Mycoplasma hyopneumoniae resides intracellularly within porcine epithelial cells.

Enzootic pneumonia incurs major economic losses to pork production globally. The primary pathogen and causative agent, Mycoplasma hyopneumoniae, colonises ciliated epithelium and disrupts mucociliary function predisposing the upper respiratory tract to secondary pathogens. Alleviation of disease is reliant on antibiotics, vaccination, and sound animal husbandry, but none are effective at eliminating M. hyopneumoniae from large production systems. Sustainable pork production systems strive to lower reliance on antibiotics but lack of a detailed understanding of the pathobiology of M. hyopneumoniae has curtailed efforts to develop effective mitigation strategies. M. hyopneumoniae is considered an extracellular pathogen. Here we show that M. hyopneumoniae associates with integrin ß1 on the surface of epithelial cells via interactions with surface-bound fibronectin and initiates signalling events that stimulate pathogen uptake into clathrin-coated vesicles (CCVs) and caveosomes. These early events allow M. hyopneumoniae to exploit an intracellular lifestyle by commandeering the endosomal pathway. Specifically, we show: (i) using a modified gentamicin protection assay that approximately 8% of M. hyopneumoniae cells reside intracellularly; (ii) integrin ß1 expression specifically co-localises with the deposition of fibronectin precisely where M. hyopneumoniae cells assemble extracellularly; (iii) anti-integrin ß1 antibodies block entry of M. hyopneumoniae into porcine cells; and (iv) M. hyopneumoniae survives phagolysosomal fusion, and resides within recycling endosomes that are trafficked to the cell membrane. Our data creates a paradigm shift by challenging the long-held view that M. hyopneumoniae is a strict extracellular pathogen and calls for in vivo studies to determine if M. hyopneumoniae can traffic to extrapulmonary sites in commercially-reared pigs.

[Teaching medical students informed consent]. / Chirurgisches Aufklärungsgespräch in der studentischen Lehre.

BACKGROUND AND OBJECTIVES: Teaching competencies in communication are important for medical education, but implementation in the surgical curriculum is still deficient. Communication during informed consent is one main issue. The aim of the study was to implement a reproducible teaching module for informed consent, which closely represents reality. MATERIAL AND METHODS: In the existing practical surgical course we implemented a module for practising communication during surgical informed consent with the help of standardized patients and feedback rounds. The outcome was assessed during a clinical examination and the students evaluated the module. RESULTS: The module was evaluated by the students positively and deemed helpful for their later work as a doctor. The outcome at clinical examination was 63% (mean) for content and structure of the informed consent and 92% for competency in communication. CONCLUSION: For improving the quality of informed consent, teaching competencies in communication during informed consent should be implemented in the curriculum of medical studies, but legal and content-based aspects should not be ignored.

[Reconstruction of a broad infected defect zone of the distal part of the radius by tractionosteogenesis]. / Distraktionsosteogenese (Kallusdistraktion) zur Behandlung eines metaphysären Schussdefektbruches des Radius.

We report about a reconstruction of a broad infected defect zone by tractionosteogenesis and following implantation of a graft from the iliac crest and a plate fixation at the distal part of the radius after a gunshot injury by a high-velocity bullet.

["Practical clinical competence" - a joint programme to improve training in surgery]. / "Praktische klinische Kompetenz" - ein Verbundprojekt zur Verbesserung der chirurgischen Lehre.

