Intraoperative sonography: a technique for localizing focal forms of congenital hyperinsulinism in the pancreas.

Congenital hyperinsulinism (CHI), syn. nesidioblastosis, is the most frequent cause of persistent, recurrent hypoglycemia in infancy. One third of patients show a single circumscribed focus. Enucleation of the focus and the removal of all affected ß-cells with preservation of healthy tissue is the treatment of choice. The intrapancreatic choledochus as well as the ductus pancreaticus major must remain intact. The diagnostic gold standard is 18F-DOPA-PET/CT. Intraoperative sonography is carried out to correctly visualize the focus preoperatively localized by PET/CT in situ during the operation. The enucleation of the focus was carried out 3 - 20 days after PET/CT in 5 patients at an age of 3.5 - 14 months. Intraoperative ultrasound was carried out with high-capacity devices of different manufacturers under use of broadband probes (9 - 14 MHz). The localization by intraoperative ultrasound was accurate in all 5 patients with focal CHI, with regard to the intraoperative localization as previously described by PET/CT and histology. D. choledochus and D. pancreaticus major were separated intraoperatively by ultrasound. 3 of 5 patients were cured by complete enucleation of the focus. Nevertheless, the entire intraoperative identification of the segmented focus is still problematic. Characteristic sonographic features of a CHI focus are: hypoechogenicity, variable homogeneous and inhomogenous texture, blurred, irregular limitation without capsule, filiform, lobular processes, and insular dispersal into the surrounding tissue. Intraoperative high-resolution sonography helps the pediatric surgeon to determine size, configuration and topography of a CHI focus.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformation. Part one: paediatric surgical evaluation and treatment of defecating disorder.

INTRODUCTION: Anorectal malformations represent a continuing challenge for the paediatric surgeon. Faecal and urinary incontinence can occur even with an excellent anatomic repair. We undertook a prospective evaluation of comorbidity and psychosocial needs in children and adolescents with anorectal malformation to test the hypothesis whether psychosocial workup in concert with an improved continence situation would lead to a better functional outcome in patients suffering from defecating disorders. Treatment of defecating disorder was based on differentiation between overflow pseudo-incontinence and true faecal incontinence. MATERIALS AND METHODS: Patients who presented with soiling regardless of the type of anomaly were included in the study: 44 patients were investigated, 14 patients did not meet the criteria of the study, 30 patients aged 4-18 were evaluated. The surgical diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, stool protocol. RESULTS: Patients were grouped in two different management programs according to their continence situation. Patients with pseudo-incontinence were treated with enemas, diet, anal hygiene, behavioural therapy and physiotherapy. Patients with true faecal incontinence were included in a bowel management program: 28 patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at re-evaluation. Two patients did not follow the therapeutic regime and therefore did not show an improved condition concerning soiling in the long run. CONCLUSION: Differentiating between overflow pseudo-incontinence and true faecal incontinence is the basis of an effective treatment of defecating disorders. All patients born with anorectal malformation can be kept clean of stool if they are subjected to an adequate treatment. A multidisciplinary approach is a valuable supplement to standard therapy.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformations. Part 2: evaluation of psychosocial need.

PURPOSE: Only a few patients with anorectal malformations (ARM) have satisfactory bowel functions. Studies of ARM have reported psychosocial problems in up to 73% of patients. The aim of the current study was to document the psychosocial needs of patients with ARM. METHODS: Between June 2004 and September 2005, 44 patients with ARM were treated; the sample included 30 patients (23 males and 7 females) aged 4-17. To focus on potential psychosocial strain, a comprehensive grading system with a sophisticated perspective of continence, associated malformations, number of surgical interventions and postoperative complications was introduced. For psychosocial screening, the following instruments were used: German "Basis-Dokumentation" (BADO), Impact on Family Scale (IFS), the Strengths and Difficulties Questionnaire (SDQ). All families assessed their own psychosocial needs. An extensive psychosocial programme was provided. RESULTS: Twenty-three patients were suffering severe burden according to the comprehensive grading system. Nearly half of the families reported increased financial stress, and one-third reported emotional or hyperactivity problems of the child. More than 70% confirmed psychosocial need. CONCLUSIONS: Paediatric surgeons should promote psychosocial support for all patients who suffer severe forms of ARM or its numerous associated malformations as well as for patients undergoing numerous surgical interventions or having many postoperative complications.

Reduction of postoperative adhesions by perfluorocarbons: an experimental study in a rat model.

