Anatomic evaluation of the triceps tendon insertion at the proximal olecranon regarding placement of fracture fixation devices.

PURPOSE: Olecranon fractures, especially with a small proximal fragment, remain a surgical challenge. Soft tissue irritation and affection of the triceps muscle bear a risk of complications. In order to find an area for a soft-tissue sparing placement of implants in the treatment of olecranon fractures, we aimed to define and measure the segments of the proximal olecranon and evaluate them regarding possible plate placement. METHODS: We investigated 82 elbow joints. Ethical approval was obtained from the local ethics committee, After positioning in an arm holder and a posterior approach we described the morphology of the triceps footprint, evaluated and measured the surface area of the triceps and posterior capsule and correlated the results to easily measurable anatomical landmarks. RESULTS: We found a bipartite insertional footprint with a superficial tendinous triceps insertion of 218.2 mm2 (± 41.2, range 124.7-343.2), a capsular insertion of 159.3 mm2 (± 30.2, range 99.0-232.1) and a deep, muscular triceps insertion area of 138.1 mm2 (± 30.2, range 79.9-227.5). Olecranon height was 26.7 mm (± 2.3, range 20.5-32.2), and olecranon width was 25.3 mm (± 2.4, range 20.9-30.4). Average correlation between the size of the deep insertion and ulnar (r = 0.314) and radial length (r = 0.298) was obtained. CONCLUSIONS: We demonstrated the bipartite morphology of the distal triceps footprint and that the deep muscular triceps insertion area by its measured size could be a possible site for the placement of fracture fixations devices. The size correlates with ulnar and radial length.

Peroneal nerve location at the fibular head: an anatomic study using 3D imaging.

INTRODUCTION: Injuries to the peroneal nerve are a common complication in operative treatment of proximal tibial or fibular fractures. To minimize the risk of iatrogenic injury to the nerve, detailed knowledge of the anatomy of the peroneal nerve is essential. Aim of this study was to present a detailed description of the position and branching of the peroneal nerve based on 3D-images to assist preparation for surgical approaches to the fibular head and the tibial plateau. METHODS: The common peroneal nerve, the deep and the superficial peroneal nerve were marked with a radiopaque thread in 18 formalin-embalmed specimens. Three-dimensional X-ray scans were then acquired from the knee and the proximal lower leg in full extension of the knee. In 3D-reconstructions of these scans, distances of the common peroneal nerve and its branches to clearly defined osseous landmarks were measured digitally. Furthermore, the height of the branching of the common peroneal nerve was measured in relation to the landmarks. RESULTS: The mean distance of the common peroneal nerve at the level of the tibial plateau to its posterior osseous limitation was 7.92 ± 2.42 mm, and 1.31 ± 2.63 mm to the lateral osseous limitation of the tibia. In a transversal plane, distance of the common peroneal nerve branching was 27.56 ± 3.98 mm relative to the level of the most proximal osseous extension of fibula and 11.77 ± 6.1 mm relative to the proximal extension of the tibial tuberosity. The deep peroneal nerve crossed the midline of the fibular shaft at a distance of 22.14 mm ± 4.35 distally to the most proximal extension of the fibula, the superficial peroneal nerve at a distance of 33.56 mm ± 6.68. CONCLUSION: As the course of the peroneal nerve is highly variable in between individuals, surgical dissection for operative treatment of proximal posterolateral tibial or fibular fractures has to be done carefully. We defined an area were the peroneal nerve and its branches are unlikely to be found. However, specific safe zones should not be utilized due to the individual anatomic variation.

[Instability after operative and conservative treatment of isolated Mason type II fractures]. / Instabilität nach operativer und konservativer Versorgung von isolierten Mason-II-Frakturen.

BACKGROUND: Radial head fractures are the most frequent fractures of the elbow joint in adults. For Mason type II fractures without concomitant injuries favorable results have been shown with operative and conservative management. There is insufficient evidence concerning elbow joint stability after conservative treatment compared to open reduction and internal fixation (ORIF). MATERIALS AND METHODS: All patients with isolated Mason type II (two part fracture displaced >2 mm and <5 mm) radial head fractures between 1 January 2003 and 1 April 2013 were retrospectively reviewed. Exclusion criteria were age <18 years, associated fractures of the ipsilateral extremity or elbow luxation. A total of 50 patients (mean age 44.2 years, range 19-71 years) who received either ORIF (n = 31) or conservative treatment (n = 19) were included. The mean follow-up was 43.2 months (range 9-61 months). Patients were evaluated using the Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance score (MEPS), and Oxford Elbow score (OES). Joint stability (varus and valgus stress) was assessed under fluoroscopy and a distinction was made between slight instability (angulation <10°), moderate instability (angulation ≥10°) and gross instability (elbow dislocation). RESULTS: Residual fracture displacement (conservative: 2.7 mm, ORIF: 1.4 mm, p < 0.042) and varus/valgus joint stability (3% ORIF vs. 26% conservative, p = 0.031) showed significant differences. The stability as tested by a radiological dynamic procedure showed an instability after ORIF in 3% of the joints compared to 26% after conservative treatment; however, this did not influence the short to mid-term clinical outcome: No significant differences were found in the DASH score (conservative 33 points, ORIF 36 points), MEPS (conservative 76 points, ORIF 78 points) and OES (conservative 41 points, ORIF 43 points). DISCUSSION: Both conservative management and operative treatment had a good functional outcome. Operative treatment showed a positive tendency concerning radiological and functional outcome without statistical significance.

