[Oberst's block anesthesia]

OBJECTIVE

Complete anesthesia of the phalanges of the fingers and toes.

INDICATIONS

All lesions distal to the metacarpophalangeal/metatarsophalangeal joint.

CONTRAINDICATIONS

Local infections at the injection site. Lesions proximal to the metacarpophalangeal/metatarsophalangeal joint.

TECHNIQUE

A subcutaneous deposit of a 0.5-2% local anesthetic is administered dorsoradially and dorsoulnarly at the base of the metacarpophalangeal/metatarsophalangeal joint. With the cannula advanced to palmar, an additional 0.5-1.5 ml is then administered to achieve complete anesthesia.

POSTOPERATIVE MANAGEMENT

The effect of the local anesthesia is self-limiting.

RESULTS

The Oberst block results in reliable anesthesia of the finger and toe. All surgical procedures distal to the metacarpophalangeal/metatarsophalangeal joint can be performed without pain.

[The Joy of Being a Surgeon - How to Generate Enthusiasm in Undergraduate Medical Education - A Local Example: The "Göttinger Aufschneidertag"]

Offering a full-day program including practical courses and the possibility of direct exchange between medical students and university teachers, the "Göttinger Aufschneidertag" was launched to generate enthusiasm for surgery. Workshops comprising four surgical disciplines enable participants to gain insight into the craft of surgery. The program aims to create interest in surgery among medical students at an early point of their studies and to make them enjoy their profession.

[Infiltration anesthesia]

OBJECTIVE

Complete anesthesia of any skin and soft tissue area by intradermal, subcutaneous, or intramuscular injections.

INDICATIONS

Small injuries or incisions in limbs or trunk, minor surgery on the face/jaw (e.g., on the teeth), or postoperative analgesia (local infiltration anesthesia, LIA).

CONTRAINDICATIONS

Local infections at the injection site.

SURGICAL TECHNIQUE

By means of intradermal, subcutaneous or intramuscular administration, a grandeur arises, here the local anesthetic blocks nerve transmission. If anesthetized distal to end arteries, vasoconstrictors (e.g., epinephrine) should be avoided. Proximal to end arteries, localized ischemia may facilitate operative care.

POSTOPERATIVE MANAGEMENT

The effect of local anesthesia is self-limiting.

RESULTS

By means of infiltration anesthesia or "field block", larger areas of skin are easily accessible for surgical treatment. The amount to be applied has to be adapted to the extent of the operation and the maximal dose. Postoperatively, after knee or hip arthroplasty, analgesia consumption can be reduced, and early mobilization promoted using LIA.

It is time for a change in the management of elderly severely injured patients! An analysis of 126,015 patients from the TraumaRegister DGU®

BACKGROUND

The number of elderly patients among the severely injured has been increasing continuously. It has been suggested that an increased life expectancy and a higher level of activity and mobility in older ages could explain this observation. Elderly trauma patients have relevant higher mortality rates and poorer functional outcomes. The reasons remain unclear. The aim of this study was to look for differences in the management of severely injured elderly patients compared to younger age groups and to evaluate their potential impact on outcome.

METHODS

The TraumaRegister DGU^® is a multicenter database that documents de-identified data of severely injured patients since 1993. Trauma cases documented between 2009 and 2016 with an ISS ≥ 9 were divided in four age groups. The groups were compared with respect to mechanism of injury, pattern of injury, severity of injury, management and outcome.

RESULTS

The analysis of 126,015 severely injured patients showed that 37.5% of the population were elderly patients (≥ 60 years). Their rate actually increased every year by 1.7%. The elderly trauma patients experience different mechanisms of injury (more low energy trauma) and different pattern of injuries (more brain trauma, less abdominal and extremity injuries). Evaluating the management of patients showed that elderly patients have lower intubation rates and less volume replacement in the prehospital setting. Diagnostic interventions like CT scans in the emergency room were performed more restrictively. Elderly trauma patients also received fewer surgical interventions for brain injuries, pelvic fractures and femur fractures. Their hospital mortality rates were higher.

