[Minimally invasive treatment of serial metatarsal fractures by antegrade intramedullary K­wire osteosynthesis]. / Minimal-invasive Versorgung von Metatarsale-Serienfrakturen durch antegrade intramedulläre K­Draht-Osteosynthesen.

Serial fractures of metatarsal bones are rare and usually caused by direct or indirect high-energy trauma; however, in cases of pre-existing diseases, such as diabetes mellitus, they also can occur spontaneously or as insidious fractures. Due to the substantial soft tissue swelling mostly associated with such injuries, minimally invasive osteosynthesis with intramedullary Kirschner-wires (K­wires) is recommended. The antegrade technique for placement of the K­wires is preferred as the technically simpler retrograde procedure has several significant disadvantages. The preferred operative approach is described in detail exemplified by two clinical cases.

[Triceps tendon rupture : Double-row repair and overview of alternative techniques]. / Trizepssehnenruptur : Reinsertion am Olekranon in Doppelreihentechnik und Übersicht alternativer Techniken.

Triceps tendon rupture is a rare injury. While partial tendon ruptures can be treated non-operatively, complete ruptures are an indication for surgical treatment in order to restore strength and a full range of motion. Although many different methods have been published, there is no consensus on the optimal surgical technique.We report the case of a patient who suffered from a complete triceps rupture after a fall. The injury was treated by open reduction and refixation of the tendon using the double-row technique. The following article describes the technique and highlights its advantages and disadvantages in comparison to other procedures.

[Arthroscopic tibiotalocalcaneal arthrodesis]. / Arthroskopische Rückfußkorrekturarthrodese.

Tibiotalocalcaneal arthrodesis (TTCA) is indicated for a variety of disorders, including end-stage osteoarthritis, severe deformities and complications after operative interventions on the upper and lower ankle joints. Due to the biomechanical advantages, TTCA is predominantly performed with curved retrograde intramedullary nails allowing compression before locking. Hindfoot arthrodesis is most commonly performed by extensive open surgical approaches. Despite a patient satisfaction rate greater than 80 %, current reviews have reported mean complication rates of more than 50 % with a pronounced variance in bone union rates. This is influenced by the sometimes severe preexisting diseases in this patient collective. A predictive risk assessment for complications following TTCA revealed a significantly increased risk in the presence of diabetes mellitus, revision surgery or preoperative ulceration. In these high-risk patients, a reduction of the invasiveness of the procedure could possibly reduce the complication rates. Arthroscopic TTCA therefore appears to be a promising alternative approach. Even though only few case reports and one case series have been published, in the total collective of 17 patients only one subtalar non-union and one minor complication were reported. Despite the limited evidence available, arthroscopic TTCA appears to be a promising therapy option in patients with an increased risk profile and comorbidities, such as critical soft tissue situations, plantar ulceration, peripheral arterial occlusive disease (PAOD) and diabetes mellitus.

The hand eczema proteome: imbalance of epidermal barrier proteins.

BACKGROUND: Chronic hand eczema (CHE) is a common skin disease with a high socioeconomic impact. While some light has been shed on the genetic factors that predispose individuals to the disease, little is known about its actual pathogenesis. OBJECTIVES: We aimed to carry out a systematic and comprehensive analysis of the differential protein expression in CHE using modern mass spectrometry. METHODS: We performed liquid chromatography with tandem mass spectrometry analyses and label-free quantification to analyse the proteomic profile of palmar skin from 12 individuals (six patients with hand eczema and six healthy volunteers). Immunohistochemistry of the palmar skin from seven different patients with hand eczema and seven different healthy volunteers was performed in a second step. RESULTS: With this method we were able to identify 185 candidate proteins with a significantly different abundance in the hand eczema samples. Among them we found several barrier proteins: filaggrin (FLG), FLG-2 and hornerin were all downregulated in the hand eczema samples, as were the desquamation-related enzymes kallikrein-related peptidase (KLK)5 and KLK7 and cystatin E/M. The antimicrobial peptides S100A7 and S100A8/A9 and the small proline-rich protein 2B and S100A11 were upregulated in the diseased skin. Immunohistochemistry confirmed these findings. CONCLUSIONS: Our results corroborate the assumption that skin barrier dysfunction plays an essential role in the pathogenesis of CHE.

Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery: an arthroscopically supported technique with antegrade intramedullary bone harvesting by a reamer-irrigator-aspirator (RIA) system.

