[Removal of a bent femoral nail : Case report: treatment strategy of a complex femoral deformity with a bent femoral nail in situ since 36 years]

To remove a bent femoral nail is always a challenging task for a surgeon. In the last 20 years several case reports and descriptions of techniques are to be found in literature, the goal being to weaken the nail at the apex and then straightening it in situ in most cases. Those reports all have one parameter in common: the necessity to remove the nail relates to a refracture of the femur.We report the case of a patient who presented with the explicit wish to have a bent femoral nail removed and a femoral angulation corrected because of pain in the ipsilateral hip. A femoral fracture had been treated by a Küntscher nail in 1982. A refracture with severe bending of the nail had occurred a short time later, which was treated conservatively without a second surgical procedure.We can show that a planned removal of a bent and well-osseointegrated Küntscher nail can be achieved without complications and that thereby a multiplane angulation in the femur can be corrected, paving the way for a future arthroplasty in this specific case.

[Medical Emergency Preparedness in offshore wind farms : New challenges in the german north and baltic seas]

BACKGROUND

Offshore windfarms are constructed in the German North and Baltic Seas. The off-coast remoteness of the windfarms, particular environmental conditions, limitations in offshore structure access, working in heights and depths, and the vast extent of the offshore windfarms cause significant challenges for offshore rescue. Emergency response systems comparable to onshore procedures are not fully established yet. Further, rescue from offshore windfarms is not part of the duty of the German Maritime Search and Rescue Organization or SAR-Services due to statute and mandate reasons. Scientific recommendations or guidelines for rescue from offshore windfarms are not available yet. The present article reflects the current state of medical care and rescue from German offshore windfarms and related questions. The extended therapy-free interval until arrival of the rescue helicopter requires advanced first-aid measures as well as improved first-aider qualification. Rescue helicopters need to be equipped with a winch system in order to dispose rescue personnel on the wind turbines, and to hoist-up patients. For redundancy reasons and for conducting rendezvous procedures, adequate sea-bound rescue units need to be provided. In the light of experiences from the offshore oil and gas industry and first offshore wind analyses, the availability of professional medical personnel in offshore windfarms seems advisible. Operational air medical rescue services and specific offshore emergency reaction teams have established a powerful rescue chain. Besides the present development of medical standards, more studies are necessary in order to place the rescue chain on a long-term, evidence-based groundwork. A central medical offshore registry may help to make a significant contribution at this point.

Trends of barriers to eye care among adults with diagnosed diabetes in Germany, 1997-2012

BACKGROUND AND AIMS

To study trends of barriers to receiving recommended eye care among subjects with diabetes aged 20-81 years in northeast Germany.

METHODS AND RESULTS

We analyzed population-based data from two repeated cross-sectional surveys conducted in 1997-2001 and 2008-2012 (Ns of 4308 and 4402). Andersen's Behavioral Model of Health Services Utilization was used to identify individual-level demographic, financial and health-related barriers to annual eye-care utilization in subjects with a self-reported physician's diabetes and to examine population trends in these barriers. The prevalence of diabetes increased from 6.5% to 11.4%. The prevalence of annual eye-care utilization among persons with diabetes decreased from 69.4% to 56.0% (adjusted relative risk = 0.77, p < 0.001). The decline of eye care utilization over the past decade in eye-care use was more pronounced in groups at risk for diabetes-related complications (i.e., lower socio-economic status, >5 years since diagnosis of diabetes, poor glycemic control, obesity, smoking, lack of physical activity, co-existing diseases). We identified relevant predictors of missed annual eye-care use among diabetics.

CONCLUSION

The increase of diabetes prevalence and downward trend of eye-care visits at the recommended level call for development, implementation and evaluation of continued efforts to improve access to eye specialists, particularly among those with poor diabetic control, co-existing diabetic complications, and comorbidities.

[Study of health in Pomerania (SHIP-Trend): : Important aspects for healthcare research in ophthalmology]

BACKGROUND

Epidemiological studies continue to receive growing attention in health services research.

OBJECTIVES

How can ophthalmological health services research benefit from the Study of Health in Pomerania (SHIP)?

METHODS

The SHIP is a population-based, epidemiological project conducted in the northeast of Germany. In 1997 a random sample of 6,265 eligible subjects was enrolled for the first SHIP cohort. Between 1997 and 2001 baseline examinations were performed, followed by 5-year follow-up from 2002 to 2006, from 2008 to 2012 and from 2014. A second independent sample of 8,016 eligible subjects was enrolled in 2008. Baseline examinations of this new cohort (SHIP-Trend) were conducted between 2008 and 2012 and the first follow-up is scheduled for 2015. Included in SHIP are a large variety of different assessments including eye examinations. All participants are subjected to non-mydriatic funduscopy and static vessel analysis (SVA).

RESULTS

A total number of 4,420 subjects participated in the interdisciplinary baseline examinations of SHIP-Trend. Standardized fundus photography was performed with a non-mydriatic camera in 3,934 subjects.

CONCLUSION

Estimations of the prevalence of major eye diseases may provide valid indicators for healthcare provision within healthcare research. New concepts of prevention with a strengthened integration of ophthalmological diagnostics can be identified from the widespread spectrum of different healthcare examinations. Regional differences in the efficiency of healthcare provision can be evaluated with comparative studies between different German populations.