CONCLUSIONS

Severely injured elderly patients are treated with a more "wait and see approach" resulting in higher mortality rates. We suggest that this population needs a more "aggressive management" to improve their outcome, if the wish to perform complete treatment including surgical procedures and intensive care medicine has not been excluded by the patients or their legal guardian.

Of Cestodes and Men: Surgical Treatment of a Spinal Hydatid Cyst

Background The cestode Echinococcus granulosus causes hydatid disease. In addition to manifestations in the liver and lung, it can lead to cystic lesions in the spine.

Case Description We report a 42-year-old male patient with primary hydatid disease in the eighth thoracic vertebra. The only clinical symptom was chronic back pain. Although laboratory findings were normal, imaging displayed lytic destruction that raised the suspicion of a metastatic disease. Diagnostics of the thoraces and abdomen did not reveal other pathologic abnormalities. Follow-up magnetic resonance imaging (MRI) depicted a progressive compression of the spinal cord and inhomogeneous structure in the fat-suppressed sequences. Because the Jamshidi biopsy was inconclusive, the tumor board recommended surgery. Dorsal decompression, spondylodesis of T6–T10, and vertebral column resection of T8 with complete cyst removal were performed. The resected vertebrae showed a mucous-like lesion with white granular tissue interfusing the whole vertebral body. A pathologic examination and enzyme-linked immunosorbent assay confirmed E. granulosus. Thus chemotherapy with albendazole was initiated. A follow-up MRI of the whole spine confirmed complete remission and found no additional resettlements. The patient's back pain was resolved without neurologic deficits.

Conclusions For lytic manifestations of the vertebral column, hydatid cysts should be considered a differential diagnosis in addition to malignant metastasis, tuberculosis, and osteomyelitis. Thorough surgical resection and strict follow-up are necessary.

Effect of alendronate or 8-prenylnaringenin applied as a single therapy or in combination with vibration on muscle structure and bone healing in ovariectomized rats

Bisphosphonate alendronate (ALN), phytoestrogen 8-prenylnaringenin (8-PN) and the whole body vibration exert a favorable effect on osteoporotic bone. However, the impact of these treatments and the combination of pharmacological therapies with biomechanical stimulation on muscle and bone has not yet been explored in detail. The effect of ALN and 8-PN and their combination with the vibration (Vib) on skeletal muscle and bone healing was investigated in ovariectomized (Ovx) rats.

Three-month old rats were Ovx (n = 78), or left intact (Non-Ovx; n = 12). Five weeks after Ovx, all rats were treated according to the group assignment (n = 12/13): 1) Non-Ovx; 2) Ovx; 3) Ovx + Vib; 4) Ovx + ALN; 5) Ovx + ALN + Vib; 6): Ovx + 8-PN; 7) Ovx + 8-PN + Vib. Treatments with ALN (0.58 mg/kg BW, in food), 8-PN (1.77 mg/kg BW, daily s.c. injections) and/or with vertical vibration (0.5 mm, 35 Hz, 1 g, 15 min, 2×/day, 5×/week) were conducted for ten weeks. Nine weeks after Ovx, all rats underwent bilateral tibia osteotomy with plate osteosynthesis and were sacrificed six weeks later.

Vibration increased fiber size and capillary density in muscle, enlarged callus area and width, and decreased callus density in tibia, and elevated alkaline phosphatase in serum. ALN and ALN + Vib enhanced capillarization and lactate dehydrogenase activity in muscle. In tibia, ALN slowed bone healing, ALN + Vib increased callus width and density, enhanced callus formation rate and expression of osteogenic genes. 8-PN and 8-PN + Vib decreased fiber size and increased capillary density in muscle; callus density and cortical width were reduced in tibia. Vibration worsened 8-PN effect on bone healing decreasing the callus width and area.

