[A 19-year-old female patient with acute pancreatitis of unusual cause]. / 19-jährige Patientin mit akuter Pankreatitis ungewöhnlicher Ursache.

We report the case of a 19-year-old woman with abdominal pain and diarrhea. The diagnosis of acute pancreatitis could be made clinically and through laboratory tests. The cause was a duodenal duplication cyst in the area of the papilla, which was initially relieved endoscopically. Once the acute inflammation had healed, the cyst was resected endoscopically to prevent recurrence and the increased risk of malignancy. Duodenal duplication cysts in the papillary area are a very rare (congenital) cause of acute pancreatitis. If a cyst is present in the area of the duodenal wall, however, this differential diagnosis should be considered. Resection is indicated for therapy.

Endoscopic or arthroscopic iliopsoas tenotomy for iliopsoas impingement following total hip replacement. A prospective multicenter 64-case series.

INTRODUCTION: Impingement between the acetabular component and the iliopsoas tendon is a cause of anterior pain after total hip replacement (THR). Treatment can be non-operative, endoscopic or arthroscopic, or by open revision of the acetabular component. Few studies have assessed these options. The present study hypothesis was that endo/arthroscopic treatment provides rapid pain relief with a low rate of complications. METHODS: A prospective multicenter study included 64 endoscopic or arthroscopic tenotomies for impingement between the acetabular component and the iliopsoas tendon, performed in 8 centers. Mean follow-up was 8months, with a minimum of 6months and no loss to follow-up. Oxford score, patient satisfaction, anterior pain and iliopsoas strength were assessed at last follow-up. Complications and revision procedures were collated. Forty-four percent of patients underwent rehabilitation. RESULTS: At last follow-up, 92% of patients reported pain alleviation. Oxford score, muscle strength and pain in hip flexion showed significant improvement. The complications rate was 3.2%, with complete resolution. Mean hospital stay was 0.8 nights. In 2 cases, arthroscopy revealed metallosis, indicating revision of the acetabular component. The only predictive factor was acetabular projection on oblique view. Rehabilitation significantly improved muscle strength. CONCLUSION: Endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. The low complications rate makes this the treatment of choice in case of failure of non-operative management. Arthroscopy also reorients diagnosis in case of associated joint pathology. Projection of the acetabular component on preoperative oblique view is the most predictive criterion, guiding treatment.

Microinstability of the hip: A review.

With the development of conservative hip surgery techniques, new entities such as microinstability have been identified. Microinstability is a painful supra-physiological mobility of the hip. It results from the association of architectural and functional abnormalities impairing joint stability. These risk factors concern hip joint bone architecture or peri-articular soft tissues. Bone abnormalities are identified on hip assessment parameters. Soft tissues also play a key role in the static and dynamic stability of the hip: the joint capsule, labrum, ligamentum teres and adjacent myotendinous structures affect joint coaptation; any abnormality or iatrogenic lesion concerning these structures may constitute a risk factor for microinstability. Diagnosis is based on interview, clinical examination and imaging. Findings of labral lesions or femoro-acetabular impingement do not rule out microinstability; they may be associated. Treatment is based first on physiotherapy for muscle reinforcement to improve joint coaptation. In case of failure, arthroscopic surgery is indicated for femoro-acetabular impingement and capsular plicature which is being evaluated. Periacetabular osteotomy or shelf acetabuloplasty may be indicated, according to the severity of joint bone architecture abnormality. Microinstability is a multifactorial entity. Lesions induced by microinstability may in turn become risk factors for aggravation. Diagnosis and indications for surgery are thus difficult to establish. Only full clinical examination and exhaustive imaging assessment allow microinstability and associated lesions to be identified.

Treatment of type B periprosthetic femur fractures with curved non-locking plate with eccentric holes: Retrospective study of 43 patients with minimum 1-year follow-up.