PURPOSE: In anterior cruciate ligament (ACL) revision surgery, refilling of misplaced or enlarged tunnels frequently requires bone harvesting from the iliac crest. Unfortunately, donor-site pain displays a relevant complication. In order to optimize patients' comfort, we developed a procedure combining minimally invasive intramedullary bone harvesting from the femur with arthroscopic tunnel refilling. METHODS: Patients with ACL reconstruction failure that were not eligible for one-step revision surgery but required tunnel refilling prior to the next ACL reconstruction were enrolled prospectively. Cancellous bone was harvested intramedullarily from the ipsilateral femur using the reamer-irrigator-aspirator system in a minimally invasive manner. Afterwards, the femoral and tibial tunnels were arthroscopically refilled using cones and push rods. Computer tomography (CT) analyses were carried out before and after the filling procedure. Pain levels were assessed during the entire follow-up. Patients undergoing iliac crest bone harvesting for other reasons served as a control group. Finally, the quality of the newly formed bone stock was evaluated in the subsequent ACL reconstruction procedure. RESULTS: Five patients were included during a 6-month period. Prior to refilling, tunnel analysis revealed a mean tunnel volume of 7.9 cm(3) at the femur [SD ± 5.3 cm(3)] and of 6.7 cm(3) [SD ± 5.1 cm(3)] at the tibia. The CT analyses further revealed that graft failure was predominantly caused by tunnel misplacement. Post-operatively, pain levels due to intramedullary bone harvesting were significantly lower compared to iliac crest bone harvesting at every analysed time point. Three to five months after tunnel filling, CT analyses showed sufficiently incorporated bone stocks with filling rates of 75 % femoral and 94 % tibial. ACL revision surgery was performed 4-5 months after tunnel filling without any complication. CONCLUSION: Intramedullary bone harvesting from the ipsilateral femur combined with arthroscopic refilling of the bone tunnels ensures a high-quality bone stock for further ACL reconstruction. The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery.

[Occult fractures of extremities in adults and children. Exemplified by foot and ankle injuries]. / Okkulte Extremitätenfrakturen im Erwachsenen- und Kindesalter. Am Beispiel von Fuß- und Sprunggelenkverletzungen.

BACKGROUND: Occult fractures in children and adults cannot by definition be diagnosed by conventional radiographs. These injuries are usually recognized as bone marrow edema by magnetic resonance imaging (MRI). There are no randomized controlled trials or prospective cohort studies concerning the correct management of occult fractures and, therefore, no evidence-based treatment guidelines can be drafted. OBJECTIVES: This article summarizes the current diagnostic and treatment concepts for occult fractures under special consideration of foot and ankle injuries. METHODS: A selective search of the current literature was performed and also taking own experience into consideration. RESULTS AND CONCLUSION: The clinical prognosis of occult fractures is generally good and there is no evidence that these lesions need specific treatment. Besides forensic applications and problems pursuant to insurance law, MRI examination is only indicated when conventional radiographs are unremarkable, pain persists for an unusually long period of time and when a relevant therapeutic consequence can be expected from the MRI results. Classical pitfalls are combinations of occult fractures with potentially unstable ligamentous injuries and patients with disordered pain perception as in cases of diabetic polyneuropathy, as the common therapeutic concept of weight bearing according to pain is not suitable for these patients and can lead to severe complications.

[Lisfranc dislocation fracture: Dynamic examination under anesthesia and minimally invasive stabilization with mini-TightRope®]. / Lisfranc-Luxationsfraktur: Dynamische Narkoseuntersuchung und minimal-invasive Stabilisierung mittels Mini-TightRope®.

As Lisfranc joint injuries are rare and standard radiographic examinations can be difficult to interpret the correct diagnosis is often initially overlooked. Delayed treatment frequently results in painful and disabling arthritis, consequently, primary targeted diagnostics are essential for the functional outcome. We report on a patient with a Lisfranc fracture dislocation, with the injury severity only becoming obvious by dynamic examination with the patient under anesthesia. Due to the massive swelling we performed a minimally invasive primary stabilization using one K-wire and a mini-TightRope®.

[Osteoid osteoma of the talus: a rare cause for pain in the ankle joint]. / Das Osteoidosteom des Talus: Eine seltene Ursache für Beschwerden des oberen Sprunggelenks.

Osteoid osteomas are typically located in the femur and tibia and are mostly easy to diagnose based on patient age, the clinical signs and plain radiographs. In contrast, the diagnosis of osteoid osteomas of the foot is often delayed because of the atypical presentation. We report the case of a 24-year-old patient with persisting pain in the ankle joint over 8 years due to an osteoid osteoma of the talus neck.

[Incomplete paraplegia after delayed diagnostics of motor function deficits. Severe malpractice?]. / Inkomplette Querschnittlähmung nach verzögerter Abklärung motorischer Ausfallserscheinungen. Schwerer Behandlungsfehler?