Our data suggest that Vib, ALN, 8-PN, or 8-PN + Vib do not appear to aid bone healing. ALN + Vib improved bone healing; however application is questionable since single treatments impaired bone healing. Muscle responds to the anti-osteoporosis treatments and should be included in the evaluation of the drugs.

•

Vibration (Vib) was beneficial for muscle structure, it tended to interfere with early bone healing.

•

Alendronate (ALN) enhanced capillary density and metabolism in muscle, slowed bone healing.

•

8-Prenylnaringenin (8-PN) had favorable effects on muscle, for bone healing it was disadvantageous.

•

8PN + Vib further worsened 8-PN effect on bone, ALN + Vib improved bone healing.

•

Muscles respond to anti-osteoporosis treatments, their analysis should be included in the evaluation of drugs.

[Posterior vertebral column resection for correction of kyphotic deformity due to osteoporotic fractures of the thoracic spine]

OBJECTIVE

The posterior vertebral column resection (PVCR) comprises a one-step resection of the vertebral body by a costotransversectomy together with a 360° spondylodesis. After removing the vertebral body, straightening of the existing kyphotic malposition is possible.

INDICATIONS

Pronounced thoracic kyphosis after osteoporotic sintering fractures in one or more vertebral bodies.

CONTRAINDICATIONS

General contraindications for surgical procedures, ASA >3 (American Society of Anesthesiologists).

SURGICAL TECHNIQUE

First, dorsal stabilization of the vertebral column on at least two levels cranial and caudal of the VCR. Next, in a one-step procedure the laminectomy with costotransversectomy and the resection of the vertebral body is done. The ventral defect gap is filled by a mesh cage to provide ventral support. By compression the malposition is reduced and the mesh cage is fixed into position. Finally the vertebrae joints are opened up using a chisel and bone or bone substitute is placed to complete the 360° spondylodesis.

POSTOPERATIVE MANAGEMENT

Functional treatment without peak load exercises as well as appropriate osteoporosis treatment.

RESULTS

In a retrospective study 10 patients treated with this surgical technique were investigated. The results show a very good correction of the kyphotic maldeformity while the complications remain moderate.

Zum Einfluss einer Tanz- und Sportintervention auf motorische und psychische Merkmale älterer Menschen

Zusammenfassung. Körperliche Leistungsfähigkeit sowie Lebenszufriedenheit als auch ein stabiler Selbstwert unterstützen gesundes Altern. Durch körperliches Training können altersbedingte motorische und psychologische Merkmale positiv beeinflusst werden. In der Studie werden Effekte von körperlichem Training auf motorische Fähigkeiten (Gleichgewicht, Reaktion) sowie psychische Merkmale (Selbstwert, Lebenszufriedenheit) älterer Menschen untersucht. 132 Seniorinnen und Senioren ( M = 69.58 Jahre, SD = 4.02 Jahre) wurden zufällig drei Interventionsgruppen Tanz, Sport, Tanz und Sport zugeordnet. Die Gruppe Tanz und die Gruppe Sport trainierten jeweils 90 Minuten wöchentlich, die Gruppe Tanz und Sport 180 Minuten über 15 Monate. Nach Messung der Ausgangssituation (Prä-Test) wurden nach sieben Monaten der Post-Test 1 und nach 15 Monaten der Post-Test 2 durchgeführt, wobei 95 komplette Datensätze nach Drop-Out ausgewertet werden konnten. Für die gesamte Stichprobe konnten positive Veränderungen in den gemessenen motorischen Fähigkeiten nachgewiesen werden. Sie traten in allen drei Versuchsgruppen gleichermaßen auf. Die psychischen Merkmale Selbstwert und Lebenszufriedenheit veränderten sich im Interventionszeitraum nicht.

[Dorsal stabilization of C1/C2 modified according to Goel-Harms with C1 pedicle screws]

OBJECTIVE

Stabilization of the atlantoaxial transition by an alternative screw position in C1.

INDICATIONS

Instabilities C1/C2 due to inflammation, tumor or trauma.

CONTRAINDICATIONS

Presence of a very small pedicle of C1. Variations in the course of the vertebral arteries.