INTRODUCTION: Periprosthetic femur fracture (PFF) is a serious complication after total hip arthroplasty that can be treated using different internal fixation devices. However, the outcomes with curved non-locking plates with eccentric holes in this indication have not been reported previously. The objectives of this study were to determine: (1) the union rate; (2) the complication rate; (3) autonomy in a group of patients with a Vancouver type B PFF who were treated with this plate. HYPOTHESIS: Use of this plate results in a high union rate with minimal mechanical complications. MATERIALS AND METHODS: Forty-three patients with a mean age of 79 years ± 13 (41-98) who had undergone fixation of Vancouver type B PFF with this plate between 2002 and 2007 were included in the study. The time to union and Parker Mobility Score were evaluated. The revision-free survival (all causes) was calculated using Kaplan-Meier analysis. The average follow-up was 42 months ± 20 (16-90). RESULTS: Union was obtained in all patients in a mean of 2.4 months ± 0.6 (2-4). One patient had varus malunion of the femur. The Parker Mobility Score decreased from 5.93 ± 1.94 (2-9) to 4.93 ± 1.8 (1-9) (P = 0.01). Two patients required a surgical revision: one for an infection after 4.5 years and one for stem loosening. The survival of the femoral stem 5 years after fracture fixation was 83.3% ± 12.6%. CONCLUSION: Use of a curved plate with eccentric holes for treating type B PFF led to a high union rate and a low number of fixation-related complications. However, PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates.

Iliac wing fracture following graft harvesting from the anterior iliac crest: literature review based on a case report.

The morbidity of bone graft harvesting from the iliac crest has been widely discussed in the literature. For some authors, it is considered to be low and for others relatively high. We report on a case of a fracture of the iliac wing after graft harvesting from the anterior iliac crest despite good surgical technique. This complication is well known and most of these fractures heal uneventfully if treated conservatively. However, if anatomical and technical considerations are respected, the patient could be spared this inconvenience. Based on a literature review, we discuss the procedure's potential complications and how to avoid them in an update.

[Endoscopic therapy for leaks in the gastrointestinal tract, the bile ducts and the pancreas]. / Endoskopische Therapie von Leckagen im Gastrointestinaltrakt, an den Gallenwegen und im Pankreas.

Surgery has been the mainstay of therapy in patients with gastrointestinal perforations, leakage or fistulas. New techniques for endoscopic closure of gastrointestinal perforations provide tools for an effective treatment by less invasive procedures. Temporary placement of covered self-expanding stents is an established therapy for oesophageal perforations and anastomotic leaks. Using conventional endoclips small perforations and leaks in the oesophagus and gastrointestinal tract may be closed. With the new over-the-scope-clips a more effective endoscopic full wall closure is possible in the upper gastrointestinal tract and the rectum. Endoscopically guided endoluminal vacuum therapy using polyurethane sponges is an established method for treating rectal leaks and is now increasingly used also in oesophageal leaks. Biliary leakage following endoscopic or surgical interventions is effectively treated with temporary bile stenting in most cases, but closure using metal stents or coiling may be necessary. Pancreatic leaks are a major therapeutic problem and may require multimodal therapies.

[Femoro-acetabular impingement]. / Le conflit fémoro-acétabulaire.

Femur-acetabular impingement is a recently discovered etiology of early hip osteoarthritis. Patient history and clinical examination allow to make the diagnosis, whereas the radiological exams allow to find the etiology of impingement. Impingement is related to morphological alterations of the acetabular rim and/or proximal femur, leading to an abnormal contact between the articular components. The localisation of the abnormal morphology determines the type of impingement and the resulting articular damages. Because of the increasing risk of chondral lesions, only an early treatment may eventually improve the prognosis of the hip joint. If primary conservative treatment is unsuccessful in confirmed impingement cases, open or arthroscopic surgical treatment is indicated.

Transolecranon anterior fracture dislocation.

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

Tuberculosis of the greater trochanter. Report of four cases.

OBJECTIVE: To present four cases of tuberculosis of the greater trochanter. CASE PRESENTATION AND INTERVENTION: The four cases (3 females and 1 male), aged 45-70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4-9 years. CONCLUSION: These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.