[The clinical outcome after occipitocervical fusion due to metastases of the upper cervical spine: a consecutive case series and a systematic review of the literature]

BACKGROUND

Increasing incidences of osseous metastatic malignancies and higher life expectancy in patients are resulting in a raise of occipitocervical metastases. Those patients with infaust prognosis have a significantly reduced quality of life. In Germany, between 800 and 1680 new cases per year are expected. Treatment algorithms include the evaluation of the general condition, the operability of visceral metastases, the tumor localization, the sensitivity to chemo-/radiotherapy, the fracture risk and the extent of neurological deficits and myelopathies.

MATERIAL/METHODS

A systematic review on clinical studies or case series in posterior occipitocervical fusions due to metastases to the craniocervical transition yielded nine publications with 48 patients without neurological deficit. The mean survival time in the given follow-up was 6.44 months (n = 26; SD: 5,28; 95 % CI: 4.3-8.57). When measured, the clinical outcome was improved towards the VAS, the DENIS Pain Scale and the quality of life through the activities of daily living (ADL). We searched our clinical database for occipitocervical stabilizations in patients with craniocervical metastases. The prospectively collected data included the preoperative Tokuhashi score, SIN score, neurological status, length of hospitalization, perioperative course/loss of blood/complication rate, as well as the Karnofsky- index and pain measured by VAS preoperatively and in follow-up.

RESULTS

Six patients were treated in this consecutive case series. The median age was 72 years (min./max.: 65/82), the average BMI 31.75 (min./max.: 19.3/38.1). The mean preoperative Karnofsky-index was 35 % (min./max.: 23.99/46.01; 95 % CI: 8.39) the mean preoperative Tokuhashi-score 7 (min./max.: 4/10), the mean preoperative VAS7 (min./max.: 4.8/9.2; 95 % CI: 1.68). There were no perioperative complications. In the follow-up, one patient showed a loosening of the screws in the osteolytic massae laterales and one patient suffered from a construct failure after fall.

DISCUSSION

Metastases of the craniocervical transition are rare. The initial treatment of instability includes the application of a rigid Miami-J-collar or a Halo fixator. The decision for an operative procedure must accurately assess the individual patient characteristics to provide him a balanced concept between operational risk and clinical benefit. The assessment should be based on the life expectation and the expected quality of life in dependency of the respective therapeutic concept and its risks. The sole posterior stabilization of craniocervical instability through occipitocervical fusion leads to a reduction of pain, has a low perioperative risk, and may prevent a hospitalization. It is justified for selected patients to receive this treatment to help alleviate pain and to improve their quality of life. From our experience, rare cases of pain without instability should undergo conservative treatment in the first line. Due to the low availability of data on the manifestation and the clinical course of craniocervical metastases, there is a need for the collection of both the descriptive patient data include the radiographic findings as well as the clinical outcome and socio-economic factors using appropriate scoring systems.

Refixation of osteochondral fractures by ultrasound-activated, resorbable pins: An ovine in vivo study

Objectives

Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions.

Methods

In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months.

Results

The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown.

Conclusion

As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures.

Midterm Results of 58 Fractures of the Coronoid Process of the Ulna and their Concomitant Injuries

BACKGROUND

In general, fractures of the coronoid process are rare and usually occur in combination with additional elbow joint injuries. The treatment of these injuries aims to regain a stable as well as a flexible and loadable joint. Although there is currently little evidence, therapy recommendations remain controversial. Therefore, the aim of this study was to prognostically determine relevant factors for therapy recommendation by analysing a representative patient population of two trans-regional trauma centres.

MATERIAL AND METHODS

Seventy-seven patients with a fracture of the coronoid process were treated within an 8-year period (2001 to 2009). After an average of 48 months (SD 31), treatment outcome of 58 patients (75%) was acquired. The results were statistically analysed.

RESULTS

The average age of the patient was 51.8 years (SD 13.6); 36 were male and 34 had a fracture on the right arm. Applying the fracture types of the coronoid process in accordance with Regan/Morrey, the result was: Type I (19), II (17) and III (22). Further injuries were also detected: 40 radial head fractures, 17 proximal ulnar fractures and 2 fractures of the olecranon. A luxation was detected in 44 of the 58 patients (76%). The patients' average MEPS (Mayo Elbow Performance Score) was 80.6 points (SD 18), with significant differences between the various therapy strategies. Fifteen% of the coronoid process fractures were reconstructable to a limited extent only by means of osteosynthesis. In 33% of the patients, instabilities remained. The average extension/flexion came to 107° (SD 28), and pronation and supination 153° (SD 38).

CONCLUSION

At present, a surgical therapy of ligamentary injuries cannot be statistically justified. A stable osseous reconstruction appears to make more sense. The strongest negative prognostic parameters in our patient population were: therapy with an external fixator, immobilisation for more than 21 days, the occurrence of complications and unstable osteosyntheses on the coronoid process.

[Osteoporotic fractures of the distal radius. What is new?]

The demographic development will result in an increase of up to 30 % of distal radius fractures. There are various therapy options but what is new? Conservative therapy: conservative therapy is reserved for stable fractures only. Osteosynthesis by K-wires: due to low biomechanical stability in older patients, insufficient functional and radiological results were achieved. External fixator: external fixators are used in compound and complex fractures and show better results than K-wire osteosynthesis. Angular stable plate osteosynthesis: with angular stable plates it is possible to achieve good results with complex fractures and they are currently the method of choice. Intramedullary osteosynthesis: intramedullary nails result in a faster functional improvement than angular stable plates but have limitations. New is that 90% of osteoporotic distal radial fractures are treated with angular stable plates which have shown good results in single study groups.