SURGICAL TECHNIQUE

The midline approach to the upper cervical spine is used for the modified instrumentation of C1 with pedicle screws instead of Harms screws and for the unaltered instrumentation of C2. Depending on the indication, dorsal spondylodesis is performed by opening the laminae and attaching ceramic bone substitute material.

POSTOPERATIVE MANAGEMENT

In mobile patients, additional immobilisation with a soft collar is recommended for 6 weeks. Full recovery is given 3-4 months after surgery.

RESULTS

From January 2017 to September 2018, 21 stabilizations of the atlantoaxial transition were performed. The mean age was 72.52 ± 15.45 years. A total of 42 screws were placed in C1. In all, 21 (50%) C1 pedicle screwscould be placed, and in other 21 cases Harms screws were used. Complications were seen in 3 patients. Overall, considering the contraindications, the instrumentation of C1 with pedicle screws appears as a safe alternative to instrumentation with Harms screws.

[Intraoperative revision of initially loosened pedicle screws]

OBJECTIVE

Intraoperative revision of initially loosened pedicle screws.

INDICATIONS

Intraoperatively loosened/stripped pedicle screws.

CONTRAINDICATIONS

None.

SURGICAL TECHNIQUE

Removal of the loosened/stripped pedicle screw. Checking the screw channel and re-implantation using a different trajectory, a larger screw diameter or a cement-augmented pedicle screw.

POSTOPERATIVE MANAGEMENT

Early functional mobilization and initiation of osteoporosis therapy if indicated.

RESULTS

A biomechanical study with human vertebral bodies was performed. Augmented and not augmented pedicle screws were tested until loosening using a fatigue testing setup. After loosening occurred a subsequent augmentation of the loosened, not augmented screw was performed, and it was tested using a fatigue test again. Both the initial (p = 0.009) and the augmentation after loosening (p = 0.001) showed a significant increase in failure load compared to the non-augmented pedicle screws. In our own patient collective from April 2016 to August 2018, 11 of 524 patients treated with pedicle screws showed intraoperative screw loosening. This was revised in 6 cases with a subsequent augmentation and in 5 cases with a larger screw diameter. In the postoperative control at 6 weeks, none of these screws showed loosening again.

[Pedicle subtraction osteotomy to correct rigid deformities]

OBJECTIVE

The aim of the surgery is to restore the sagittal profile in the event of a mismatch of the patient's spinopelvic parameters and high patient suffering.

INDICATIONS

Clinically symptomatic sagittal imbalance due to degeneration, trauma or after spinal surgery which can not be adequately treated by conservative therapy.

CONTRAINDICATIONS

Severe general disease of the patient; local or systemic inflammation.

SURGICAL TECHNIQUE

A dorsal approach is used to resect the dorsal vertebral structures and to perform an osteotomy to the anterior edge of the spine.

POSTOPERATIVE MANAGEMENT

Rest with a load limit of 5 kg for 3 months. Prohibition of deep sitting for this time.

RESULTS

The pedicle subtraction osteotomy is described in the literature as a reliable method for the treatment of sagittal imbalance. The high rate of described complications should be discussed preoperatively with the patient.

Determinants for success in climbing: A systematic review

Background

The number of athletes engaged in climbing sports has risen. Specific physical and psychological skills are required. The objective of this review was to determine factors for high climbing performance. We evaluated physiological, biomechanical and psychological characteristics that simplify the ascent. We also assessed training and recovery strategies.

Methods

Medline (Pubmed), Cochrane Library and Google scholar up to September 2018.

Results

A low skinfold thickness, body fat and large forearm volume were anthropometric traits in successful climbers. Well-trained forearm flexors with high aerobic capacities lead to an efficient style. Hand grip strength and endurance, postural stability and optimized kinematic motions were favourable. Elite climbers had long finger and bent-arm hang times. Psychologically, an “iceberg profile” was typical. Constant training with fingerboard and dynamic eccentric-concentric training helped to push the “red-point grade”.