Peritoneal adhesions are a well-known and frequently occurring postoperative complication. Many published studies have looked into the prophylaxis of adhesions following abdominal surgery, but only few clinically relevant agents have been reported. Most publications refer to adult patients and not to paediatric patient collectives. This experimental study in a rat model compares the effect of perfluorocarbons as adhesion prophylaxis with those of a well-known anti-adhesive agent Adept and with an untreated control group. We hypothesized that PFC might have a double effect: initially it could suppress the accumulation of monocytes and neutrophilic granulocytes, and subsequently it would work as a barrier to prevent contact between the visceral and parietal layers of the peritoneum. After a standardised operation, PFC was injected into the abdominal cavity of rats in the study group. Macroscopically, the PFC group did not fare significantly better, but nevertheless a clear tendency towards fewer adhesions after the application of PFC could be ascertained.

[Acetabular reinforcement rings in revision total hip arthroplasty: midterm results in 298 cases]. / Abstützschalen in der Revisionsendoprothetik der Hüfte : Mittelfristige Ergebnisse von 298 Implantaten.

BACKGROUND: Acetabular revision in total hip arthroplasty (THA), especially for loose or migrated cup components with collateral bone loss, remains a great surgical challenge. The aim should always be a functionally favorable reconstruction of the rotation center with sufficient load capacity of the acetabulum. Commonly used implants in Europe are the Mueller ring, the Ganz ring, and the Burch-Schneider cage. PATIENTS AND METHODS: We report our results of 298 patients (298 hips) with a median follow-up period of 4 (range 0-17) years in a retrospective series. RESULTS: Follow-up data were available in 224 cases (75%). A radiographic examination was performed in 176 (59%) patients. Another 54 patients (18%) had died in the follow-up period, while another three patients (1%) were lost to follow-up. Eighteen patients (16%) underwent re-revision, in nine cases for aseptic loosening and in the remaining nine cases for infection. In seven additional cases (2%), radiological and clinical failure was found during follow-up. The overall survival rate was 94% at 5 years and 89% at 8 years. CONCLUSION: Revision THA using acetabular reinforcement rings results in acceptable midterm results. However, septic complications and lysis of the bone graft with consecutive failure of the reinforcement ring remain problematic.

Huge intra- and extrathoracic lymphangioma in a baby successfully treated by sclerotherapy with OK-432.

Lymphangiomas are rare congenital malformations of the lymphatic system. They typically appear within the first two years of life. They present as soft, indolent and benign tumors. As they have a tendency to grow in an infiltrating manner and rarely regress spontaneously, treatment may be necessary if the lymphangioma's location is functionally and cosmetically disturbing. Surgical therapy, which has been the treatment of choice so far, includes a risk of complications, depending on the location and extent of the tumor. Therefore alternative treatments such as sclerotherapy, especially with OK-432, have been developed. We present the case of a female baby with a huge macrocystic lymphangioma, extending over one half of the trunk, located intra- and extrathoracically, which was treated successfully by surgical resection and several intralesional injections of OK-432.

[Congenital cystic lung malformations]. / Konnatale zystische Lungenfehlbildungen.

PURPOSE: The aim of the study concerning congenital cystic lung malformations was to evaluate prenatal diagnoses postnatally to determine prognostic factors as well as to define optimized perinatal management. MATERIALS AND METHODS: The study is based on 45 prenatal ultrasound examinations depicting fetal cystic lung lesions. 32 of the mothers had follow-up examinations. 5 pregnancies were terminated due to CCAM and additional malformations. Complete regression of the lesions was seen prenatally in 8 cases and postnatally in 5 children. RESULTS: Surgical intervention due to respiratory insufficiency was necessary in 4 neonates. According to the imaging results, CCAM was present in 4 cases and sequestration in 7 patients. No correlation between the imaging findings and the surgical results was found in 3 children: One child suffered from rhadomyoid dysplasia, and in the case of the second child, a left-sided hernia of the diaphragm and additional sequestration were detected. The third child showed AV malformation. The cystic lesions of the 14 children operated upon were proven histologically. The degree of accuracy in the present study was high. CONCLUSION: Precise perinatal management is warranted in order to determine according to the clinical relevance surgical intervention and to prevent complications after the first year of life. This is performed during the neonatal period for respiratory insufficient neonates and within the first year of life for clinically stable children.

[The cemented MS-30 stem. A multi-surgeon series of 333 consecutive cases]. / Der zementierte MS-30-Schaft : Ergebnisse einer Multi-surgeon-Serie von 333 konsekutiven Fällen.