Telemetric assessment of bone healing with an instrumented internal fixator

In an interdisciplinary project involving electronic engineers and clinicians, a telemetric system was developed to measure the bending load in a titanium internal femoral fixator. As this was a new device, the main question posed was: what clinically relevant information could be drawn from its application? As a first clinical investigation, 27 patients (24 men, three women) with a mean age of 38.4 years (19 to 66) with femoral nonunions were treated using the system. The mean duration of the nonunion was 15.4 months (5 to 69). The elasticity of the plate-callus system was measured telemetrically until union. Conventional radiographs and a CT scan at 12 weeks were performed routinely, and healing was staged according to the CT scans. All nonunions healed at a mean of 21.5 weeks (13 to 37). Well before any radiological signs of healing could be detected, a substantial decrease in elasticity was recorded. The relative elasticity decreased to 50% at a mean of 7.8 weeks (3.5 to 13) and to 10% at a mean of 19.3 weeks (4.5 to 37). At 12 weeks the mean relative elasticity was 28.1% (0% to 56%). The relative elasticity was significantly different between the different healing stages as determined by the CT scans.

Incorporating load measuring electronics into implants is a promising option for the assessment of bone healing. Future application might lead to a reduction in the need for exposure to ionising radiation to monitor fracture healing.

[Health economical aspects of telemedical glaucoma monitoring]

BACKGROUND

Telemedical home monitoring of glaucoma patients is not covered by health insurance in Germany. Various clinical studies have indicated that 24 h monitoring of intraocular and blood pressure of glaucoma patients allows a better evaluation of the individual disease condition. If the necessary parameters can be collected with telemedical home monitoring it will be possible to reduce the number of 24 h intraocular pressure profiles which necessitate hospital admission. Therefore inpatient 24 h profiles have been chosen as a health economical allocation base with a presentable economical value for the comparative examination. Assuming an at least identical or even higher clinical outcome of the telemedical glaucoma home monitoring inpatient 24 h profiles were chosen as a health economical allocation base to compare and contrast these methods.

METHODS

All procedures of the inpatient 24 h profiles at the ophthalmic clinic of Greifswald were measured using the stopwatch method. In a 1 day test run all activities of the medical staff were identified and documented in a list and afterwards measurements were carried out over 7 days with several stopwatches to allow the documentation of parallel activities. To determine the consumption of resources in telemedical home monitoring the self-documentation of all employees involved in the research project TT-MV were evaluated. Expert interviews helped to determine the economically relevant data about the applied medical technology, e.g. measuring devices, server and electronic health records.

RESULTS

The number and complexity of the subprocesses of the inpatient 24 h intraocular pressure profiles were significantly higher compared to telemedical home monitoring. The total costs of the inpatient 24 h profiles were 571.21 € per patient including 291.21 € for medical care and 280 € for accommodation. In contrast the total costs of telemedical home monitoring were 288.72 € per patient. A direct cost comparison shows that telemedical home monitoring resulted in lower costs compared to hospital admission of glaucoma patients.

CONCLUSION

Telemedical home monitoring of glaucoma patients is not only effective but also cost-efficient. As modern health care systems have to consider cost efficiency, a randomized, controlled longitudinal clinical study of both methods would be required.

Biopolymer augmentation of the lag screw in the treatment of femoral neck fractures--a biomechanical in-vitro study

The cut-out of the sliding screw is one of the most common complications in the treatment of intertrochanteric fractures. The reasons for the cut-out are: a suboptimal position of the hip-screw in the femoral head, the type of fracture and poor bone quality. The aim of this study was to reproduce the cut-out event biomechanically and to evaluate the possible prevention of this event by the use of a biopolymer augmentation of the hip screw. Concerning the density and compression force of osteoporotic femoral bone polyurethane foam according to the terms of the Association for Standard Testing Material (ASTMF 1839-97) was used as test material. The polyurethane foam Lumoltan 200 with a compression force of 3.3 Mpa and a density of 0.192 g/cm(3) was used to reproduce the osteoporotic bone of the femoral fragment (density 12 lbm/ft(3)). A cylinder of 50 mm of length and 50 mm of width was produced by a rotary splint raising procedure with planar contact. The axial load of the system was performed by a hydraulic force cylinder of a universal test machine type Zwick 1455, Ulm, Germany. The CCD-angle of the used TGN-System was preset at 130 degrees. The migration pattern of the hip screw in the polyurethane foam was measured and expressed as a curve of the distance in millimeter (mm) against the applied load in Newton (N) up to the cut-out point. During the tests the implants reached a critical changing point from stable to unstable with an increased load progression of steps of 50 Newton. This unstable point was characterized by an increased migration speed in millimeters and higher descending gradient in the migration curve. This peak of the migration curve served as an indicator for the change of the hip screw position in the simulated bone material. The applied load in the non-augmented implant showed that in this group for a density degree of 12 (0,192 g/cm(3)) the mean force at the failure point was 1431 Newton (+/- 52 Newton). In the augmented implant we found that the mean force at the failure point was 1987 Newton (+/- 84 Newton). This difference was statistically significant. In conclusion, the bone density is a significant factor for the stability of the hip screw implant. The osteosynthesis with screws in material with low density increases the chance for cut-out. A biopolymer augmented hip screw could significantly improve the stability of the fixation. The use of augmentation with a fast hardening bone replacement material containing polymer-ceramic changes the point of failure under axial load in the osteoporotic bone model and could significantly improve the failure point. Our study results indicate, that a decrease of failure in terms of cut-out can be achieved with polymer augmentation of hip screws in osteoporotic bones.