Conclusion

Hand, forearm strength and endurance are highly important elements in elite climbers. An efficient climbing style with perpetual focus and accuracy, high speed and low exhaustion due to adaption to repeated isometric exercise is helpful in the ascent, while low body fat and a large bone-to-tip pulp make it easier. Constant training is essential, e.g. eccentric-concentric training of finger flexors, which should be followed by active recovery.

•

Physiological parameters of high climbing performance are forearm flexor strength and a good strength-to-weight ratio.

•

An efficient climbing style is based on perpetual focus, accuracy and a high postural stability.

•

With constant training, especially isometric exercise, followed by active recovery, climbing red-point grade can be improved.

Evaluation of ostarine as a selective androgen receptor modulator in a rat model of postmenopausal osteoporosis

Selective androgen receptor modulators (SARMs) have shown beneficial effects on muscle wasting, general physical function and bone properties in male mammals. However, data on the effects of SARMs in postmenopausal osteoporotic bone are scarce. We evaluated the effects of the SARM drug ostarine on postmenopausal osteoporotic bone in a rat osteoporosis model. Ovariectomy was performed on 46 of 56 3-month-old female Sprague-Dawley rats. Eight weeks after ovariectomy, ostarine was orally administered daily for 5 weeks in dosages of 0.04 (low, OVX + Ost. 0.04), 0.4 (intermediate, OVX + Ost. 0.4), and 4 mg/kg (high, OVX + Ost. 4) body weight. Another ovariectomized group received no ostarine. Lumbar vertebrae and femora were removed for biomechanical, gene expression, ashing, and computer tomography analyses. Low dose showed no effects. The effects of intermediate and high doses were comparable overall. Improvements were mainly seen in structural properties such as bone mineral density and bone volume density. However, the effects in femora were superior to effects in vertebrae. Ostarine treatment for 5 weeks did not improve significantly biomechanical properties. mRNA expression of the receptor activator of NF-κB ligand decreased after treatment, and uterine weight increased. Serum levels of phosphorus increased following ostarine treatment in intermediate and high-dose groups. Short-term treatment of osteoporotic bone with ostarine leads to improvement of several microstructural bone indices. While we did not observe changes in biomechanics, it is conceivable that longer treatment may also improve biomechanical properties. Further studies are needed to characterize longer time effects and side effects of ostarine in osteoporosis.

A bioactive nano-calcium phosphate paste for in-situ transfection of BMP-7 and VEGF-A in a rabbit critical-size bone defect: results of an in vivo study

The aim of this study was to prepare an injectable DNA-loaded nano-calcium phosphate paste that is suitable as bioactive bone substitution material. For this we used the well-known potential of calcium phosphate in bone contact and supplemented it with DNA for the in-situ transfection of BMP-7 and VEGF-A in a critical-size bone defect. 24 New Zealand white rabbits were randomly divided into two groups: One group with BMP-7- and VEGF-A-encoding DNA on calcium phosphate nanoparticles and a control group with calcium phosphate nanoparticles only. The bone defect was created at the proximal medial tibia and filled with the DNA-loaded calcium phosphate paste. As control, a bone defect was filled with the calcium phosphate paste without DNA. The proximal tibia was investigated 2, 4 and 12 weeks after the operation. A histomorphological analysis of the dynamic bone parameters was carried out with the Osteomeasure system. The animals treated with the DNA-loaded calcium phosphate showed a statistically significantly increased bone volume per total volume after 4 weeks in comparison to the control group. Additionally, a statistically significant increase of the trabecular number and the number of osteoblasts per tissue area were observed. These results were confirmed by radiological analysis. The DNA-loaded bone paste led to a significantly faster healing of the critical-size bone defect in the rabbit model after 4 weeks. After 12 weeks, all defects had equally healed in both groups. No difference in the quality of the new bone was found. The injectable DNA-loaded calcium phosphate paste led to a faster and more sustained bone healing and induced an accelerated bone formation after 4 weeks. The material was well integrated into the bone defect and new bone was formed on its surface. The calcium phosphate paste without DNA led to a regular healing of the critical-size bone defect, but the healing was slower than the DNA-loaded paste. Thus, the in-situ transfection with BMP-7 and VEGF-A significantly improved the potential of calcium phosphate as pasty bone substitution material.