INTRODUCTION: Practical clinical competence is, as a result of the complexity of the required skills and the immediate consequences of their insufficient mastery, fundamentally important for undergraduate medical education. However, in the daily clinical routine, undergraduate training competes with patient care and experimental research, mostly to the disadvantage of the training of clinical skills and competencies. All students have to spend long periods in compulsory surgical training courses during their undergraduate studies. Thus, surgical undergraduate training is predestined to exemplarily develop, analyse and implement a training concept comprising defined learning objectives, elaborated teaching materials, analysed teaching methods, as well as objective and reliable assessment methods. THE PROJECT: The aim of this project is to improve and strengthen undergraduate training in practical clinical skills and competencies. The project is funded by the German Federal Ministry of Education and Research with almost two million Euro as a joint research project of the medical faculties of the universities of Frankfurt/Main, Gießen and Marburg, in collaboration with the German Society of Surgery, the German Society of Medical Education and the German Medical Students' Association. Nine packages in three pillars are combined in order to improve undergraduate medical training on a methodical, didactic and curricular level in a nation-wide network. Each partner of this network provides a systematic contribution to the project based on individual experience and competence. Based on the learning objectives, which were defined by the working group "Education" of the German Society of Surgery, teaching contents will be analysed with respect to their quality and will be available for both teachers and students as mobile learning tool (first pillar). The existing surgical curricula at the cooperating medical faculties will be analysed and teaching methods as well as assessment methods for clinical skills will be evaluated regarding their methodological quality and evidence. The existing surgical curricula will be revised and adapted on the basis of these results (second pillar). Qualification programmes for physicians will be implemented in order to improve both undergraduate education and the attractiveness of educational research, the required teaching quality will be imparted in a nationwide "train-the-teacher" program for surgical clinical skills (third pillar).

Tuberculous coxitis: diagnostic problems and varieties of treatment: a case report.

Although the prevalence of tuberculosis reduces, it still belongs to the most important infectious diseases worldwide even in industrial countries.We report an unusual case of tuberculous coxitis in a 28-year-old healthy native female with recurrent hip pain. While X-ray and microbiological examination of the aspirate showed no abnormality, only extended diagnostic measurements and detailed history led to the diagnosis of TBC. Although the patient did not show any pulmonary symptoms open tuberculosis was confirmed. After a course of antibiotic treatment she underwent reconstructive surgery which consecutively improved range of motion. This case report emphasizes that tuberculosis should still be considered as a significant disease even in healthy patients with uncertain complaints in joints without significant initial radiographic abnormalities. We recommend the described diagnostic procedures as well as an antibiotic and surgical treatment.

[Operative treatment of osseous pull out of the extensor tendon using a hook plate]. / Die Versorgung der dorsalen Endphalanxbasisfraktur der Langfinger mittels Hakenplatte.

OBJECTIVE: Anatomical reposition and stabilization of dorsal distal phalanx fractures with a hook plate. INDICATIONS: Dislocated mallet fractures type Doyle IVb with dislocation of the fragment by more than 2 mm and/or tilting of the fragment as well as dislocation of the dorsal distal phalanx fractures type Doyle IVc. CONTRAINDICATIONS: Florid inflammation of and injuries to the soft tissues in the operation area. SURGICAL TECHNIQUE: Dorsal approach to the distal interphalangeal joint (Y-, S-, H-shaped). Preparation of the fragment, cleaning the fracture gap, repositioning of the fragment, mounting of the plate, placing the screw. Controlling by image converter. Suture of the skin; tape. POSTOPERATIVE MANAGEMENT: Stack splint for 4 weeks. After week 3, start with exercising of the distal interphalangeal joint within the splint. Physiotherapy is usually not required. Full exertion after 6-8 weeks is possible. The period of inability to work is dependent on the patient's occupation. Due to the danger of perforation and infection, it is recommended that the plate be removed after 3-6 months. RESULTS: From February 2002 to September 2009, 77 mallet fractures type Doyle IVb and IVc were operatively stabilized with a hook plate. In a retrospective study, 59 patients were followed up at a mean interval of 38.3 (3-69) months after the operation. Wound healing problems or inflammation were not observed. Visible disturbances of nail growth were macroscopically seen in 11.9%. Results were very good in 35 patients (59.3%), good in 16 patients (27.1%), sufficient in 5 patients (8.5%), satisfying in 1 patient (1.7%), and insufficient in 2 patients (3.4%).

