[Are 55 cents always better value than 90 cents for venous thromboembolism prophylaxis? Comparison of three low-molecular-weight heparins with regard to economics and guideline compliance]. / Sind bei der venösen Thrombembolieprophylaxe 55 Cent immer günstiger als 90 Cent? - Vergleich von 3 niedermolekularen Heparinen hinsichtlich Wirtschaftlichkeit und Leitlinien-Compliance.

BACKGROUND: Four low-molecular-weight heparins with different dosage regimens are allowed for venous thromboembolism prophylaxis in patients with a high risk of thromboembolism in Germany. If comparison is made purely on the basis of drug costs, multi-dose vials are the favourable solution. We try to answer the question whether the choice of low-molecular-weight heparin influences the compliance with the S2 guideline "Inpatient and outpatient thromboembolism prophylaxis in surgery and perioperative medicine." Beyond that we ask if multi-dose administration is superior to the pre-filled syringe when total costs are calculated on the basis of procedure and technical application. PATIENTS AND METHODS: After training the nursing and medical staff in guideline-compliant implementation of thromboembolism prophylaxis with pre-filled certoparin safety syringes (03/09-05/09) or nadroparin (06/09-08/09) and enoxaparin (02/10-04/10) from multi-dose vials, we calculated the total costs on the basis of procedure and technical application. Furthermore, the satisfaction of the nursing staff was interrogated and the proportion of non-guideline-compliant prescriptions was determinated prospectively on the basis of a total of 388 patient files. RESULTS: When total costs are calculated on the basis of procedure and technical application, the costs for nadroparin are 1.16 €/0.3 mL, 1.30 €/0.4 mL and 1.58 €/0.6 mL, for enoxaparin 1.04 €/20 and 1.42 €/40, and for certoparin 1.25 €/pre-filled safety syringe. The pre-filled certoparin safety syringe made a very good overall impression on the nursing staff (versus sufficient for nadroparin and enoxaparin). Guideline-compliance was achieved in 100 % with body weight- and risk-independent certoparin, in 79.4 % with risk-adapted enoxaparin, and in 66.4 % with body weight- and risk-dependent nadroparin. CONCLUSION: The complexity of the dosage regimen of a low-molecular-weight heparin has a decisive influence on guideline-compliance. By calculating total costs on the basis of procedure and technical application multi-dose vials only offer a price advantage in patients with a low or moderate risk of thromboembolism compared with pre-filled safety syringes in the venous thromboembolism prophylaxis of orthopaedic and trauma surgery patients.

[Reduction of unstable and dislocated hips applying the Tübingen hip flexion splint?]. / Die Tübinger Hüftbeugeschiene als Repositionsorthese?

BACKGROUND: The indication for the use of the Tübingen hip flexion splint is a dysplastic hip without instability. According to current knowledge dysplastic unstable or dislocated hips should be treated with a stable retention device such as a modified Fettweis cast. The aim of this study was to evaluate the treatment effect of the Tübingen hip flexion splint when applied to dysplastic unstable hips (type IIc unstable according to the classification of Graf) and dislocated hips (types D, III and IV according to the classification of Graf) within the first week of life. PATIENTS AND METHODS: All newborns with an unstable hip type IIc or worse detected by ultrasound in the first week of life were treated with a Tübingen hip flexion splint. A prospective cohort trial was performed between November 2007 and December 2010. The initial hip type according to the ultrasound classification of Graf, the start and the duration of treatment with the Tübingen hip flexion splint as well as the rate of success were evaluated. Due to the small number of patients non-parametric tests were used for statistical analysis. RESULTS: A total of 50 dysplastic unstable or dislocated hips in 42 newborns were treated with the Tübingen hip flexion splint. The distribution of pathological hip types was 6 type IIc unstable, 33 type D, 10 type III and 1 type IV. Therapy was started on average on day 3.5 (range 1-8 days) of life and 49 out of 50 hips were successfully treated with the Tübingen hip flexion splint. Solely the type IV hip could not be reduced in the Tübingen hip flexion splint. Thus 98% of the dysplastic unstable or dislocated hips were successfully converted into type I hips with an α-angle of more than 64° in the splint. The mean time for achieving an α-angle ≥ 64° was 51.6 ± 18.9 days (range 21-87 days). No statistically significant relationship was found between the duration of therapy and the time when treatment was started, early or late within the first week of life (p = 0.152). Furthermore, no correlation was detected between the duration of therapy and the initial hip type determined by ultrasound (p = 0.886). In all successfully treated cases therapy could be discontinued during the exponential part of Tschauner's maturation curve of hip development. CONCLUSION: When recognized within the first week of life dysplastic unstable hips (type IIc unstable according to the classification of Graf) and dislocated hips with a cranially dislocated cartilage roof (types D and III according to the classification of Graf) can be successfully treated with the Tübingen hip flexion splint provided that the parents show good compliance concerning the treatment regimen.