Effect of the lipoxygenase inhibitor baicalein on bone tissue and bone healing in ovariectomized rats

BACKGROUND

Osteoporosis is one of the world's major medical burdens in the twenty-first century. Pharmaceutical intervention currently focusses on decelerating bone loss, but phytochemicals such as baicalein, which is a lipoxygenase inhibitor, may rescue bone loss. Studies evaluating the effect of baicalein in vivo are rare.

METHODS

We administered baicalein to sixty-one three-month-old female Sprague-Dawley rats. They were divided into five groups, four of which were ovariectomized (OVX) and one non-ovariectomized (NON-OVX). Eight weeks after ovariectomy, bilateral tibial osteotomy with plate osteosynthesis was performed and bone formation quantified. Baicalein was administered subcutaneously using three doses (C1: 1 mg/kg BW; C2: 10 mg/kg BW; and C3: 100 mg/kg BW) eight weeks after ovariectomy for four weeks. Finally, femora and tibiae were collected. Biomechanical tests, micro-CT, ashing, histological and gene expression analyses were performed.

RESULTS

Biomechanical properties were unchanged in tibiae and reduced in femora. In tibiae, C1 treatment enhanced callus density and cortical width and decreased callus area. In the C3 group, callus formation was reduced during the first 3 weeks after osteotomy, correlating to a higher mRNA expression of Osteocalcin, Tartrate-resistant acid phosphatase and Rankl. In femora, baicalein treatments did not alter bone parameters.

CONCLUSIONS

Baicalein enhanced callus density and cortical width but impaired early callus formation in tibiae. In femora, it diminished the biomechanical properties and calcium-to-phosphate ratio. Thus, it is not advisable to apply baicalein to treat early bone fractures. To determine the exact effects on bone healing, further studies in which baicalein treatments are started at different stages of healing are needed.

Assessing the risk for major injuries in equestrian sports

Background/aim

Horse riding is a popular sport, which bears the risk of serious injuries. This study aims to assess whether individual factors influence the risk to sustain major injuries.

Methods

Retrospective data were collected from all equine-related accidents at a German Level I Trauma Centre between 2004 and 2014. Logistic regression was used to identify the risk factors for major injures.

Results

770 patients were included (87.9% females). Falling off the horse (67.7%) and being kicked by the horse (16.5%) were the two main injury mechanisms. Men and individuals of higher age showed higher odds for all tested parameters of serious injury. Patients falling off a horse had higher odds for being treated as inpatients, whereas patients who were kicked had higher odds for a surgical therapy (OR 1.7) and intensive care unit/intermediate care unit (ICU/IMC) treatment (OR 1.2). The head was the body region most often injured (32.6%) and operated (32.9%). Patients with head injuries had the highest odds for being hospitalised (OR 6.13). Head or trunk injuries lead to the highest odds for an ICU/IMC treatment (head: OR 4.37; trunk: OR 2.47). Upper and lower limb injuries showed the highest odds for a surgical therapy (upper limb: OR 2.61; lower limb: OR 1.7).

Conclusion

Risk prevention programmes should include older individuals and males as target groups. Thus a rethinking of the overall risk assessment is necessary. Not only horseback riding itself, but also handling a horse bears a relevant risk for major injuries. Serious head injures remain frequent, serious and an important issue to be handled in equestrians sports.

Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

consensus paper with systematic literature review.

OBJECTIVE

The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts.

METHODS

The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences.

RESULTS

As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers.