INTRODUCTION: So far there is only one peer-reviewed long-term publication from the inventors' clinic for the MS-30 stem. MATERIAL AND METHODS: In a retrospective study we followed the first 333 consecutive MS-30 stems. All patients with 5- to 11-year follow-up were clinically and radiographically evaluated. At the time of implantation the criteria of modern cementing techniques were not implemented. Clinical evaluation was done using the scores of Harris and Merle d'Aubigné and Postel. Radiographic evaluation included quality of the cement mantle (true lateral radiographs taken under fluoroscopy), stem subsidence, loosening signs, and the risk for pending failure. RESULTS: At follow-up 12 hips had undergone femoral revision: 3 for aseptic loosening, 6 for infection, 1 for periprosthetic fracture, and 2 for recurrent dislocation. The overall survival for all reasons at 10 years was 96.1%; survival with aseptic loosening as an end point was 99.0%. The median Harris Hip Score at follow-up was 80 (26-100) points. Radiological evaluation revealed a thin cement mantle (<2 mm) in approximately 2/3, predominantly on the lateral views (Gruen zones 8/9). One-third of all reviewed prostheses were considered at risk for pending failure, which strongly correlated with the initial quality of the cement mantle. CONCLUSION: Midterm results with the MS-30 stem are encouraging and an even better long-term outcome can be expected with a better cement technique.

[Effect of femoral cementing technique on results. Comparison between retrograde technique and vacuum application]. / Einfluss der femoralen Zementiertechnik auf das Zementierergebnis. Vergleich von retrograder Technik und Vakuumapplikation.

METHODS: To evaluate the penetration depth of cement into trabecular femoral bone, femora of 14 sheep were subjected to simultaneous bilateral cementing. After femoral neck osteotomy, preparation of the bone cavities and jet lavage, cement was applied simultaneously using the conventional retrograde method for one side and vacuum application for the contralateral limb. Bilateral simultaneous pressurisation was then applied. All femoral specimens were X-rayed, sawed into standardised, horizontal, stereometric, identical slices and microradiographed. Cement penetration was assessed using a morphometric software system. RESULTS: No significant differences in depth of cement penetration between sheep femora cemented with the vacuum application method and the standard retrograde method could be found or between the ratio of cement-consolidated and non-cement-consolidated cancellous bone. CONCLUSION: The more complicated and technically challenging method of cement application under vacuum had no advantage in terms of cement interdigitation over the standard retrograde method.

[Prevalence and correlates of osteoarthritis in Germany. Representative data from the First National Health Survey]. / Prävalenz und Korrelate der Osteoarthrose in der BRD. Repräsentative Ergebnisse des ersten Bundesgesundheitssurvey.

BACKGROUND: The purpose of the paper was to generate up-to-date, representative osteoarthritis prevalence data for individual population subgroups and to identify potential risk factors. MATERIAL AND METHODS: A cross-sectional study, the "First National Health Survey", investigated the prevalence of osteoarthritis, comorbidity and health-relevant behaviours of the post-unification German population on the basis of interviews with physicians and medical evaluations conducted in the period from October 1997 to March 1990. The study was based on a net sample comprising 6205 subjects aged 18-79 years. RESULTS: The three main correlates for osteoarthritis are age, obesity and occupational stress factors. Osteoarthritis patients are more likely to have osteoporosis, thyroid disease, chronic bronchial disease, hypertension and elevated blood lipids, but do not tend to have a higher incidence of diabetes. CONCLUSION: Our data show the importance of preventive behavioural approaches such as weight management and workplaces designed to limit joint overuse.

Meconium peritonitis and pseudo-cyst formation: prenatal diagnosis and post-natal course.

OBJECTIVES: Intra-uterine bowel perforation can occur secondary to a variety of abnormalities and cause sterile peritonitis in the fetus (generalised = type I). If sealing of the perforation does not take place, a thick-walled pseudo-cyst can form (type II). METHODS: Over a 12-year period, 21 616 pregnancies were screened for gastro-intestinal malformations using prenatal ultrasound. We identified 1077 cases suspicious of surgically correctable malformations. Post-natal diagnoses and outcome were worked up retrospectively. RESULT: We found 96 fetuses with suspected gastro-intestinal malformations. Prenatal bowel perforation with meconium peritonitis was confirmed in 11 cases. In 5 of these 11, the correct diagnosis had been predicted prenatally. One child presented as a fetal and neonatal emergency (case report). Ten of the eleven infants were operated on during their first day of life. Intra-operative findings were atresia (n = 4), meconium ileus (n = 6) and no obvious cause (n = 1). Two children suffered fatal complications. CONCLUSION: Meconium peritonitis and meconium pseudo-cysts as its special manifestation are assessable by prenatal diagnosis but present in different ways. They can present as fetal ascites or echogenic bowel and cause fetal or neonatal distress, requiring close observation and highly specialised care.

