[Closed medial talus dislocation with damage to the tibial nerve]. / Geschlossene mediale Talusluxation mit N.-tibialis-Schädigung.

This article reports a case of medial dislocation of the talus as a rare injury caused by a fall from a low height.Treatment recommendations given in the literature for this rare injury are heterogeneous but closed reduction is predominant. Little is known about possible obstacles in closed reduction. The known complications include posttraumatic arthritis and necrosis of the talus.A posttraumatic lesion of the tibial nerve has not been reported, which is why a treatment recommendation is illustrated and discussed based on this case report.

[Tumor-induced osteomalacia caused by an FGF23-secreting myopericytoma : Case report and literature review]. / Tumorinduzierte Osteomalazie, verursacht durch ein FGF23-sezernierendes Myoperizytom : Literaturübersicht und Fallbericht.

BACKGROUND: The symptoms of muscle weakness, bone pain and fragility fractures can be an indication of osteomalacia. Phosphate is often not considered within osteologic parameters, decreased levels are therefore easily overseen. The additional test for fibroblast growth factor 23 (FGF23) as indicator for tumor-induced osteomalacia (TIO) is still largely unfamiliar. OBJECTIVE: By emphasizing the role of phosphate and furthermore FGF23 in bone metabolism illustrated by the long-term disease process of our clinical case we would like to introduce these parameters to a broader public. METHODS: We performed a literature search via PubMed and Google Scholar with the relevant key words and summarized the diagnostic and therapeutic information. The studies evaluated were mainly case reports. We present a case report of a 70-year-old patient with TIO and a myopericytoma and retrospectively analyzed the clinical case. The follow-up was 6 months. RESULTS: Our literature search found one case of TIO and evidence of FGF23 among 124 cases of myopericytomas in total. Over 300 cases of TIO are reported. In our case, we retrospectively found an FGF23-secreting myopericytoma in the phosphaturic mesenchymal tumors (PMT) group to be the cause of pseudarthrosis on the right humerus shaft and increasing disablement in a patient with osteomalacia. After surgical resection the patient was mobile again, and the osteologic parameters, especially phosphate, normalized from 0.21 to 1.52 mmol/l. CONCLUSION: Low phosphate levels are the decisive indication of TIO in our case. Therefore, we should always think of phosphate level control when dealing with osteomalacia. A hypophosphatemia and hyperphosphaturia should be recognized in time and be diagnostically verified. The additional FGF23 test (c-terminal and intact FGF23) should be considered.

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.

Posttraumatic severe infection of the ankle joint - long term results of the treatment with resection arthrodesis in 133 cases.

Although there is a clear trend toward internal fixation for ankle arthrodesis, there is general consensus that external fixation is required for cases of posttraumatic infection. We retrospectively evaluated the technique and clinical long term results of external fixation in a triangular frame for cases of posttraumatic infection of the ankle. From 1993 to 2006 a consecutive series of 155 patients with an infection of the ankle was included in our study. 133 cases of the advanced "Gächter" stage III and IV were treated with arthrodesis. We treated the patients with a two step treatment plan. After radical debridement and sequestrectomy the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted in the tibia and in the calcaneus and the gap was temporary filled with gentamicin beads as the first step. In the second step we performed an autologous bone graft after a period of four weeks. The case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues. Mean age at the index procedure was 49.7 years (18-82), 104 patients were male (67.1%). Follow up examination after mean 4.5 years included a standardised questionnaire and a clinical examination including the criteria of the AOFAS-Score and radiographs. 92.7% of the cases lead to a stable arthrodesis. In 5 patients the arthrodesis was found partly-stable. In six patients (4,5%) the infection was not controllable during the treatment process. These patients had to be treated with a below knee amputation. The mean AOFAS score at follow up was 63.7 (53-92). Overall there is a high degree of remaining disability. The complication rate and the reduced patient comfort reserve this method mainly for infection. Joint salvage is possible in the majority of cases with an earlier stage I and II infection.