CONCLUSION

Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

The Advantages of Bilateral Osteotomy Over Unilateral Osteotomy for Osteoporotic Bone Healing

Most models of osteoporotic bone fractures are performed unilaterally (UL). We investigated healing of tibia osteotomy performed either UL or bilaterally (BL) in ovariectomized rats. Behavior of animals and muscle structure were assessed. Three-month-old female Sprague-Dawley rats were ovariectomized (n = 32). After 10 weeks, half the rats underwent UL osteotomy of tibia metaphysis (right limb) with plate osteosynthesis. The other rats were osteotomized BL. Half of the rats in each group received either standard pain treatment with carprofen (5 mg/kg body weight (BW), 1x/day for 2 days) or carprofen and buprenorphine (5 mg/kg BW, 1x/day and 0.03 mg/kg BW, 2x/day for 5 days) after osteotomy. The UL rats started to load the injured limb from day 27 ± 9; BL rats did this from day 4 ± 4 onward. The UL rats more frequently loaded only one hind limb; BL rats more often loaded both hind limbs. Osteotomy was not bridged in 20% of UL rats and in 4% of BL rats. Callus volume and bone volume fraction were lower in UL group. Weight and fiber size of UL-intact limb muscles were enhanced, compared to the osteotomized limb and those in BL group. Most of the other parameters which assess physiology, activity, body posture, head, or coat were not different. The effect of two pain therapies was not significant on any variable studied. Welfare of the animals was acceptable in all rats. In UL rats, bone healing was delayed. The more advanced healing in BL rats suggested a positive effect of earlier loading. In studies on bone healing, it is advisable to perform BL osteotomy.

The Platelet Function of the Thrombopathy on the Åland Islands

In the summer of 1962 we checked a total of 20 bleeders from Åland in order to elucidate the pathogenesis of the haemorrhagic diathesis on the Åland Islands/Finland (“hereditary pseudohaemophilia” – “constitutional thrombopathy” – “v. Willebrand’s disease”). They partly belong to the same families described in 1933 by v. Willebrand and R. Jürgens. We came to the following results :

1. On the determination of the volumetric retraction under consideration of the heamatocrit value 17 of 19 patients presented a hyporetractility of the coagulum.

2. The thrombelastogram showed in 14 out of 18 patients a completely normal blood coagulation and only in 4 cases a very slight prolongation of the clotting time (increase of r and k).

3. The clot retraction disturbance could not be normalized by adding tissue thromboplastin to the venous blood of the 4 patients with mild hypocoagu-laemia mentioned under no. 2. The hyporetractility of the coagulum can therefore not be due to the hypocoagulaemia or a lack of the intrinsic system of thromboplastin generation.

4. In 18 out of 19 patients there was a partially extremely decreased platelet adhesiveness on glass surfaces.

5. In 17 out of 19 patients a disorder of the platelet agglomeration in citrated plasma released by the effect of glass surfaces was established.

6. 14 out of 16 patients showed a pathologic rotation thrombelastogram.

7. It is possible, but not yet proved that all these phenomenons are caused by the decreased platelet adhesiveness on glass. In any case, however, the decreased platelet adhesiveness on glass speaks in favor of a disturbed platelet function which could possibly play a part in the development of the haemostatic defect in this disease. Whether we are dealing with an endothrombocytic defect, or whether the decreased adhesiveness on glass presents a secondary disorder of the platelet function due to the lack of an antibleeding factor, is another question which could not yet be definitely settled. Investigations concerning this question are continued.

Arthroscopic Reconstruction of Intratendinous Lesions of the Supraspinatus Tendon - a Systematic Review

BACKGROUND

Intratendinous lesions of the rotator cuff of the shoulder are frequent and may be a distinct clinical entity. Nevertheless, there are only a few publications which deal specifically with this subject. This study analyses the existing literature for the arthroscopic reconstruction of the intratendinous lesion of the supraspinatus tendon, by means of a systematic review, and identifies relevant research questions for future studies.

MATERIAL AND METHODS

In January 2017, a systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) Database and the Cochrane Library was conducted using the PRISMA checklist. The search words were "supraspinatus" and "interstitial"; "supraspinatus", "tear" and "intratendinous"; "supraspinatus" and "concealed". In the course of the review, articles written in English with at least a partial arthroscopic case series dealing with the reconstruction of the supraspinatus tendon were identified and further analysed.

