dose UCN rats showed significantly improved mechanical stiffness (341.6 N/mm) compared with the untreated OVX animals (275.9 N/mm). In the histomorphometric evaluation, the high-dose UCN rats demonstrated an improved trabecular microarchitecture especially and significantly at the distal femur (distal femur Tb.Ar = 41.4% and N.Nd/mm(2) = 26.8, proximal femur Tb.Ar = 71.8% and N.Nd/mm(2) = 28.7) compared with untreated OVX rats (distal femur Tb.Ar = 23.3% and N.Nd/mm(2) = 11.7, proximal femur Tb.Ar = 60.2% and N.Nd/mm(2) = 25.2). Our results show that short-term treatment with UCN seems to have a positive effect on the metaphyseal bone structure and strength of the femur in ovariectomized rats.

Whole body vibration during fracture healing intensifies the effects of estradiol and raloxifene in estrogen-deficient rats.

Current osteoporosis therapies aim to delay bone destruction and have additional anabolic effects. While they have demonstrated some positive effects on bone healing, more progress is needed in this area. This study used the well-known osteoporotic agents estrogen (E) and raloxifene (R) in conjunction with biomechanical whole body vibration (WBV) at a frequency of 70 Hz twice daily for six weeks to stimulate bone healing. Eighty-four 3-month old female Sprague-Dawley rats (12 per group) were bilaterally ovariectomized to develop osteopenia within eight weeks. Osteotomy of the metaphyseal tibiae was performed and fracture healing was then studied using mechanical tests, histomorphometry, computed tomography (µCT), and gene analysis. We found that E and R improved the structure of osteopenic bones as did WBV alone, although significant levels for WBV were seldom reached. Combination treatments significantly enhanced stiffness (R+WBV; p<0.05), endosteal bone (R+WBV; p<0.01), and trabecular density (E+WBV; p<0.05, R+WBV; p<0.05). In addition, the expression of osteoclast-specific Trap was significantly reduced after treatment with E, R, or their combination with WBV (p<0.01). The effects were additive and not inhibitory, leading us to conclude that the combined applications of WBV with E or R may improve the healing of osteopenic bones. The therapies studied are all currently approved for human use, suggesting ready applicability to clinical practice. To better understand the effects of WBV on osteopenic bones, the ideal vibration regime will require further study.

Impact of 4-methylbenzylidene camphor, daidzein, and estrogen on intact and osteotomized bone in osteopenic rats.

The study investigated the influence of 4-methylbenzylidene camphor (4-MBC), daidzein, and estradiol-17ß-benzoate (E(2)) on either intact or osteotomized cancellous bone in ovariectomized (Ovx) rats. Three-month old Ovx rats were fed with soy-free (SF) diet over 8 weeks; thereafter, bilateral transverse metaphyseal osteotomy of tibia was performed and rats were divided into groups: rats fed with SF diet and SF diet supplemented with 4-MBC (200 mg), daidzein (50 mg), or E(2) (0.4 mg) per kilogram body weight. After 5 or 10 weeks, computed tomographical, biomechanical, histological, and ashing analyses were performed in lumbar spine and tibia of 12 rats from each group. 4-MBC and E(2) improved bone parameters in lumbar spine and tibia, were not favorable for osteotomy healing, and decreased serum osteocalcin level. However, daidzein improved bone parameters to a lesser extent and facilitated osteotomy healing. For lumbar spine, the bone mineral density was 338±9, 346±5, 361±6, and 360±5 mg/cm(3) in SF, daidzein, 4-MBC, and E(2), respectively, after 10 weeks. For tibia, the yield load was 98±5, 114±3, 90±2, and 52±4 N in SF, daidzein, 4-MBC, and E(2), respectively, after 10 weeks. Serum daidzein was 54±6 ng/ml in daidzein group and equol was not detected. Alp and Igf1 genes were down-regulated in callus after daidzein and E(2) compared with 4-MBC (week 5). The response of bone tissue and serum markers of bone metabolism could be ordered: daidzein<4-MBC

Changes in the histomorphometric and biomechanical properties of the proximal femur of ovariectomized rat after treatment with the phytoestrogens genistein and equol.