Modified triangular posterior osteosynthesis of unstable sacrum fracture.

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

[Hip arthroscopy for femoroacetabular impingement]. / Arthroskopische Behandlung des femoroazetabulären Impingements.

Femoroacetabular impingement (FAI) is likely one of the main causes for osteoarthritis in young adults. Surgical treatment has until now been performed via open dislocation of the hip joint. With respect to its invasive nature and long rehabilitation, arthroscopic techniques have become established in recent years. The following article presents the latest developments in hip arthroscopy for FAI with a detailed description of technical aspects, pitfalls, and limitations. Hip arthroscopy is performed in the standard fashion with and without traction for arthroscopy of the central and peripheral compartments. Under traction, the anterosuperior cartilage and adjacent base of the acetabular labrum have to be inspected for frequent lesions such as cartilage flap tears and delaminations of the cartilage from the subchondral bone. An ossified labrum can be trimmed back with a burr. Currently, techniques are being developed for temporary detachment of the labrum, trimming of the acetabular rim, and refixation of the labrum with suture anchors. Without traction, femoroacetabular impingement has to be confirmed arthroscopically under flexion, internal rotation, and adduction of the hip. With respect to the frequent loss of internal rotation, the zona orbicularis and the iliofemoral ligament are released and removed if needed. The anterolateral bump of the head-neck junction is trimmed back for restoration of a more physiological head-neck offset. Postoperatively, continuous passive motion is important to prevent adhesions between the bleeding bone of the head-neck junction and the articular capsule. Weight bearing as tolerated is allowed if no treatment of cartilage defects or refixation of the acetabular labrum was performed. The early results after hip arthroscopy for FAI are very promising. Arthroscopic techniques will upstage open exposures of the hip joint for the treatment of FAI.

[Differential diagnosis of focal liver lesions using contrast-enhanced MRI with SHU 555 A in comparison with unenhanced MRI and multidetector spiral-CT]. / Dignitätsbeurteilung fokaler Leberläsionen mit der kontrastverstärkten MRT mit SHU 555 A im Vergleich zur nativen MRT und zur Mehrzeilen-Detektor-Spiral-CT.

PURPOSE: To evaluate the ability of contrast-enhanced MRI with SHU 555 A to provide additional information for characterization of focal liver tumors compared with non-enhanced MRI and multislice spiral CT. MATERIALS AND METHODS: In a prospective manner the images of 45 patients who underwent multislice spiral CT, unenhanced MRI alone and unenhanced and SHU 555 A-enhanced MRI including dynamic imaging at a field strength of 1.0 T were analyzed in a blinded reading. The readers had to determine on a scale from 1 to 5 whether a tumor was benign or malignant. Furthermore, the readers had to give a definitive diagnosis for each lesion. A true cut needle biopsy served as gold standard against which all imaging procedures were compared. RESULTS: The sensitivity for differentiation malignant vs. benign lesion was 77 % with spiral CT, 72 % with unenhanced MRI and 94 % with SHU 555 A-enhanced MRI, respectively (p < 0.05). The specificity for spiral CT was 73 %, for unenhanced MRI 83 % and for contrast-enhanced MRI 83 %, respectively (n. s.). Compared with the histopathologic results, the correct diagnosis was made with spiral CT in 25/45 (56 %), unenhanced MRI in 16/45 (36 %) and contrast-enhanced MRI in 32/45 (71 %) of the patients (p < 0.05). For the subgroup of patients with liver cirrhosis, the correct diagnosis was established with spiral CT in 16/23 (70 %), unenhanced MRI in 9/23 (39 %) and contrast-enhanced MRI in 19/23 (83 %) of the patients (p < 0.05). CONCLUSION: Contrast-enhanced MRI with SHU 555 A has the ability to improve the differential diagnosis of focal liver tumors compared with unenhanced MRI and multislice spiral CT.

Percutaneous retrograde screwing for stabilisation of acetabular fractures.