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

UNLABELLED: 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. PATIENTS AND METHODS: From 1994 to 2001 a consecutive series of 95 patients with end stage arthritis of the ankle joint were treated. Retrospectively the case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues and the clinical examination before arthrodesis. Mean age at the index procedure was 45.4 years (18-82), 67 patients were male (70.5%). Via a bilateral approach the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted with approximately 8 cm distance in the distal tibia, one in the neck of the talus and one in the dorsal calcaneus. The fixator was removed after approximately 12 weeks. Follow up examination at mean 4.4 years included a standardised questionnaire and a clinical examination including the criteria of the AOFAS-Score and radiographs. RESULTS: Due to different complications, 8 (8.9%) further surgical procedures were necessary including 1 below knee amputation. In 4 patients a non-union of the ankle arthrodesis developed (4.5%). The mean AOFAS score improved from 20.8 to 69.3 points. CONCLUSION: Non-union rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods. The complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations.

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.

[Resection and replacement of the cervical esophagus and hypopharynx--an interdisciplinary responsibility for visceral, micro- and ENT surgeons]. / Resektion und Ersatz der cervikalen Speiseröhre und des Hypopharynx--eine interdisziplinäre Aufgabe für Viszeral-, Mikro- und HNO-Chirurgen.

From 1984 to 1996, 136 carcinomas of the esophagus and 8 of the hypopharynx were resected using 3 different procedures (94 transmediastinal, 36 transthoracic, 14 cervicoabdominal). The hospital mortality rate for cervicoabdominal resection (0%) is unequivocally lower than that of the transmediastinal (17.1%) or transthoracic (14.3%) methods. The 5-year survival rates are not significantly different (24%, 22%, 17%).

[Pyogenic skin infections of the extremities with vascular involvement. Local vascular reconstruction and systemic therapy concepts]. / Pyogene Hautinfektionen der Extremitäten mit Gefässbeteiligung. Lokale gefässrekonstruktive und systemische Therapiekonzepte.

In a 6-year period, we treated 14 patients with severe groin infections involving the femoral artery following drug injection in addicts. In 13 cases, we used autologous material for arterial reconstruction; in one case of massive bleeding the femoral artery had been embolized. Ten patients were treated with full success, two patients had claudication postoperatively, and in two cases above-knee amputations were necessary.

Differential metabolic effects of energy restriction in dogs using diets varying in fat and fiber content.

The role of dietary fat and fiber in energy restriction for the management of obesity was examined. Twelve male castrated dogs were energy restricted for 7 weeks by feeding 60% of their calculated maintenance energy requirements (MER = 1500 kcal/m2/d) for ideal body weight. Six dogs were restricted on a high-fat (35.4 kcal% from fat), low-fiber (2.9% dry matter basis [DMB]) diet while the other six dogs were restricted on a low-fat (24.5 kcal% from fat), high-fiber (27% DMB) diet. Compared with the high-fat, low-fiber diet, energy restriction on the low-fat, high-fiber diet resulted in significantly greater decreases in body fat (1472 +/- 166 vs. 853 +/- 176 g; p < 0.05) and total serum cholesterol concentrations (108.7 +/- 11.3 vs. 51.5 +/- 13.9 mg/dL; p < 0.005). Reductions in body weight (2.86 +/- 0.3 vs. 2.14 +/- 0.3 kg; p < 0.09), and mean arterial blood pressure (17.4 +/- 6.1 vs. 6.7 +/- 2.9 mmHg; p < 0.12) were also greater on the low-fat diet; however, these diet effects did not reach statistical significance. These data suggest that the fat and fiber content of the diet during energy restriction are important factors in the management of obesity.

[Gastrointestinal lymphomas: results of multimodal therapy in 57 patients of one center]. / Gastrointestinale Lymphome: Ergebnisse einer multimodalen Therapie bei 57 Patienten eines Zentrums.

From 1982-1995, 57 patients with primary gastrointestinal lymphoma were treated with a multimodality therapy. Of these patients, 36 were primary operated, 43 were given an isolated or postoperative chemotherapy and 17 were treated with radiation. Primary operated patients have a significantly better chance of relapse-free survival than those only treated conservatively.