[On the topical tolerance of aminoglycoside antibiotics--a prospective comparative cytomorphological study]

BACKGROUND

The local application of drugs is an efficient method for treating diseases of the external eye. However, some active substances can also cause a chronic toxic reaction at the ocular surface. No results from clinical experiments on the local tolerance of kanamycin which would meet the requirements of evidence-based medicine are as yet available.

METHODS

Thus, the cytomorphological processes of the treatment with kanamycin were examined in a prospective randomised placebo-controlled double blind cross-over study. The effect of the topical application (5 times a day for 7 days) of Kanamycin POS® eye ointment on the conjunctival epithelial barrier was studied in comparison with an eye ointment base (placebo) in 25 healthy subjects. To detect cytopathological microchanges of the epithelium, we carried out a standardised impression cytology (primary compatibility parameter). Biomicroscopy, Schirmer II test and non-invasive measurement of the break-up-time (tearscope) were also examined. The subjective compatibility parameters (itching, tearing, foreign body sensation, burning sensation, mucus) were measured on a 0 - 10 visual analogue scale.

RESULTS

The cytological findings of 23 subjects were included in the final evaluation of the study. The impression cytology did not reveal a different effect of kanamycin ophthalmic ointment on the conjunctival ocular surface in comparison with the placebo. Only in one subject was a marked shift found in the nuclear-cytoplasmic ratio after application of verum. No signs of increased apoptosis ("snake-like chromatin") were found at the conjunctival epithelial barrier. The mean goblet cell count was 109 goblet cells per mm (2). No significant reduction of the goblet cell density was found in any treatment group. Among the subjective compatibility parameters, only the mean for itching constantly remained above the placebo group after application of kanamycin. Statistically significant differences were not found by the Wilcoxon test.

CONCLUSIONS

In contrast to the clinical experience with the systematic application of kanamycin, the standardised evaluation of this study confirmed the very good topical tolerability of the tested kanamycin eye ointment. In view of the continuing clinically relevant aspect of the availability of a wide spectrum of antibiotics to avoid the development of resistance while at the same time keeping within what is reasonable economically, Kanamycin POS® for topical application supplements the options of ophthalmological antibacterial chemotherapy.

[Pseudo-arthroses]

Pseudo-arthroses are disorders of fracture healing after conservative or operative treatment of fractures which are older than 6 months. Decisive for a targeted therapy is a differentiation between aseptic and septic or atrophic, oligotrophic or hypertrophic pseudo-arthrosis. The operative principals include revitalization of atrophic bone fragments, stabilizing reosteosynthesis for instability and the treatment of infection by transformation of a septic into a stabilized or aseptic pseudo-arthrosis.

[Possibilities and limitations of telemedical home monitoring in ophthalmology]

For medical professionals, home monitoring represents an innovative health service for remote patient care: The patient may remain in his or her domestic environment and continue normal activities. The physician can also, through technical and organizational integration, provide medical attendance from his or her usual working environment. All in all, in the near future home monitoring can help provide sufficient health services while also enabling medical resources to be used more effectively. The patient may benefit from individually optimized treatment and active integration into medical care. The better we manage the technical, organizational, medical, legal, and economic challenges of telemedicine, the better we can minimize the limitations of telemedical home monitoring. Other existing subjective concerns will be eliminated only if telemedical concepts are adapted to the specific needs of affected patients and physicians.

[Technical options and prospects for telemedical devices in ophthalmology]

Home monitoring will soon be established as an innovative way to provide telemedical care in ophthalmology. At present there are no fundamental technical restrictions for telemedical enhancements in ophthalmology, however a wider application range and depth could lead to harmonized and simplified device and interface development. This may help to initiate new concepts in ophthalmological home monitoring.

[Single bundle anterior cruciate ligament reconstruction using quadriceps tendon autografts]

AIM

The purpose of this study was to evaluate postoperative outcome and functional scores after single bundle anterior cruciate ligament (ACL) reconstruction with the use of quadriceps tendon autografts after a 16 (12-24) month follow-up.

METHOD

54 patients (9 women, 45 men, body mass index [BMI] 25.3 [18.1-36.3 kg/m (2)]) were included in this prospective series, treated between January 2004 and December 2005. Ligament stability was assessed with the Lachmann and pivot-shift tests and a KT 1000 arthrometer. Tegner index, Lysholm-Gilquist score and the International Knee Documentation Committee (IKDC) were employed to evaluate the functional outcomes. In addition, the single leg hop test was performed.

RESULTS

Ligament arthrometry using the KT 1000 arthrometer demonstrated a mean side-to-side difference of 1.53 mm (0.2-4.1 mm). Regarding the Lachmann test, 17 patients (32%) showed 1+ laxity and no patient had an abnormal pivot-shift. The mean Tegner activity score was 4.22 (1-10), the mean Lysholm score was 80.8 (20-100) and the mean IKDC score 68.1 (29-87). Results of the single leg hop test revealed a mean decline of the treated leg to 87.7% (70-100%) of the contralateral side. The mean extension was reduced by 1.7 degrees (0-10 degrees) on the treated knee and the flexion by 2.1 degrees (0-10 degrees), compared to the contralateral knee.