[Operative treatment of rhizarthritis: comparison of ligament reconstruction according to Epping with trapezectomy and interposition of pyrocarbon spacers as replacement of the trapezium]. / Operative Versorgung der Rhizarthrose: Vergleich der Resektionssuspensionsarthroplastik mit der Trapezektomie und Interposition eines Pyrocarbonspacers als Trapeziumersatz.

BACKGROUND: Rhizarthritis is the most common form of arthritis of the hand with a frequency of 10% and conservative as well as surgical methods of treatment are available. The aim of this study was to compare the results of resection suspension arthroplasty according to Epping with trapezium replacement using pyrocarbon spacers. MATERIAL AND METHODS: Between January 2001 and December 2008 a total of 84 patients were surgically treated for rhizarthritis in our clinic. Of these patients 12 were treated with other surgical procedures, 40 with resection suspension arthroplasty according to Epping and 32 with pyrocarbon spacers as trapezium replacement. The patients were examined in a retrospective study and success of treatment was evaluated according to the Buck-Gramcko criteria. RESULTS: According to the evaluation criteria over 80% of patients in both collectives achieved very good or good operative results with the same degree of satisfaction. CONCLUSION: The results of this study confirm the value of resection suspension arthroplasty according to Epping for surgical treatment of rhizarthritis. Using trapezectomy with interposition of pyrocarbon spacers good or very good results can be achieved in the majority of cases. Essential points of criticism are the current material cost of 930 Euros and 4 dislocations in our collective but with good multiaxial movement and loading capacity. Comparable results using alternative procedures indicate that the results of further studies and long-term results will be decisive for establishment of this operational procedure.

[Operative treatment of the mallet fracture using a hook plate]. / Die Versorgung der Fraktur der dorsalen Endphalanxbasis mit der Hakenplatte.

AIM: The aim of the present investigation was to evaluate the outcome after operative treatment of dorsal distal phalanx fractures near to the base of type Doyle IVb and IVc by means of a hook plate. PATIENTS AND METHODS: Between February 2002 and September 2009 77 patients were treated by operation by means of 77 hook plates because of a fracture of the dorsal distal phalanx near to the base of type Doyle IVb and IVc. 59 of these patients, 13 women, 46 men, with an average age of 29.3 (13-72) years were followed up for on average 38.3 (3-69) months after operation. At follow-up the range of movement in the distal interphalangeal joint was measured compared to the other hand, nail growth defects were registered and an X-ray examination of the finger was performed. The patients were asked about pain, limitations of function, the satisfaction with the aesthetic result and whether the patients would undergo the same operation once more. The total result was judged by means of a self-made scale of assessment by evaluating the objective and subjective data. RESULTS: Postoperative bleeding, disorders of wound healing and infections were not observed. In 7 patients nail growth defects were found, 3 of which were subjectively very irritating. The material for osteosynthesis was removed 14 times, while the plate had to be removed prematurely due to imminent perforations two times. After a renewed trauma, a dislocation of the fragments was observed. The mean range of movement in the distal interphalangeal joint was amounted to 77 (0-90) degrees, showing a mean deficiency in extension of 7 degrees (0-32 degrees) and a mean deficiency in flexion of 7 degrees (0-40 degrees) compared to the unharmed opposite side. The total result was assessed 51 times (84.7%) as very good, 5 times (8.5%) as good and 4 times (6.8%) as bad. CONCLUSION: Even if the operation technique is relatively uncomplicated and even in the majority of the cases one can achieve very good or good results in the treatment of the dorsal distal phalanx fractures near to the base, the rate of complication is significant with 7 nail growth defects and two premature removals of the plate due to imminent perforation of the skin. Considering this rate of complication the indication, the operation technique and the implant require verification.

[Treatment of epicondylitis - a current review]. / Die Therapie der Epicondylitis - eine aktuelle Übersicht.