A 72-year-old female patient was transferred to a rehabilitation centre after surgical stabilization of a subtrochanteric femoral fracture. However, adequate mobilization was not possible there and 5 days after transfer deficits in the motor function of both lower extremities were documented for the first time and an initial paraplegia was diagnosed the following day by a neurologist. Magnetic resonance imaging (MRI) revealed the suspicion of an unstable fracture of the seventh thoracic vertebral body 8 days after the initial symptoms, which was confirmed by computed tomography after another 3 days. Surgical decompression and stabilization were performed at a department for neurosurgery 4 days later but incomplete paraplegia persisted permanently. The patient complained about insufficient diagnostic measures at the rehabilitation centre. The expert opinion concluded that it would have been mandatory to investigate the matter of the newly occurring neurological symptoms immediately but this had only been performed after undue delay, which had to be interpreted as a case of medical malpractice. The expert pointed out that it was not possible to provide clear evidence that emergent diagnosis and surgery would have enabled a significantly better outcome.The arbitration board ascertained a lack of examination and argued that prompt and adequate diagnostic measures would have revealed the relevant pathological finding and thus surgery would have been performed immediately. According to the reversal of evidence in favor of the patient it could be assumed that no permanent neurological damage existed when the first neurological symptoms occurred and that emergent surgery at least had the potential to prevent permanent paraplegia. This opinion of the arbitration board is supported by numerous references in the literature.

[Infection after anterior cruciate ligament reconstruction: grave error in treatment?]. / Infektion nach arthroskopischer Kreuzbandersatzplastik: schwerer Behandlungsfehler?

A 28-year-old patient showed clear signs of knee joint infection 8 days after arthroscopic reconstruction of the anterior cruciate ligament. The treating physicians recommended further observation although they stated that a knee joint infection could not be reliably excluded. One week later arthroscopic revision was performed and intraoperative smear tests showed infection by Pseudomonas aeruginosa. Therefore, another 6 days later the obviously infected transplant had to be removed. In the long run painful and limited range of motion of the affected knee joint persisted. The patient complained about medical malpractice concerning management of the complication. The expert opinion stated that due to the fateful course of infection the tendon graft could not be retrieved after the eighth day post surgery anyway. Thus, only flawed delay of treatment was criticized. The arbitration board argued, however, that scientific data concerning the fate of infected tendon grafts do not support the expert opinion and that immediate arthroscopy and antibiotic treatment at least had the potential to influence the course of infection in a positive manner. Evidence clearly shows that survival of an infected tendon graft depends on early diagnosis and emergency treatment rather than just on fate. Due to the fact that, although having in mind the possibility of a knee joint infection, the necessary therapy was delayed for 8 days, the arbitration board considered the described medical malpractice a severe treatment error, leading to reversal of evidence in favour of the patient.

Management of prehospital shoulder dislocation: feasibility and need of reduction.

PURPOSE: Dislocation of the shoulder is rare in the prehospital setting. The medical specialities of the emergency physicians are heterogeneous, and the level of experience is different. Aim of this study was to evaluate the feasibility, sufficiency, and need of prehospital reduction. METHODS: Over 12 months, 16 rescue stations in Germany and Austria documented cases. Points of examination were: incidence of reduction, influence of pathological findings, therapy and effectiveness of reduction. RESULTS: We included 70 patients. A reduction was undertaken in n = 47 (66.6 %). In n = 70 (100 %) perfusion was without pathological finding after reduction, all n = 7 (10 %) neurological pathologies declined after reduction. There was no significance in total implementation of prehospital reduction between surgeons and anaesthetists. N = 63 (90 %) of all patients received an immobilisation of the shoulder. N = 68 (97 %) of all patients were transported to a hospital. Time to arrival in hospital was in n = 50 (71.4 %) ≤10 min, in n = 17 (24.2 %) ≤20 min and in n = 3 (4.4 %) ≤30 min. CONCLUSION: Implementation of reduction is independent of pathological neurological or vascular findings. Knowledge and skill is enough to perform a reduction quiet effectively in all emergency physicians. No specific technique can be recommended for prehospital use, the importance of being skilled is more important than one method. Early reduction was performed most rapidly in surgeons, but as well in the recommended time by other medical disciplines. On documented timings to admission hospital waiver of reduction is doubt. Therefore, a reduction in the prehospital setting is possible, but not obligatory.

[Anterior dislocation of the shoulder--a reduction technique that is easy on the patient]. / Neue Technik soil iatrogene Komplikationen vermeiden: Schonende Reposition bei ventraler Schulterluxation.