Pattern of periprosthetic bone remodeling around stable uncemented tapered hip stems: a prospective 84-month follow-up study and a median 156-month cross-sectional study with DXA.

Bone resorption in the proximal femur is commonly seen after total hip arthroplasty (THA). With dual energy X-ray absorptiometry (DXA), the amount of bone mass (BMD) after implantation of a total hip stem can be precisely determined. However, prospective evaluation of the change of bone mass around the stem is only available for selected stems and short-term follow-up (up to 36 months). We analyzed BMD in patients who had undergone uncemented THA by DXA. Only patients with good clinical outcome (Merle d' Aubigné score > 12) were included to obtain normative data for regular bone response. Two separate studies were performed: a prospective longitudinal study over 84 months with baseline values acquired within the first postoperative week (group A) (n = 26 patients) and a separate cross-sectional study, median follow-up 156 (124-178) months (group B) (n = 35 patients). Regions of interest were defined according to Gruen (ROI 1-7) and as net average ROI (net avg) for the periprosthetic femoral bone. After the initial remodeling process (12 months), BMD was compared to the 84-month (longitudinal) and the 156-month (cross-sectional) follow-up values to determine long-term periprosthetic changes of bone mineral density. The longitudinal study (group A), after the initial bone remodeling, showed no relevant further bone loss for women and men with BMD values 1.19 +/- 0.15 and 1.40 +/- 0.19, respectively, 12 months (women 89.8%, men 93.6%), and 1.19 +/- 0.13 and 1.36 +/- 0.18, respectively, after 84 months (women 90.0%, men 91.3%) (P = 0.98, P = 0.08,) respectively. The distribution of the BMD around the stem changed during the first 12 months. The ROIs around the proximal stem (ROI 1 and 7) showed the lowest absolute values at the 12-month follow-up and BMD in ROI 7 decreased most during the further follow-up until 84 months. The cross-sectional study (group B) showed no significant difference in BMD (net avg) values at a median of 156 months follow-up compared to the 12-month values (group A) (women: P = 0.77, men: P = 0.44). Initial BMD, implant diameter, and body mass index did not influence BMD loss (net avg) in this study, whereas age showed a weak correlation with BMD loss. The results show that after the initial remodeling process, no relevant further bone loss (net avg) occurs up to 84 months postsurgery, and values after a median of 156 months are similar. Normative long-term changes in the periprosthetic bone can be demonstrated in defined ROIs after implantation of a tapered corundum-blasted titanium stem with a good clinical result.

[Stability and occlusion of six different femoral cement restrictors]. / Stabilität und Okklusionsverhalten 6 verschiedener femoraler Markraumstopper.

Cement restrictors play an integral part in modern cementing technique in total hip arthroplasty. By sealing the femoral cavity, distal cement leakage is prevented and the intramedullary pressure is increased. Thus both the ability of the cement to interdigitate with bone and secondarily the shear strength of the cement bone interface are enhanced. For this purpose various plug models are available, which differ in design and material. Six different cement restrictors were investigated in a biomechanical model with regard to intramedullary implantation pressure, insertion force and in particular stability and sealing ability. We performed a pressure and stability measurement in artificial saw bones during the insertion and standardised cement application and pressurisation. The REX Cement Stop, which is the only intramedullary expandable cement restrictor, yielded the best results in all of the parameters investigated. The flexible gelatin plugs (Biostop G, IMSET, Plugin Tech) also reached a sufficient canal occlusion and stability, but with slightly higher insertion pressures and forces. However, the more rigid polyethylene restrictors (BUCK, Universal Cement Restrictor) showed a reduced stability and poor sealing ability. The latter devices cannot be recommended for use with modern cementing techniques.

A ten- to 15-year follow-up of the cementless spotorno stem.