Lateral epicondylitis or tennis elbow is a common injury, which affects not only people who play tennis but occurs with many different activities. It reflects overuse of the extensor muscles of the forearm. There are some other pathologies which have to be separated from epicondylitis. The choice of different treatments is hard to overlook and there are only a few good clinical trials which support one treatment option by means of evidence based medicine. During the acute phase topical NSAIR, steroid injections, ultrasound and acupuncture are helpful. There is no consensus about the effectiveness of physiotherapy, orthoses, laser, electrotherapy or botulinumtoxininjections. During the chronic phase none of the different treatment modalities is effective according to criterias of evidence based medicine. By now, it has not been proven whether patients profit during that time of physiotherapy, orthoses, extracorporeal shock wave therapy or an operation. Whether orthobiological treatment options may play a role in the future is presently uncertain.

[The operative treatment of the dorsal distal phalanx near to the base (osseous pull out of the extensor tendon) with extreme exposure of the hand by athletic activities - is the hook plate a option for treatment?]. / Ist die Hakenplatte die geeignete Osteosynthese zur Versorgung der dorsalen Endphalanxbasisfraktur (knöcherner Strecksehnenausriss) beim Sportler mit starker Belastung der Finger?

AIM: Aim of the presented investigation was to work out the short- and mid-term outcomes after operative treatment of distal phalanx fractures near to the base of type Doyle IVb and IVc (osseous pull out of the extensor tendon) by means of a hook plate in patients with extreme exposure of the hand by athletic activities. PATIENTS AND METHODS: Between February 2002 and September 2009 77 patients were treated by operation in our hospital by means of a hook plate due to a traumatic fracture of the dorsal distal phalanx near to the base of type Doyle IVb and IVc (osseous pull out of the extensor tendon) by means of a hook plate (Aerni plate/S2-Prong-Plate) of Stryker Leibinger. 64 of these 77 patients incur the fracture while exercising sport. 46 of these 64 patients were clinically and radiologically followed up within a retrospective study. To assess the therapy's outcome a specific scoring scheme containing subjective and objective parameters was elaborated in order to gain a transparent result of the treatment. RESULTS: According to this scoring scheme 84.79 % of the patients reached a very good or good result. Nail growth defects by an intraoperative injury of nail matrix represents an essential complication of the presented surgical method. CONCLUSION: By means of the presented method in the majority of the cases good or very good results could be achieved. That method represents a simple, safe and less complicate possibility to treat the distal phalanx fractures near to the base type IVb and IVc according to Doyle and it is considered as a useful alternative to other procedures.

[Usefulness of 16S rDNA polymerase-chain-reaction (PCR) in the intraoperative detection of infection in revision of failed arthroplasties]. / Wert der 16S rDNA Polymerase-Ketten-Reaktion (PCR) zur intraoperativen Infektdetektion bei Endoprothesenrevisionseingriffen.

AIM: In this study the accuracy of the 16S DNA polymerase chain reaction (PCR) in revision arthroplasties was compared to that of conventional bacterial culture when correlated to intraoperative histological findings. Furthermore, the influence of antibiotic treatment and different ways of collecting samples was evaluated. METHOD: In a prospective study we collected samples of tissues, aspiration fluids and swabs during revision arthroplasty surgery and examined them with PCR as well as conventional bacterial culturing methods. Also, we correlated these two methods with the histological findings of intraoperative tissue samples. Two independent examiners evaluated the samples according to the criteria of Mirra et al. Sensitivity, specificity, positive and negative prediction value and the accuracy were calculated for the molecular biological and culture methods. Three groups were defined to evaluate the influence of accompanying antibiotic treatment and the way of collecting the microbiological samples. RESULTS: Nine periprosthetic infections could be detected by PCR as well as by conventional bacterial culturing. Correlated with the 25 positive histological findings this resulted in a sensitivity of 0.36, a specificity of 1.0, a negative prediction value of 0.61, a positive prediction value of 1.0 and an accuracy of 0.68 for both methods. Swabs compared to aspiration fluids and tissues samples showed the highest sensitivity with both methods. No higher sensitivity of PCR compared to conventional bacterial culturing could be observed in patients with accompanying antibiotic treatment. CONCLUSION: Although PCR is more rapidly available for the diagnosis of periprosthetic infection, a definite advantage of this more expensive method could not be demonstrated in view of the same low sensitivity of PCR and conventional bacterial culturing.