Modified scapula manipulation represents a simple, highly successful and--both for the physician and the patient--pleasant new reduction technique in cases of anterior dislocation of the shoulder. The advantages of this technique--in particular in comparison with the previously employed methods are well founded. Non-evaluated methods, which are fraught with complications, such as the Hippocrates' method, should no longer be applied.

[Complete rupture of the proximal semimembranosus tendon. Minimally invasive surgical repair by use of a suture anchor in a rare but often underestimated injury]. / Komplette Ruptur der proximalen Semimembranosussehne. Minimal-invasive Refixation mittels Nahtanker bei einer seltenen und in ihrer Schwere häufig unterschätzten Verletzung.

Complete rupture of the proximal semimembranosus tendon is a rare injury associated with significant functional loss. Conservative treatment has proven inadequate in returning patients to their previous activity level. However, diagnosis is often delayed because of underestimation of the severity of this injury. Satisfactory results can be achieved with both early and late surgical tendon repair in the majority of cases. However, repair delayed by more than 4 weeks post trauma usually requires extended mobilisation of the injured muscle and neurolysis of the sciatic nerve. Therefore, we recommend surgical repair as early as possible. We report on the successful minimally invasive surgical repair of a complete rupture of the proximal semimembranosus tendon by use of a suture anchor 18 days after injury.

[New-bone formation by osteogenic protein-1 and autogenic bone marrow in a critical tibial defect model in sheep]. / Knochenneubildung durch Osteogenic Protein-1 und autogenes Knochenmark im Problemdefektmodell der Schafstibia. OP-1 im Problemdefektmodell der Schafstibia.

AIM: Osteogenic Protein-1 (OP-1) is known to be a very potent osteoinductive growth factor. However, experimental studies using critical-size defect models in the weight-bearing lower extremity show non-uniform results. Therefore, we studied the osteoinductivity of OP-1 in a tibial worst-case defect model in sheep. Potential improvement of OP-1 induced new bone formation using a composite graft with autogenous bone marrow was to be investigated. METHOD: In 19 sheep a 5 cm segmental defect of the tibial diaphysis was treated by intramedullary nailing and filled with the following implants: 5 mg OP-1 + inactivated demineralized bone matrix (group 1; n = 6); 5 mg OP-1 + inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 2; n = 5); autogenous cancellous bone (group 3; n = 4), or inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 4; n = 4). RESULTS: In total, 3 out of 10 defect sites treated with OP-1 were completely bridged radiographically by 12 weeks. Initially, x-rays showed accelerated new bone formation by use of the composite grafts containing OP-1 and autogenous bone marrow. However, 12 weeks post surgery 3D-CT-volumetry could not detect significant differences of new bone formation within the defect sites treated by OP-1 with or without bone marrow, while new bone formation by autogenous cancellous bone was better than by OP-1. CONCLUSION: In our worst case defect model, the osteoinductive potential of OP-1 is initially accelerated but 12 weeks post surgery not increased when combined with autogenous bone marrow transplantation. So far, critical segmental bone defects of the weight-bearing lower extremity can not be bridged regularly in our model by use of OP-1. Therefore, for the treatment of such critical defects with rotational instability the examined application device of OP-1 can not yet be recommended.

[The case of a patient with multiple superinfected necrosis of both legs caused by vasculitis disease]. / Fallbericht einer Patientin mit multiplen superinfizierten Nekrosen beider Ober- und Unterschenkel auf dem Boden einer Vaskulitis.

Vasculitis can lead to skin necrosis, which typically shows decayed recovery tendency and is able to lead to local as well as systemic inflammation. By repeated necrosectomy, vacuum therapy, split skin graft transplantation as well as simultaneous immunosuppression and systemic antibiotics, the cutaneous manifestations of vasculitis where cured.

[Tissue engineering of bone. Integration and migration of human mesenchymal stem cells in colonized contructs in a murine model]. / Tissue Engineering von Knochen. Integration und Migration von humanen mesenchymalen Stammzellen in besiedelten Konstrukten im Mausmodell.

Tissue engineering opens up new ways for therapy of bone defects. Therefore, the aim of this study was to establish a mouse model to investigate local cell growth of human mesenchymal stem cells (hMSC) on the scaffold in vivo. Moreover, migration of cells to other organs should be excluded.hMSC (Cambrex, USA) were cultivated according to supplier's recommendations. After inoculation on cylindric scaffolds, one matrix cell construct and one scaffold without hMSC were implanted subcutaneously left and right paravertebrally in athymic nude mice. After 2, 4, 8, and 12 weeks constructs and organs were harvested for immunohistological evaluation and PCR. In conclusion, we found integration of scaffolds loaded with hMSC implanted ectopically. HMSC seeded on 3D scaffolds survived for a period of up to 12 weeks. In addition, we could not detect hMSC in any other organ of the host.