The isoflavonoids found in soy have attracted great interest as dietary phytoestrogens that might be effective for postmenopausal hormone replacement therapy. Special attention has been devoted to the hormonal effects of various isoflavonoids, like genistein (GEN) and daidzein's (DAID) potent metabolite, equol (EQ). Here we aimed to investigate the short-term effects of genistein and equol on the proximal femur of ovariectomized (OVX) rats. Forty-eight, 3-month-old female Sprague-Dawley rats were ovarectomized; after eight weeks the bilateral osteotomy and osteosynthesis (OS) of their tibiae was performed and the rats were randomly divided into the following four groups: OVX control group (C), treated with estradiol-17beta (E2) -benzoate (E; daily intake 0.086 mg/d per animal), genistein (GEN; daily intake 12.7 mg/d per animal) and equol (EQ; daily intake 4.65 mg/d per animal). At 5 weeks postoperatively (OS), the breaking test was performed on the trochanteric region of femur. Additionally, histomorphometric assessment, and trabecular and cortical bone microstructure analyses were performed. The relative gain of body weight (BW) in the EQ (24 %) group was significantly (p < 0.05) lower than in the C (33 %) and GEN (30 %) groups. After treatment for 5 weeks, the maximal load (F(max)) and yield load (yL) were higher (p < 0.05 for the weight-adapted results) in the E (188.4 N resp. 113.1 N) and EQ (177.3 N resp. 112 N) groups as compared to C (162.8 N resp. 109.1 N) and GEN (165.7 N resp. 108.8 N). In the histomorphometric tests the E- (trabecular area (Tb.Ar) = 74.93 %, trabecular nodes/mm(2) (N.Nd/mm(2)) = 48.65) and EQ-treated (Tb.Ar = 63.13 %, N.Nd/mm(2) = 43.72) animals showed significant improvement with regard to Tb.Ar and trabecular connectivity (N.Nd./mm(2)) in comparison to C (Tb.Ar = 46.84, N.Nd/mm(2) = 31.86) and GEN (Tb.Ar = 48.22 %, N.Nd/mm(2) = 34.15). There were no differences in relative cortical width (Ct.Wi) among the four groups. The treatment with EQ resulted in improved biomechanical and histomorphometric properties as compared to the treatment with GEN. Thus, of the studied substances, EQ seems to be a possible alternative to hormone replacement therapy, but further studies are needed.

Differentiation dependent expression of urocortin's mRNA and peptide in human osteoprogenitor cells: influence of BMP-2, TGF-beta-1 and dexamethasone.

Urocortin-1 (UCN) a corticotropin releasing-factor (CRF) related peptide, has been found to be expressed in many different tissues like the central nervous system, the cardiovascular system, adipose tissue, and skeletal muscle. The effects of UCN are mediated via stimulation of CRF-receptors 1 and 2 (CRFR1 and 2, CRFR's) with a high affinity for CRFR2. It has been shown that the CRF-related peptides and CRFR's are involved in the regulation of stress-related endocrine, autonomic and behavioural responses. Using immunocytochemistry, immunohistochemistry and RT-PCR, we now can show the differentiation dependent expression of UCN mRNA and peptide in human mesenchymal progenitor cells (MSCs) directed to the osteoblastic phenotype for the first time. UCN expression was down regulated by TGF-beta and BMP-2 in the early proliferation phase of osteoblast development, whereas dexamethasone (dex) minimally induced UCN gene expression during matrix maturation after 24 h stimulation. Stimulation of MSCs for 28 days with ascorbate/beta-glycerophosphate (asc/bGp) induced UCN gene expression at day 14. This effect was prevented when using 1,25-vitamin D3 or dex in addition. There was no obvious correlation to osteocalcin (OCN) gene expression in these experiments. In MSCs from patients with metabolic bone disease (n = 9) UCN gene expression was significantly higher compared to MSCs from normal controls (n = 6). Human MSCs did not express any of the CRFR's during differentiation to osteoblasts. Our results indicate that UCN is produced during the development of MSCs to osteoblasts and differentially regulated during culture as well as by differentiation factors. The expression is maximal between proliferation and matrix maturation phase. However, UCN does not seem to act on the osteoblast itself as shown by the missing CRFR's. Our results suggest new perspectives on the role of urocortin in human skeletal tissue in health and disease.