[Infection diagnosis after knee-TEP-implantation]. / Infektdiagnostik nach Knie-TEP-Implantation.

AIM: In this study, the accuracy of antigranulocyte scintigraphy as a diagnostic means prior to revision in infected total knee replacement was compared to that of preoperative joint aspiration and laboratory parameters. The most efficient combination of all diagnostic methods was calculated and thus a diagnostic algorithm recommended. The value of PCR was compared to commonly used techniques of microbiological culturing. METHODS: Preoperative diagnostic means for infection of 50 total knee replacements in 45 patients requiring revision surgery, were retrospectively analyzed. Inclusion criteria were the intraoperative microbiological and histological verification of infection. Sensitivity, specificity, negative and positive prediction value of C-reactive protein (CRP) and leukocytes, antigranulocyte scintigraphy with (99m)Tc-labeled antibodies, and preoperative joint aspiration were calculated. Furthermore, the accuracy of the different techniques of culturing was compared to that of the polymerase chain reaction (PCR) based on the intraoperative histological findings. Two blinded examiners evaluated specimens taken intraoperatively according to the criteria of Mirra. RESULTS: We observed a sensitivity of 1.0, a specificity of 0.82, a positive prediction value of 0.83 and a negative prediction value of 1.0 for the antigranulocyte scintigraphy. The sensitivity of preoperative joint aspiration was 0.5, the specificity 1.0, and the positive and negative prediction values were 1.0 and 0.5. Correlated to the intraoperative histological findings the accuracy of PCR and culturing was comparable. The highest accuracy was obtained for blood culture samples. CONCLUSION: Compared to preoperative joint aspiration the antigranulocyte scintigraphy proved to be more sensitive in the diagnosis an infected knee replacement while having a high specificity. An advantage of PCR compared to the common microbiological culturing techniques was not observed.

[Stage diagnostics for postinfection revision of hip and knee replacement: value of laboratory parameters and antigranulocyte scintigraphy]. / Stufendiagnostik bei postinfektiöser Hüft- und Knie-TEP-Implantation: Aussagekraft von Laborparametern und Antigranulozytenszintigraphie.

AIM: In the case of two-stage infect revision arthroplasties of hip and knee joint, of primary resection arthroplasties and before implantation of arthroplasties after septic arthritis the accuracy of preoperative laboratory parameters and antigranulocyte scintigraphy was analysed. Furthermore, we stained the intraoperatively taken joint synovial samples with hematoxylin-eosin and also with antibodies against human neutrophil elastase in order to investigate if immunohistological examination provides further or different information. METHOD: In 24 patients with intraoperative verification of infection we calculated sensitivity, specificity, positive and negative predictive values for laboratory tests, antigranulocyte scintigraphy and the most suitable combination of both. The joint synovial samples stained with antibodies against human neutrophil elastase were compared to those stained with hematoxylin-eosin according to the criteria of Mirra. RESULTS: We observed the best results for the combination of C-reactive protein and antigranulocyte scintigraphy with a sensitivity of 1, a specificity of 0.92, a positive predictive value of 0.75 and a negative predictive value of 1. No additional or different information was observed by the immunohistological stained samples. CONCLUSION: Stage diagnostic using C-reactive protein and antigranulocyte scintigraphy provides accurate information to assess the status of infection before hip and knee replacement after infect revision. Additional immunohistological staining besides the routinely taken hematoxylin-eosin staining of joint synovial samples is not recommended.

[Patella resurfacing in patients without substantial retropatellar knee pain symptoms?]. / Patellarückflächenersatz bei Patienten ohne wesentliche retropatellare Beschwerdesymptomatik?