Rigid internal fixation of fractures of the proximal humerus in older patients.

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus.

[Clinical and radiological results after arthroscopic partial medial meniscectomy. Are there risk factors?]. / Klinische und radiologische Ergebnisse nach arthroskopischer partieller Innenmeniskusresektion. Gibt es prädisponierende Faktoren?

In a retrospective study 100 patients underwent a clinical and radiological follow-up 7 years and 7 months after an arthroscopic partial medial meniscectomy. None of these patients had associated intraarticular lesions apart a minor chondral damage of the medial compartment. The follow-up showed excellent clinical results in 96% of patients according to the modified Marshall Score. The radiological results demonstrated a deterioration or development of osteoarthritis of the operated knee joint in 33% of patients, with a statistical significance between radiological and clinical results (p < 0.05). The age of the patients at time of operation and any angular deformity of the knee joint had no statistical significant influence on the radiological results. Women had a statistically significant higher risk to deteriorate or develop gonarthrosis after partial medial meniscectomy than men (p < 0.05). The arthroscopic partial medial meniscectomy leads to excellent subjective and functional results, but it could not totally prevent the increase or development of degenerative changes in the medial knee compartment.

Late results after arthroscopic partial medial meniscectomy.

In a retrospective study, 100 patients underwent a clinical and radiological follow-up examination after a minimum of 7 years (range 7.0-9.3 years) following an arthroscopic partial medial meniscectomy. None of these patients had associated intra-articular lesions, apart from minor chondral damage (max. grade 2 Outerbridge classification; < 1 cm2) of the medial compartment at the time of the primary arthroscopy. According to the modified Marshall score, the follow-up evaluation showed excellent clinical results in 96%. Nevertheless, the radiological outcome, as measured by comparing preoperative and postoperative X-rays, demonstrated a development or progression of the osteoarthritis of the affected knee joint in 33%, with a statistically significant correlation between the radiological and clinical outcomes (P < 0.05). The age of the patients at the time of operation and any angular deformity of the knee joint did not influence the radiological results. Women had a statistically significantly higher risk of developing gonarthrosis after partial medial meniscectomy than men (P < 0.05). The arthroscopic partial medial meniscectomy led to excellent subjective and functional results but could not prevent the increase or development of late degenerative changes in the medial knee compartment.

Muscular imbalance and shoulder pain in volleyball attackers.

OBJECTIVE: In overhead sports such as volleyball, baseball, or tennis shoulder problems are very common. The aim of this study was to identify features which may correlate with shoulder problems in volleyball attackers. METHODS: 30 competitive volleyball attackers (mean age 25 years) were included in the study; 15 were suffering from shoulder pain and 15 had no history of shoulder pain. The results were compared with those of a control group of 15 recreational athletes without any overhead sports activities. RESULTS: Volleyball attackers have a different muscular and capsular pattern at the playing shoulder compared to the opposite shoulder. Their playing shoulder is depressed, the scapula lateralised, and the dorsal muscles and the posterior and inferior part of the shoulder capsule shortened. These differences were of more significance in volleyball attackers with shoulder pain than in volleyball players without shoulder pain. In contrast to recreational athletes without any overhead sports activity, there were no significant difference in the comparison of the two shoulders. The histories, clinical and sonographic findings did not reveal further typical features for volleyball attackers with shoulder pain. CONCLUSIONS: Muscular balance of the shoulder girdle is very important in this sport. It is therefore imperative to include adequate stretching and muscular training programme for the prevention, as well as for therapy, of shoulder pain in volleyball attackers.