CONCLUSION

Single bundle anterior cruciate ligament reconstruction using quadriceps tendon demonstrates highly satisfactory results. Due to a moderate donor site morbidity and preservation of the medial stabilizing structures of the knee a wider use in primary cruciate ligament reconstruction may arise in the future.

[Data security and the handling of patient data in home monitoring systems]

Data security must be considered seriously in the context of telemedical home monitoring because of the transmission and communication of patients' personal data. The contract governing medical treatment allows the ophthalmologist to process all data relevant to treatment. In Germany the legal framework for this purpose is provided by the Data Protection Act, various German hospital acts, and codes of medical professional conduct. In principle, these rules apply to telemedical home monitoring as well as to common physician-patient relationships. The patient must be informed extensively in an understandable manner and must give his or her written consent. However, the advanced options of new IT technologies demand the development of technical and organizational concepts that guarantee compliance with legal and regulatory affairs, assure data security, and prevent data abuse.

Acoustic monitoring (RFM) of total hip arthroplasty - Results of a cadaver study

Introduction

At present there are no reliable non-traumatic and non-invasive methods to analyse the healing process and loosening status after total hip replacement. Therefore early as well as late loosening of prosthesis and interface component problems are difficult to be found or diagnosed at any time.

Methods

In a cadaver study the potential application of Resonance Frequency Monitoring (RFM) will be evaluated as a non-invasive and non-traumatic method to monitor loosening and interface problems in hip replacement. In a 65 year old female cadaver different stability scenarios for a total hip replacement (shaft, head/modular head and cup, ESKA, Luebeck, Germany) are simulated in cemented and cement less prosthesis and then analysed with RFM. The types of stability vary from secure/press-fit to interface-shaft disruption.

Results

The RFM shows in cemented as well as cement less prosthesis significant intra-individual differences in the spectral measurements with a high dynamic (20 dB difference corresponding to the factor 100 (10000%)), regarding the simulated status of stability in the prosthesis system.

Conclusion

The results of the study demonstrate RFM as a highly sensitive non-invasive and non-traumatic method to support the application of RFM as a hip prosthesis monitoring procedure. The data obtained shows the possibility to use RFM for osteointegration surveillance and early detection of interface problems, but will require further evaluation in clinical and experimental studies.

[Computer-based graphic documentation of retinal findings]

AIM

To develop a software package that improves the standardized clinical documentation of retinal findings. In the clinical routine, retinal findings are usually documented with sketchy freehand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to a change in location, size, or color of graphic primitives (e.g., ovals, rectangles, lines, textboxes). As a result, a feasible creation of standardized graphic documentation in retinal imaging is almost impossible.

METHODS

We developed a Java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as a findings sheet or digitally archived. Particularly for clinical ophthalmologists, we created a set of standardized symbols that can be digitally rendered for graphic documentation. All symbols were integrated into a graphics library and separated in specific categories: preoperative, postoperative, angiomas and tumors, and retinopathy of prematurity. The user can simply choose the required symbol from the library and place it onto the retina scheme using drag-and-drop functionality.

RESULTS

The practicability of existing features for graphic documentation of retinal findings is not sufficient because freehand drawings are too time-consuming and also share the risk of false interpretation due to individual handwriting. In contrast to freehand sketching, our software tool not only allows faster graphic creation but also improves medical documentation using a standardized symbol library, which is also specifically categorized.

CONCLUSIONS

Graphic symbols for retinal documentation have found universal acceptance by ophthalmologists for a long time, but their practical use is still not efficient in clinical routine. This report shows how the appropriate use of software technology can contribute to documentation quality and clinical practice.

[Home-monitoring in ophthalmology--prerequisites for an improvement in quality of life: conclusions from the management research study Teletonometry Mecklenburg-Vorpommern]

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patient's quality of life.