Effect of daidzein, 4-methylbenzylidene camphor or estrogen on gastrocnemius muscle of osteoporotic rats undergoing tibia healing period.

The effect of daidzein (D), 4-methylbenzylidene camphor (4-MBC) or estradiol-17beta-benzoate (E(2)) on muscle of osteoporotic rats during fracture healing was studied. After performing a metaphyseal tibia osteotomy in 96 osteoporotic 5-month-old female Sprague-Dawley rats, they received daily 50 mg D, 200 mg 4-MBC or 0.4 mg E(2) per kg body weight, or soy free (SF) diet up to 36 and 72 days. Mitochondrial activity, fiber area, and capillary density were analyzed in M. gastrocnemius. Osseous callus bridging of fracture was observed in half of the rats after 36 days. By day 72, fracture was healed in most of the animals. State 3 mitochondrial respiration significantly enhanced in E(2), 4-MBC and D groups versus SF after 36 days (30, 32 and 32 vs 23 pmol O(2)/s per mg). It declined after 72 days, however, in E(2) group it was still at a higher level versus SF (25, 23 and 21 vs 20 pmol O(2)/s per mg). Size of fast oxidative glycolytic (FOG) and fast glycolytic (FG) fibers, capillary density did not differ significantly between the groups, however, at day 36 an increase in D and 4-MBC groups was detectable. FOG diameter was 64, 66, 68, and 58 microm and FG diameter was 88, 98, 95, and 89 microm in SF, D, 4-MBC, and E(2) groups. The ratio of capillaries to muscle fiber was 1.1, 1.4, 1.3, and 1.1 in SF, D, 4-MBC and E(2) groups by day 36. D and 4-MBC react similar to estrogen thereby improving oxidative cell metabolism in severe osteoporotic rats. The level of mitochondrial activity was higher, though no significant morphological differences could be shown.

The Elastic Bridge Plating of the Forearm Fracture: A Prospective Study.

Rigid plate osteosynthesis with compression is still the treatment of choice for forearm fractures to gain anatomic reposition, provide proper rotation and avoid a bridging callus. Due to necessary operative dissection there is a serious risk for infection and malunion. Based on good clinical results with elastic bridge plating at femur, humerus and tibia, this technique was also started to be used for forearm fractures in our clinic in 1995. In a prospective study, 86 of 124 consecutive patients at the age of 35.2 ± 14.7 years with 129 diaphyseal fractures of the radius or ulna (AO: 37 type A, 36 type B, 13 type C) were analyzed between January 1998 and December 2003. All fractures were stabilized by bridge plating. Radiographic union and clinical outcome were documented. Of the 129, 122 diaphyseal fractures (94.5%) healed within 10.2 ± 3.4 weeks without complications (no nerve lesions, nonunion, synostosis callus). One re-osteosynthesis, one secondary lag screw, and five cancellous bone grafts were necessary before final healing. About 79.1% of the patients had a perfect clinical outcome; 17.4% had additional severe injuries of the same arm. Bridge plating without interfragmentary compression is a reliable surgical procedure even for forearm fractures with low risk of infection and nonunion.

Myoclonus-induced bilateral acetabular fracture dislocations.

An uncommon case of myoclonus-induced bilateral central acetabular fracture-dislocation is presented. Although different fracture types due to forceful muscular contractions have been reported, this is an exceedingly uncommon injury pattern. Bilateral total hip arthroplasty, in combination with a reinforcement ring and autologous bone grafting, was performed after open reduction and internal fixation.

Urinary tract injuries in patients with multiple trauma.

This article mainly reviews urinary tract injuries in patients with multiple trauma. Approximately 10% of all traumatic injuries resulting from an external force will involve the genitourinary system. The article discusses mechanisms of injury, diagnosis, and therapeutical approaches for renal, ureteral, bladder, and urethral trauma. Due to the complexity of such injuries--despite several attempts to provide a standard strategy in trauma patients with urinary tract involvement--an individual and patient-specific-therapeutic approach is mandatory in most cases. However, the availability of classified guidelines may help the surgeon to reach the most accurate decision. Because of the similarity of American and European guidelines on urological trauma, this article adapts injury severity scales and classification from the American Association for the Surgery of Trauma.