RESULTS

Primarily 70 hits could be generated. Five articles met the inclusion criteria and were analysed in detail. The number of arthroscopic cases ranged between 6 and 33. Level of evidence was IV in all studies. The diagnosis of an intratendinous lesion was made by MR imaging when T2/fat-saturated sequences showed an intratendinous high intensity signal without disruption of the bursal or articular layer. Three different concepts were followed in surgical treatment: opening of the intratendinous lesion from the bursal or articular side or by complete resection of the lesion. The reconstruction was performed with suture anchors in all cases. In the majority of cases, an acromioplasty was also performed. The reported clinical results were mostly good. Healing of the tendon was shown by MR imaging in 81.5 to 100% of cases.

CONCLUSION

After failure of conservative treatment, symptomatic intratendinous lesions of the supraspinatus tendon can be localised intraoperatively and reconstructed after failure of conservative treatment. The expected results are good in the medium term. The evidence level of the studies analysed was low. Future studies should examine the role of alternative conservative and surgical therapies.

Cartilage calcification of the ankle joint is associated with osteoarthritis in the general population

Background

Cartilage calcification (CC) is associated with osteoarthritis (OA) in weight-bearing joints, such as the hip and the knee. However, little is known about the impact of CC and degeneration on other weight-bearing joints, especially as it relates to the occurrence of OA in the ankles. The goal of this study is to analyse the prevalence of ankle joint cartilage calcification (AJ CC) and to determine its correlation with factors such as histological OA grade, age and BMI in the general population.

Methods

CC of the distal tibia and talus in 160 ankle joints obtained from 80 donors (mean age 62.4 years, 34 females, 46 males) was qualitatively and quantitatively analysed using high-resolution digital contact radiography (DCR). Correlations with factors, such as the joint’s histological OA grade (OARSI score), donor’s age and BMI, were investigated.

Results

The prevalence of AJ CC was 51.3% (95% CI [0.40, 0.63]), independent of gender (p = 0.18) and/or the joint’s side (p = 0.82). CC of the distal tibia was detected in 35.0% (28/80) (95% CI [0.25, 0.47]) and talar CC in 47.5% (38/80) (95% CI [0.36, 0.59]) of all cases. Significant correlations were noted between the mean amount of tibial and talar CC (r = 0.59, p = 0.002), as well as between the mean amount of CC observed in one ankle joint with that of the contralateral side (r = 0.52, p = 0.02). Furthermore, although the amount of AJ CC observed in the distal tibia and talus correlated with the histological OA-grade of the joint (r = 0.70, p < 0.001 and r = 0.72, p < 0.001, respectively), no such correlation was seen in the general population with relation to age (p = 0.32 and p = 0.49) or BMI (p = 0.51 and p = 0.87).

Conclusion

The prevalence of AJ CC in the general population is much higher than expected. The relationship between the amount of AJ CC and OA, independent of the donors’ age and BMI, indicates that CC may play a causative role in the development of OA in ankles.

Forms of Capital and Habitus in the Decision to Go on Academic Exchange

Although Canadian universities have made internationalization a strategic priority, only few Canadian students currently participate in any international study opportunities. Drawing on interviews with Canadian students who were about to spend some of their undergraduate education abroad as exchange students, or had recently returned from a study exchange, we argue that despite the importance of relatively high costs associated with international study experiences, cultural factors play a more important role in enabling the decision to study abroad. Being habitually exposed to travel in one's family, and having been encouraged to travel independently as a teenager or young adult emerge as important precursors to our participants' decision to take part in study exchanges. Although one needs to engage critically with university administrators' current preoccupation with internationalization, being exposed to an extended time abroad has shown to have positive effects, especially for otherwise underprivileged students. Given the exploratory nature of this study, we conclude with suggestions for further research aimed at confirming our findings and developing policy.