The role of human beta-defensin-2 in bone

Osteomyelitis often causes functional impairment due to tissue destruction. This report demonstrates a novel previously unappreciated role of osteoblasts. Samples of osteomyelitic bone and bacterially challenged osteoblasts produce increased amounts of antimicrobial peptides in order to combat bacterial bone infection. An osteomyelitis mouse model confirmed the osseous induction of the murine homologue of human beta-defensin-2, suggesting a central role in the prevention of bacterial bone infection. Antimicrobial peptides are effectors of the innate defence system and play a key role in host protection at cellular surfaces. Some of them are produced constitutively, whereas others are induced during infection. Human beta-defensins represent a major subclass of antimicrobial peptides and act as a first line of defence through their broad spectrum of potent antimicrobial activity. The aim of the present in-vitro and in-vivo investigations was to study the expression and regulation of human beta-defensin-2 in the case of bacterial bone infection and to analyse the effects of immunosuppressive drugs on bone-derived antimicrobial peptide expression. Samples of healthy human bone, osteomyelitic bone and cultured osteoblasts (hFOB cells) were assessed for the expression of human beta-defensin-2. Regulation of human beta-defensin-2 was studied in hFOB cells after exposure to bacterial supernatants, proinflammatory cytokines and immunosuppressive drugs (glucocorticoids and methotrexate) and was assayed by enzyme-linked immunosorbent assay. An osteomyelitis mouse model was performed to demonstrate the regulation of the murine homologue of human beta-defensin-2, named murine beta-defensin-3, by real-time reverse transcription-polymerase chain reaction and immunohistochemistry. Healthy human bone and cultured osteoblasts are able to produce human beta-defensin-2 under standard conditions. Samples of infected bone produce higher levels of endogenous antibiotics, such as human beta-defensin-2, when compared with samples of healthy bone. A clear induction of human beta-defensin-2 was observed after exposure of cultured osteoblasts to gram-positive bacteria or proinflammatory cytokines. Additional treatment with glucocorticoids or methotrexate prevented bacteria-mediated antimicrobial peptide induction in cultured osteoblasts. The osteomyelitis mouse model demonstrated transcriptional upregulation of the murine homologue of human beta-defensin-2, namely murine beta-defensin-3, in bone after intraosseous contamination of the tibia. Human and murine bone have the ability to produce broad-spectrum endogenous antibiotics when challenged by micro-organisms in vitro and in vivo. Immunosuppressive drugs, such as glucocorticoids or methotrexate, may increase the susceptibility to bone infection by decreasing antimicrobial peptide expression levels in case of microbial challenge. The induction of human beta-defensin-2 following bacterial contact suggests a central role of antimicrobial peptides in the prevention of bacterial bone infection.

Clinical results of resection arthrodesis by triangular external fixation for posttraumatic arthrosis of the ankle joint in 89 cases

The methods for ankle arthrodesis differ significantly, probably a sign that no method is clearly superior to others. In the last ten years there is a clear favour toward internal fixation. We retrospectively evaluate the technique and evaluate the clinical long term results of external fixation in a triangular frame.

[Diurnal variation of ocular pressure in open-angle glaucoma with telemonitoring]

BACKGROUND

The aim of this study was to study and analyse distribution, range and intraday variation of ocular perfusion pressure (OPP) in patients with primary open-angle glaucoma (POAG) in the framework of telemedical home-monitoring.

METHODS

In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home-monitoring system for self-measurement of intraocular pressure and blood pressure. All measurements were transmitted via telephone modem to an electronic patient record that automatically calculated OPP. We present the temporal characteristics of OPP in 70 patients with POAG. After the measurement of blood pressure and intraocular pressure was performed, the individual ocular perfusion pressure was calculated by the formula: (OPP=[2/3 x (2/3 x DBP + 1/3 x SBP)]-IOP).

RESULTS

In 3282 OPP measurements the percentage of values less than 50 mmHg was: left eye 2273/69.2%--right eye 2362/71.9 % and less than 40 mmHg: left eye 687/20.9 %--right eye 794/24.2%. 50/51 (left eye/right eye) patients had an individual OPP average of less than 50 mmHg and 10/10 (left eye/right eye) patients less than 40 mmHg. The diurnal OPP trend showed 4 phases (7-12, 12-18, 18-22, 22-7 hour). In the intervals from 22-7 hour and 7-12 hour ocular perfusion pressure values were low. Between 7-12 hour ocular perfusion pressure was significantly depressed as in the other phases (p<0.05).

CONCLUSIONS

Ocular perfusion pressure of glaucoma patients calculated using intraocular pressure (self-tonometry) and blood pressure demonstrates a feasible method to evaluate individual diurnal OPP fluctuations. However, this OPP could be described a bit more precisely as the really topical ocular perfusion. Many physiological conditions may not be included, e. g., autonomic circulation. Simultaneous measurement of blood pressure and intraocular pressure enable the detection and analysis of side effects and interactions between glaucoma and hypertension therapy. In clinical practice OPP telemonitoring presents a new way to examine ocular blood circulation in routine glaucoma work-up. The diurnal OPP variations were associated with the fluctuations of systemic blood pressure for the most of part.

Initial results of the s3-humerus plate

Fractures of the humeral head account for 5% of all fractures and incidence increases with age. Depending on fracture form and patients age a wide variety of therapeutical options exist. Stable fractures can be treated conservatively, while the majority of unstable and displaced fractures require surgical treatment. Many different surgical options are available; open reduction and internal fixation are widely preferred. The S3 Proximal Humerus Plate is a contoured plate to match the complex shape of the proximal humerus. It is designed to be positioned distal to the greater tuberosity preventing subacromial impingement.

Between august 1 and 30, 2007, 5 patients meeting the inclusion criteria (that is primary operative stabilization within 7 days after trauma in a standardized way and minimal follow up period of 3 month) with acute fractures of the proximal humerus were treated with S3 Proximal Humerus Plate. Follow up was performed using the Constant Score. The mean age was 59.0 years. According to the Neer classification fractures were rated as Neer 2,3 and 4. A mean Constant score of 72.3 (57-86) points was obtained.

We did not observe any complications like humeral head necroses, loss of reduction, deep infection or breakage of the plate.