OBJECTIVES: To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population. PATIENTS AND METHODS: Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67--90 years). In all cases, the fracture was minimally or undisplaced (<2mm). Two cannulated cancellous 7.3mm screws were inserted in a retrograde fashion to stabilise the posterior and the anterior column. Bed to chair transfer began after 24h. Weight bearing as tolerated was allowed at 4 weeks. RESULTS: Eighteen patients were reviewed at a mean of 3.5 years (range 2--5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8--15 weeks). Clinical results were satisfactory in 17 patients. CONCLUSION: Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

[Treatment of acetabular fractures in the elderly with primary total hip arthroplasty and modified cerclage. Early results]. / Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und primärer Hüfttotalprothese. Erste Ergebnisse.

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring. Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement. All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident. Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

[Hepatocellular carcinoma: rising incidence of hepatitis C virus-associated cases at a university clinic in Germany]. / Hepatozelluläres Karzinom - Steigende Inzidenz der Hepatitis-C-bedingten Fälle einer Universitätsklinik in Deutschland.

BACKGROUND AND OBJECTIVE: Hepatocellular carcinoma (HCC) ranks eighth among malignant tumors worldwide. Western countries belong to areas of low HCC prevalence, but incidence of HCC is rising. The aim of the present, retrospective study was to determine changes in the incidence rates and risk factors for HCC in Germany based on the data of a single center. PATIENTS AND METHODS: Epidemiological data of 205 consecutive patients with HCC (163 males, 42 females, mean age 64+/-1 years), admitted to the University clinic Düsseldorf between January 1988 and December 2001, were evaluated. For comparison this time period was divided into two equal intervals (1988 - 1994 and 1995 - 2001). RESULTS: The number of newly diagnosed HCC has more than doubled in the years 1995 - 2001 compared to the years 1988 - 1994. Chronic hepatitis C (HCV), hepatitis B (HBV), and chronic alcohol abuse accounted for almost 80 % of HCC. The number of HCV-associated HCC increased from 31.0 % in the years 1990 - 1995 to 44.6 % (p < 0.04) in the years 1996 - 2001, whereas the proportion of HBV-associated HCC decreased. There were no changes in the Okuda tumor stage, tumor diameter and alpha-fetoprotein levels at the time of HCC diagnosis throughout the years 1988 - 2001. More than 65 % of HCC were non-resectable at the time of HCC diagnosis due to tumor diameter or number of tumor lesions. CONCLUSION: Screening for HCC, possibly rising in its incidence, should be further improved, taking into account that chronic HCV infection is the major risk factor for HCC in Germany.

[Clinical outcome of a cohort of 63 patients with hepatocellular carcinoma treated with octreotide].

Unresectable hepatocellular carcinoma (HCC) are associated with a poor prognosis. Recently, one controlled study reported a strikingly prolonged survival of patients with HCC who were treated with octreotide. Until other randomised controlled trials become available, this multicentric retrospective study therefore assesses the outcome of HCC-patients who received octreotide treatment. 63 patients (53 males, 10 females) who had been treated with octreotide at 13 participating German centres were included in the analysis. In 54 cases liver cirrhosis was present (25 Child-Pugh A, 20 Child-Pugh B, 7 Child-Pugh C, 2 unknown). The liver disease was associated with alcohol abuse in 19 patients, alcohol and viral hepatitis in four patients, while 12 patients had only markers of past or present hepatitis B infection, 11 patients suffered of chronic hepatitis C infection, and four patients were seropositive for both hepatitis B and hepatitis C markers. The Okuda stage was stage I in 23, stage II in 33, and stage III in 7 patients. The patients initially received octreotide as a long-acting release formula (20-30 mg/month) in 43 cases or through subcutaneous injection (dose 3 x 50-3 x 300 ug/day) in the remaining cases. 11 of the patients receiving subcutaneous treatment were later converted to the long-acting release form of the drug. At three months, a partial remission was achieved in two patients, while 22 tumours showed no change and 26 tumours progressed. At six months, 11 tumours showed no change, while 15 tumours progressed. The patients' median survival was 9 months (Okuda stage I 16 months, stage II 9 months, stage III 4 months). In conclusion, octreotide treatment did not result in markedly prolonged survival in this retrospective series of 63 patients.