We followed the first 354 consecutive implantations of a cementless, double-tapered straight femoral stem in 326 patients. Follow-up was at a mean of 12 years (10 to 15). The mean age of the patients was 57 years (13 to 81). At follow-up, 56 patients (59 hips) had died, and eight (eight hips) had been lost to follow-up. Twenty-five hips underwent femoral revision, eight for infection, three for periprosthetic fracture and 14 for aseptic loosening. The overall survival was 92% at 12 years (95% CI 88 to 95). Survival with femoral revision for aseptic loosening as an endpoint was 95% (95% CI 92 to 98). The median Harris hip score at follow-up was 84 points (23 to 100). Radiolucent lines (< 2 mm) in Gruen zones 1 and 7 were present in 38 (16%) and 34 hips (14%), respectively. Radiolucencies in zones 2 to 6 were found in five hips (2%). The results for mid- to long-term survival with this femoral component are encouraging and compare with those achieved in primary cemented total hip arthroplasty. The high rate of loosening of the cup and the high rate of pain are, however, a source of concern.

[Fat embolism during total hip arthroplasty. Cementless versus cemented--a quantitative in vivo comparison in an animal model]. / Fettembolie bei der Hüftendoprothesenimplantation. Zementfrei gegen zementiert--ein quantitativer In vivo-Vergleich im Tiermodell.

Thrombembolic complications,which include the fat embolism syndrome, are well-known consequences of cementless and cemented femoral total hip replacement. Thrombembolic phenomena have been demonstrated in clinical and experimental situations with both these fixation techniques, but so far no exact quantification of the intravasated fat emboli has been performed. In a standardized animal model in 15 Merino sheep we investigated the intravasation of fat into the bloodstream during simultaneous bilateral prosthetic implantation (cemented versus cementless). After identical preparation of the intramedullary canal on both sides, a cement restrictor was additionally inserted on the cemented side and the canal was cleaned by 250 ml jet lavage. Catheters in the external iliac veins made it possible to collect the drained blood in two phases, after preparation of the intramedullary canal and during insertion of the prosthesis, and the fat content of these blood samples was measured. The amount of fat that passed into the venous draining system of the femur induced by cemented implantation (2.2749 g; S=+/-1.0079) was twice the amount seen with cementless implantation (1.1586 g; S=+/-0.4555) ( P=0.0002). An obvious effect of the canal preparation was recognizable with the cemented implantation, 8 of the 13 animals evaluated showing a peak in the fat intravasation caused by application of the cement restrictor. Our results emphasize the importance of a thorough preparation of the intramedullary canal, particularly when cemented fixation is performed. The jet lavage,which should be considered mandatory standard in cemented total hip arthroplasty, should be implemented before the insertion of the cement restrictor in order to further reduce the risk of fat embolism.

[New PMMA bone cements for vacuum mixing systems]. / Neue PMMA-Knochenzemente zur Anwendung in Vakuummischsystemen.

In cemented total hip replacement, fractures and cracks in the cement mantle may facilitate mechanical loosening of the prosthesis. Especially large voids and flaws within the cement can cause fatigue fractures. Reduction of cement porosity is a logical step in the attempt to improve the quality and durability of bone cement. An effective reduction of pores during vacuum mixing requires prechilling of Palacos R at 4 degrees C. For easier handling, new bone cements have been developed with characteristics similar to Palacos R, but with no chilling necessary prior to mixing under vacuum. In our study two newly developed bone cements (Palamed G, VersaBond) and a bone cement used widely in clinics (Palacos R) were mixed in three different vacuum mixing systems (Optivac, MixOR, Palamix). Macro-, micro-, and total porosity and bending strength (ISO 5833) were determined. All three mixing systems proved effective in reducing porosity and showed constant mixing results. All cement specimens that we tested fulfilled the ISO requirements for bending strength. VersaBond yielded the lowest porosities, but showed lower viscosity compared to Palacos R and Palamed G. The new cements are equal in vitro to Palacos R with regard to bending strength, but further clinical studies are necessary before widespread use is advisable.

[Is the Bishop-Koop anastomosis in treatment of neonatal ileus still current?]. / Ist die Bishop-Koop'sche Anastomose bei der Behandlung des Neugeborenenileus noch zeitgemäss?

Fourty-three cases of ileus in newborns are presented. Twenty-seven newborns received a Bishop-Koop anastomosis. In 19 cases, the Bishop-Koop anastomosis was performed primarily and in 8 cases as a second intervention. We consider the Bishop-Koop anastomosis to be a safer procedure than primary end-to-end or end-to-side anastomosis. Only one anastomotic leak occurred in our patients. We prefer the Bishop-Koop anastomosis not only in cases of meconium ileus, but also in other types of intestinal atresia and stenosis, especially for the management of greatly different intestinal diameters. In our experience, this method is also suitable for re-anastomosing a double-barrel anastomosis. The Bishop-Koop procedure minimizes the risks of primary anastomosis without enterostoma, and later extraperitoneal closure of the stoma is easy and safe.