["Basketball Foot"--long-time prognosis after peritalar dislocation]

Subtalar dislocation is considered a severe injury but occurs rarely and studies generally refer to relatively small patient collectives. We investigated the functional outcome in 22 cases to determine the long-term prognosis. Since associated foot injury is common, we compared the outcome for 12 cases of isolated subtalar luxation with 10 cases of collateral fractures of the adjacent bones of the hind foot and Talus. 19 cases of complex, partially open injuries after high energy trauma have got excluded because of the apparently poor long-term results. The Kitaoka-hind-foot-Score (AOFAS) after mean follow up of 8.3 years indicated a significantly better outcome for isolated luxation. Nearly 50 % of isolated luxations had a excellent outcome (73 %, mean score 89), luxations with associated fractures had mainly good and fair results (73 %, mean score 74). Analysis of the gait pattern by dynamic plantar pressure measurement demonstrated lower pressures in the isolated luxation group and higher pressures in the group with associated fractures in the lateral region of the forefoot with shorter phases of weight bearing.

Selbstmedikation mit Lokalanästhetika durch Glaukompatienten bei der Teletonometrie

BACKGROUND

Self-tonometry, a supplementary measurement of the intraocular pressure in ophthalmology by glaucoma patients using an automatic tonometer, will become more and more important in the future. As long as the self-tonometry has to work in the contact modus with the ocular surface, home application of a topical anaesthetic by the glaucoma patient will be a requirement for a successful measurement. So far no severe problems within this controlled self-medication have been seen. Nevertheless, public health authorities believe patient health is put at high risk by the application of local anaesthetics during self-tonometry. As there are no clinical studies of the health care, we evaluated the local tolerability of a topical anaesthetic in line with self-tonometry employing a modified tonometer OCUTON S.

MATERIAL AND METHODS

A total of 100 glaucoma patients participated in a prospective clinical study of the routine clinical service in which each was monitored for 1 year. The telemonitoring involved self-tonometry for at least 6 months in every case and Ocuton S Proparakain-POS 0.5% eyedrops (proxymetacaine-HCl) were applied by the probands before every measurement of the intraocular pressure with a modified self-tonometer. Information regarding the local tolerability of the topical anaesthetic was analysed using a standardised questionnaire. The intensity of the following subjective symptoms was listed in separate visual analogue scales for: lacrimation, burning, foreign body sensation, mucus aggregation, pruritus and pain.

RESULTS

Information from 83 glaucoma patients on local tolerability of proparacaine eyedrops could be analysed. For several reasons no data could be gathered from 17 probands, which were refusal to complete the questionnaire, cancelled participation and, in two test persons, there emerged an allergic reaction (local eyelid redness and swelling) which necessitated a change to a different topical anaesthetic. In all other participants the application was carried out without any significant local or systemic symptoms or side-effects. Immediately after application of the eyedrops 36.1% of the test persons suffered a minor conjunctival hyperaemia which eased off within 1 h in 20.4% of these patients. Of the interviewed glaucoma patients 91.5% judged the single symptoms on the visual analogue scale between zero and medium intensity. The severest effects, according to the subjective evaluation, were felt in symptoms of burning with a score of 94 and lacrimation graded 96. The least intensity was established in the symptom of mucus aggregation where 72.3% rated this symptom in the visual analogue scale between 0 and 10. The other symptoms pruritus, feeling of pressure and foreign body sensation hardly differed in subjective ratings.

CONCLUSION

A self-medication with topical anaesthetics on undamaged ocular surfaces for self-tonometry purposes can be performed by glaucoma patients without a high risk potential. However, the application presupposes that routine ophthalmological examinations are carried out according to the ophthalmological associations' recommendations. Therefore, medical care concepts which integrate self-tonometry into routine ophthalmological services and comply with the complex requirements of a modern glaucoma management should be applied more often.

Robotic systems in total hip arthroplasty--is the time ripe for a new approach?

The technical aspects of manual total hip arthroplasty are briefly described. The development, technique and technical problems of previous robotic systems in total hip arthroplasty are described with special details of the Robodoc--System. Recent advances regarding the minimally invasive technique of total-hip implantation and navigation are described. The current development of a robotic assisted system for total hip arthroplasty is presented. This project aims to combine the advantages of minimally invasive techniques and navigational systems with the accuracy that robotic assisted bone milling can provide. The project-name is RomEo (Robotic minimally invasive Endoprosthetics), the main project partners are the Helmut-Schmidt-University/Hamburg and the Department of Trauma and Orthopaedics of the BG Trauma Hospital Hamburg.

Physical evaluation of a new technique for X-ray dose reduction: Measurement of signal-to-noise ratio and modulation transfer function in an animal model

Aim of this study was to record objective changes in image quality of optically re-exposed, radiation-reduced X-ray images in comparison to a normally exposed reference image in an animal model. Under investigation is the question if optical re-exposure of conventional, radiation-reduced X-ray images partially or even fully compensates the loss of information caused by underexposure. Dose-reduced, underexposed images were prepared by reducing the mAs product to 50% with constant anode voltage. Reproduction of the image was performed with a 52% decrease in the radiation dose. Comparing different re-exposure times, the optimal time was found to be 60s. These underexposed X-rays were then optically re-exposed for a defined period of time before development. In all X-ray images of the animal model, different osseous structures were defined as regions of interest (ROI) for evaluation of the objective changes in image quality. The density curves were plotted with the two-beamed densitometer. The contrast transfer factors as the function of local frequency were determined from this, which served as the basis for calculating the modulation transfer factor. To establish if X-ray sensitisation by optical re-exposure leads to a change in the sensitometric gradation, the sensitometric curves were determined using a standardized aluminum scale and thermal luminescence dosimetry. In the comparison the lowest correlation with the standard technique film (X-ray 1) was seen in the purely dose-reduced X-ray. In the range of 1.6-3.4Lp/mm, both SNR curves have an identical course. Despite a 52% dose reduction in the re-exposed image, both densitometry curves of the conventional and re-exposed X-ray show an almost identical distribution of the transmittance levels. In conclusion film sensitisation provides a technically simple and inexpensive procedure, which is easily integrated into previous film development processes and considerably reduces the patient radiation exposure as well as clearly improving the image quality.