Modulation of the heme oxygenase HO-1 expression by hyperosmolarity and betaine in primary rat hepatocytes.

The influence of hyperosmotic shrinkage and the osmolyte betaine on heme oxygenase HO-1 expression was studied in cultured rat hepatocytes. Hyperosmolarity transiently suppressed HO-1 induction in response to hemin or medium addition at the levels of mRNA and protein expression. Pretreatment of the cells with betaine largely restored induction of both HO-1 mRNA and protein under hyperosmotic conditions. Exposure of HO-1-expressing hepatocytes to cycloheximide unraveled a hyperosmotic acceleration of HO-1 degradation which was counteracted by betaine and the proteolysis inhibitor MG-132. The HO-1 mRNA stability remained unaffected by hyperosmolarity and betaine as shown by application of the transcription inhibitor actinomycin D. The data suggest a modulation of HO-1 expression by hyperosmolarity and betaine at the transcriptional level and at the level of proteasomal degradation. Hyperosmotic suppression of HO-1 expression was accompanied by a moderate but significant loss of hepatocyte viability, which was prevented by betaine. The hyperosmotic impairment of hepatocyte viability was insensitive to betaine in presence of the heme oxygenase inhibitor zinc protoporphyrin IX. However, treatment of the hepatocytes with bilirubin or 8-Br-cGMP improved hepatocyte viability under hyperosmotic conditions to the control niveau. Thus, stabilizing HO-1 expression may contribute to hepatocyte protection against hyperosmotic stress by organic osmolytes.

[Nonsurgical therapy methods in hepatocellular carcinoma]. / Nicht operative Therapieverfahren bei hepatozellulärem Karzinom.

The incidence of the hepatocellular carcinoma (HCC) is increasing in western countries mainly due to chronic hepatitis C. Therapy is dependent on the size and localization of the tumors as well as age and condition of the patient. If resection or transplantation are not possible, smaller tumors can be treated with local therapy either by percutaneous ethanol instillation, radiofrequency ablation or laser thermocoagulation. Larger tumors can be treated by transarterial chemoembolization which can also be combined with the methods named above. The results of systemic chemotherapy and medical treatment are disappointing. With early diagnosis and individualized therapeutic strategies prolongation of life or healing may be reached in many patients.

Retrieval of the mrp2 gene encoded conjugate export pump from the canalicular membrane contributes to cholestasis induced by tert-butyl hydroperoxide and chloro-dinitrobenzene.

Oxidative stress is known to induce cholestasis, but the underlying mechanisms are poorly understood. In this study we have characterized the short-term effects of tert-butyl hydroperoxide (t-BOOH)- and 1-chloro-2,4-dinitrobenzene (CDNB) on the mrp2 gene encoded canalicular export pump (Mrp2). The effects of t-BOOH and CDNB on bile formation, tissue GSH levels and subcellular Mrp2 localization were studied in perfused rat liver. Both, t-BOOH (0.5 mM) and CDNB (0.1 mM) induced within 60 min a decrease of hepatic GSH levels by more than 90% and an almost complete cessation of bile flow. As revealed by confocal laser scanning microscopy, this cholestasis was accompanied by a loss of immunoreactive MRP2 from the canalicular membrane and its appearance inside the hepatocytes in putative intracellular vesicles. On the other hand, the intracellular distribution of dipeptidyl peptidase IV (DPPIV), another canalicular protein, and of zonula occludens associated polypeptide (ZO-1) remained unaffected, indicating selectivity of the Mrp2 retrieval pattern. Both, t-BOOH and CDNB induced a rapid net K+ efflux from the liver and a significant decrease of liver cell hydration. We conclude that severe glutathione depletion induces cholestasis by a retrieval of Mrp2, but not of DPPIV from the canalicular membrane. The underlying mechanism is unclear; however, a decrease in liver cell hydration, which occurs under these conditions, may contribute to this effect.