[Esthetic and functional improvement in proximal femoral focal deficiency with lacking hip joint by rotation plasty Winkelmann type BIII]. / Rotationsumkehrplastik Winkelmann BIII bei proximalem Femurdefekt ohne Hüftgelenkanlage.

BACKGROUND: Proximal femoral focal deficiency (PFFD) types II and III (Pappas) have no femoral or only abortive femoral head development. Winkelmann published a case of one patient treated with a modification of rotation plasty by creating a new articulation after 180° rotation of the lower leg and insertion of the lateral tibial plateau into the deficient acetabulum. This article reports on three consecutive patients treated with this technique to validate this procedure and to consider this operation in selected patients. PATIENTS AND METHODS: At the time of rotation plasty the patients (2 boys and 1 girl) were aged between 5 and 10 years. The observation period is between 5 and 9 years after surgery. All patients used an orthoprosthesis with full contact in the foot region and a shaft connecting the thigh. A hip basket and any additional walking support were not necessary (e.g. canes). They were all highly satisfied and would choose the same treatment again. CONCLUSION: Rotation plasty is a technically highly demanding procedure, especially in situations such as PFFD where the anatomy is distorted and structures such as blood vessels and nerves are too short. However, it is an option to improve the orthoprosthetic fitting functionally and esthetically.

Successful management of a B-type cardiac allograft into an O-type man with 3(1/2)-year clinical follow-up.

BACKGROUND: In May 1997, a 19-year-old male patient of histo-blood group type O suffering from congenital end-stage heart failure accidentally received a cardiac allograft of type B and is still alive in fair condition. METHODS: In addition to conventional immunosuppressive therapy, plasma exchange (PEX), extracorporeal immunoabsorption (EIA), intravenous immunoglobulins (IVIG), and C1 inhibitor were used. RESULTS: Such treatment successfully reduced both IgM and IgG anti-B levels and complement hyperactivity and allowed to reach the state of accommodation without obvious signs of rejection. The patient has been surviving for 42 months; retransplantation with an O-type heart remained unnecessary. CONCLUSION: Humoral rejection has been avoided in this patient, with PEX, EIA, IVIG, and C1 inhibitor substantially contributing to this success. With future availability of such combined therapies, preferably before transplantation, vascular rejection events caused by preformed antibodies and complement (ABO mismatch or anti-HLA) could be prevented or treated.

[Ethical aspects of heart transplantation]. / Ethische Aspekte der Herztransplantation.

Since the very beginning of organ transplantation, ethical considerations have been regularly discussed. However, all important religions support transplantation. On the donor side there is continuous argument on the definition of brain death. The legal approach in determining whether explantation of organs is allowed or not is country-specific. In Switzerland, moreover, rules still differ from one canton to another and a new transplantation law is at present under consideration. To avoid further shortage of organs, various models have been suggested (such as rewarded giftings) but rejected on ethical grounds. On the recipients' side the main discussion centres on who should be the first to receive an offered organ. Specific questions on xenotransplansplantation and transplantation in newborns are briefly addressed.

[Political and economic aspects of heart transplantation]. / Politische und ökonomische Aspekte der Herztransplantation.

Organ transplant, like any other area of modern medicine, has manifold implications for human values and ethics, while sociology, law, economics and politics are equally involved. A brief review is presented of the political and economic aspects of cardiac transplantation, covering a short overview of current Swiss legislation, the problem of organ allocation, limitation of transplant centres, restriction of transplant medicine to public hospitals, cost of transplant procedures and subsequent treatment, and costs generated by alternative options such as ventricular assist devices. Current transplant medicine is affected by a growing shortage of organs, despite the fact that organ transplantation is generally well accepted by the public. On the other hand, the steadily growing disproportion between the number of organs available and the overall number of potential recipients is a source of concern for transplant surgeons and the medical profession, as well as the community at large. To be able to face these significant problems, transplant centres should offer all aspects of treatment for heart failure. In particular, before cardiac transplant is offered to a patient, all aspects of more conservative treatment should be exhaustively discussed. The economic aspects of each type of transplantation are usually discussed, but the cost of a transplant procedure should be compared with that of conventional treatment. The increasing use of all currently available options (including mechanical and antiarrhythmic bridging) makes a critical confrontation with the economic implications necessary. Assumptions based on current literature suggest that heart transplant generates additional costs of approximately CHF 50,000 per year of extended life. The treatment of heart failure involves additional costs of CHF 20,000 per year, provided only a few hospitalizations are necessary. CHF 80,000 of the cost of a heart transplant is refunded. Medical treatment in the first year after transplant mainly includes immunosuppressive drugs, antibiotic and antihypertensive medication, involving additional costs of CHF 20,000. The future will require complete use of all conventional treatment modalities, recipient selection, strengthened social rehabilitation and a quality control database, as well as consensual recommendations and coordination in research, follow-up and basic treatment.

[Fibrinolysis in a regional hospital]. / Fibrinolyse am Regionalspital.

From January 1, 1989 to September 30, 1990, 116 patients with acute myocardial infarction were hospitalized at the regional hospital of Langenthal. Of those 116 patients, 27 (23%) were treated with intravenous streptokinase; in 12 of them (44%) CPK reached its peak within 6 hours after starting lysis; all were admitted within 4 hours after the beginning of chest pain. Of the fibrinolyzed patients, 18 (67%) had arrhythmias which needed to be treated. In 10 of these 18 patients CPK reached its peak within 6 hours. Of the 89 patients not treated with streptokinase, 27 (30%) did not fulfill the entry criteria of the protocol, 16 (18%) had exclusion criteria, and 46 (52%) had exclusion criteria as well as absent inclusion criteria. In only 4 patients (4.5%) was lysis not possible because they entered hospital later than 6 hours after the beginning of pain, and 8 patients (9%) exceeded the upper age limit of 70 years. Of the 116 patients, 13 (11.2%) died; 12 were not treated with streptokinase. Our study shows that fibrinolytic treatment with streptokinase is a safe and effective therapy for patients with acute myocardial infarction and can easily be performed in a regional hospital.

[Clubfoot orthosis with integrated dynamic cuff for retention and redressing]. / Klumpfussorthese mit integrierter dynamischer Manschette für Retention und Redression.

Conservative treatment of clubfoot deformities with braces and bandages is traditionally several hundred years old. The clubfoot braces of Venel, Scarpa, and Schulthess, as well as the redressing bandage of Cheselden, are reviewed as typical examples. The treatment of clubfoot deformities was initiated in the Balgrist Hospital for Orthopedic Surgery by W. Schulthess. Recently, in Balgrist, we developed a brace that retains and redresses the foot. This brace is described, and early clinical results are reported.