Locked vs. unlocked plate osteosynthesis of the proximal humerus - a biomechanical study

BACKGROUND

Locked plates (internal fixators) have been found to be an optimal method for the fixation in proximal humeral fractures. In a biomechanical cadaver study the difference between locked and non-locked osteosyntheses was investigated.

METHODS

Paired humeri were harvested, bone density measured. Locked internal fixators were mounted on one specimen; identical plate-screw-systems without locking mechanism applied to the contralateral specimen for comparison. After that, a transverse subcapital osteotomy was performed. With 7 pairs of humeri static tests with increasing axial loads and with 5 pairs dynamic tests with 10 N preload and 80 N maximal axial load for up to 1 million cycles were performed.

RESULTS

In the static experiments the elastic stiffness of the construct was 74% higher in the locked group (median 80 N/mm, quartile range 77-86 N/mm) compared with the non-locked group (46 N/mm, 35.5-56.5 N/mm). The difference was statistically significant (Wilcoxon test for paired samples, P<0.05). Similarly, the linear range until failure was definitely extended in the locked group by 64% (92 N, 89-98 N vs. 56 N, 36.5-73.5 N, P<0.05). Under dynamic loading the non-locked group showed fixation failures between 97,000 and 500,000 cycles. In the locked group no failure was observed until the end of the experiment at 1 million cycles (P<0.0.5). The final deformation was found to be 1 mm (median, quartil range 1.0-1.2 mm) in the non-locked group and 0.3 mm (0.2-0.3 mm) in the locked group (P<0.05). The differences were found equally in lower as well as in higher bone density specimen.

INTERPRETATION

Because of the optimal load transfer between implant and cancellous bone, a locked screw plate interface will reduce fixation failure in proximal humeral fractures.

[A sizeable chance--surgical management of profound obesity concurrent with post-traumatic osteoarthrosis]

In times of plentiful nutrition an environmental advantage turns into a problem - obesity. Apart from an increase in morbidity and overall mortality the development of osteoarthrosis is well documented. Pre-arthrotic conditions may arise from trauma and can lead, depending on the pattern of injury, to full-blown arthrosis. The presence of obesity can play the role of a relevant progressive factor in this setting. Here we report about the case of an obese man (BMI 53.5 kg/m(2)), who suffered a fracture of the femoral head with acetabular participation (Pipkin IV) as well as a fracture of the tibial plateau. Operative management and rehabilitation were followed by gastric bypass surgery for weight reduction. The case is discussed with regard to the present literature.

Elektronische Patientenakte zum telemedizinischen Monitoring von Augeninnendruck, Blutdruck und Blutzucker

BACKGROUND

At the University Eye Hospital of Greifswald, we have developed a digital patient record that allows close monitoring of glaucoma, diabetes and hypertension. The record stores contemporary, long-term profiles containing intraday variation and interaction of intraocular pressure, blood pressure and serum glucose levels even at night.

METHODS

All patients are equipped with a home monitoring system. They subsequently transmit self-measurements via the "telemedical interface" to the server. Physicians use a web front-end to access electronic patient records; this provides a PDF export filter for printing. We intend to include a total number of 120 patients from Mecklenburg-Vorpommern who suffer from glaucoma possibly combined with hypertension/diabetes. This long-term investigation was designed as a randomised cross-over study in two groups.

RESULTS

Especially for this project an electronic patient record was developed and implemented. The components of the home monitoring system were modified and connected to a custom-built "telemedical interface". To date the study includes 120 patients, 60 of whom constantly measure and transmit their values to the electronic patient record, while the others are treated without home monitoring. All self-measurements are presented in a tabular form. In addition, dynamically generated graphics provide a diagrammatic view of all values. On demand, a detailed protocol for every single measurement report allows a comprehensive evaluation of the quality of the self-measurements. Ocular perfusion pressure is calculated automatically from intraocular pressure and blood pressure. The presented system documents continuously all information that is relevant for treatment and provides fast access for all attending physicians.

CONCLUSIONS

Central data collection and unlocalised access improve information exchange between involved physicians. Flexible measurement periods allow the detection of pressure spikes even at night. In addition, this may help to classify glaucoma (normal-pressure glaucoma) and its causal connection to blood pressure. The patients benefit from individualised therapy adaptation and early therapeutic intervention in case of critical parameters.

Fortschritte in der geriatrischen Betreuung durch Telemedizin

A constantly aging population leads to an increasing number of elderly patients. As a result, the treatment of chronic illnesses becomes a significant part of daily routine. Today's concepts in social services and healthcare require time consuming and barely cost-effective efforts for the special needs of geriatric care. The use of telemedicine offers a possible solution, because telemedical methods may help to realize improved monitoring systems for optimized and effective patient management. This report provides an overview of the scenarios and advantages of telemedicine in general. In addition, we provide information on practical experiences in a project on telemedical glaucoma management in Mecklenburg-Vorpommern.