OBJECTIVE: The aim is of this prospective randomised study was to investigate the necessity of resurfacing the patella in combination with total knee arthroplasty in patients without or mild anterior knee pain before undergoing total knee replacement. METHODS: Between May 1999 and May 2000 fifty patients were enrolled in a prospective, randomised study. All patients received the same posterior-cruciate-sparing total knee replacement and were randomised to treatment with and without resurfacing of the patella. Inclusion criteria were primary osteoarthritis of the knee, preoperatively no pain when the patella was shifted during clinical examination, a maximal grade III radiological degeneration of the patella according to Sperner et al. and at most a mild anterior knee pain in preoperative interview. Evaluations consisted of the determination of the Knee Society clinical score, the completion of a patient satisfaction questionnaire, and radiographic assessment basing on the Knee Society roentgenographic evaluation and scoring system. All patients were examined preoperatively and 3, 6, and 12 months postoperatively. RESULTS: In all postoperative examinations patients with patella resurfacing demonstrated a higher overall Knee Society score. At month 6 the difference was statistically significant. The patient satisfaction questionnaire demonstrated no significant difference between both groups. However, regarding to relief of anterior knee pain and improvement of pain in general patients with nonresurfacing were less satisfied at all follow-ups. Furthermore, after 12 months all answers to the patient satisfaction questionnaire of the resurfaced group were better. Patella-associated revisions were performed in two patients without resurfacing. Radiographic analysis demonstrated no loosening, fracture, subluxation or dislocation. CONCLUSION: The presented study demonstrated after one year follow-up a better functional result, a higher degree of contentment and fewer complications after total knee replacement with patella resurfacing in patients without or mild preoperative anterior knee pain.

[Femoral neck fractures in the elderly -- bipolar hemiarthroplasty in total hip replacement]. / Die Schenkelhalsfraktur beim alten Menschen--Bipolare Hemiendoprothese vs. Totalendoprothese.

INTRODUCTION: In this study surgical risk and functional outcome of bipolar hemiarthroplasty and total hip replacement in elderly patients with femoral neck fractures were compared. METHODS: In a prospective study 54 patients with femoral neck fractures (median age: 80.5 years) were treated by implanting a total hip replacement (group I). Group II comprised 52 patients with 55 femoral neck fractures (median age: 81 years) who underwent bipolar hemiarthroplsty. Pre- and postoperative mobility and social history, perioperative parameters such as duration of surgery, blood loss, and number of transfused blood units as well as postoperative complications and mortality were compared. Function was ascertained by a scoring system. RESULTS: Duration of surgery, blood loss, and numbers of transfused blood units were significantly lower in group II, and mortality rate was lower. Postoperative mobility and medium-term functional score were comparable, whereas in the longer-term follow-up after 8 years group I had a significantly better functional score. CONCLUSION: In elderly patients with femoral neck fracture and high comorbidity, we recommend the implantation of hemiarthroplasty and in healthy, active patients with longer life expectancy the total hip replacement.

[Osteochondritis dissecans - an easy classification in MRI]. / Osteochondrosis dissecans - Darstellung einer einfachen und praktikablen Klassifizierung mittels MRT.

AIM: For the diagnosis of osteochondritis dissecans (OD) MRI is used besides X-ray. However, there is no consensus about the necessity of MRI or the interpretation of MRI. The aim of this prospective study was to find a diagnostic concept for OD which is simple and practicale for daily routine. METHOD: In 90 patients with OD of the knee or ankle MRI (T1- and T2-w SE) was carried out before arthroscopy. According to the interface between the osteochondral fragment and the parent bone, MRI was classified in 2 stages ("stable" or "unstable") and compared with the arthroscopic findings. RESULTS: With the 2-stage classification of MRI, a prediction of the stability of the osteochondral fragment was possible in 92 %. Out of the 90 patients 7 (8 %) differed regarding preoperative stability in MRI compared to stability in arthroscopy. Incorrect diagnosis in MRI was only found among the patients with unstable fragments. CONCLUSION: The chosen 2-stage classification in MRI is well suitable for the planning of stage-related therapy.