[Olecranon fractures]. / Olekranonfrakturen.

Olecranon fractures represent a common elbow injury and they are usually treated operatively. Depending on fracture morphology conservative therapy can be considered in geriatric patients. When surgical treatment is performed the anatomical features of the proximal ulna have to be taken into consideration. Tension band wiring is considered a standard procedure for simple fractures and provides good clinical results. Plate osteosynthesis is indicated for more complex fracture patterns. Nowadays, many surgeons prefer plate fixation over tension band wiring even for simple fractures as it leads to a more stable fixation. Both methods frequently require hardware removal for persisting soft tissue irritation. The use of modern low-profile plates could reduce the need for implant removal due to better soft tissue coverage. The available clinical data regarding low-profile plates are promising but limited.

[Elbow prostheses in rheumatic diseases]. / Ellenbogenprothese bei rheumatischen Erkrankungen.

When the elbow is destroyed due to rheumatic diseases, the joint can be replaced by a prosthesis and total arthroplasty. Improved pharmaceutical treatment for rheumatic diseases has, however, reduced the number of implantations in these patients. Reported 10-year survival rates of the implant currently achieve 81-90%.; however, due to limited long-term survival of the implant and high complication rates, total elbow arthroplasty should still be used with caution. Continuous technical improvements in the available prostheses and in surgical techniques could lead in the future to a decline in complications, such as aseptic loosening and infections.

Opioid intake prior to admission is not increased in elderly patients with low-energy fractures: A case-control study in a German hospital population.

BACKGROUND: Recent studies revealed an increased prescription rate of opioids for elderly patients suffering bone fractures. To gain further insight, we conducted face-to-face interviews in the present study to compare the opioid intake between patients with low-energy fractures and patients suffering from internal diseases. METHODS: In this case-control study, 992 patients, aged 60 years and older, were enrolled between March 2014 and February 2015. The interview comprised a fall and medication history, comorbidities, mobility and other risk factors for fractures. Odds ratios (OR) and a multiple logistic regression model were calculated. RESULTS: The number of patients with pre-admission opioid intake in the last 12 months was comparable in the fracture (n = 399, 13.3%) and the control group (n = 593, 14.7% OR: 0.89, CI: 0.62-1.29). The number of patients with current opioid intake of short duration (<3 months) was similar in both groups (14% vs. 20%; OR: 0.66, CI: 0.23-1.93). Patients with opioid intake in the fracture group reported more frequently fatigue as an adverse event of opioid medication (58% vs. 30%; OR: 3.32, CI: 1.48-7.45). Patients with opioid intake showed more severe comorbidities and significantly decreased mobility compared to those without opioids. CONCLUSION: Elderly patients internalized due to low-energy fractures did not take opioids more frequently than patients with internal admission, for both short (<3 months) and longer duration intake. Patients with opioid intake were generally in poorer physical condition. The risk of fracture might increase in patients suffering from fatigue as a side effect of opioid medication. SIGNIFICANCE: This study is based on face-to-face interviews with patients, including details about side effects and fracture history, providing a more pronounced picture of the relation of opioid intake and risk of fracture.

[Bony Bankart lesions and glenoid defects : From refixation techniques to bony augmentation]. / Knöcherne Bankart-Läsion und Glenoiddefekte : Von Techniken der Refixierung bis zur knöchernen Augmentation.

Rim defects of the anterior glenoid cavity are a main reason for residual shoulder instability after traumatic dislocation of the shoulder. These defects can be the result of a glenoid rim fracture or chronic glenoid erosion after repeated shoulder dislocations. Treatment concepts for these entities are entirely different. While in the acute fracture situation glenoid rim fractures can be treated operatively or non-operatively, augmentation of the anterior glenoid for stabilization of the shoulder should be considered if the defect exceeds 15-25% of the anterior glenoid. The purpose of this article is to summarize the diagnostics and indications for treatment of glenoid rim fractures. Radiological assessment and options for augmentation are reviewed for both acute fractures as well as chronic instability following an anterior glenoid rim defect.

[Winged scapula in lyme borreliosis]. / Scapula alata nach Borreliose-Infektion.

Here we present the case of a young patient with one-sided winged scapula and lyme borreliosis. This disease can be very delimitating in daily life. If non-operative treatment fails, dynamic or static stabilization of the scapula can be a therapeutic option.

The novel c-Met inhibitor cabozantinib overcomes gemcitabine resistance and stem cell signaling in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDA) is one of the most lethal malignancies. Cancer stem cells (CSCs), which are not targeted by current therapies, may be the reason for pronounced therapy resistance. A new treatment option in phase II trials is cabozantinib that inhibits the pancreatic CSC surface marker and tyrosine kinase receptor c-Met. The purpose of this study was to evaluate the effect of cabozantinib to stem-like features and therapy resistance. Established PDA cell lines, a gemcitabine-resistant subclone, non-malignant pancreatic ductal cells and primary spheroidal cultures from patient tumors were analyzed by MTT-assay, flow cytometry, colony and spheroid formation assays, western blotting, qRT-PCR, antibody protein array, immunohistochemistry and morphological features. Cabozantinib inhibited viability and spheroid formation and induced apoptosis in malignant cells with minor effects in non-malignant cells. After long-term cabozantinib treatment, PDA cells had altered anti- and pro-apoptotic signaling, but still responded to cabozantinib, as apoptosis only slightly decreased and viability only slightly increased suggesting a low resistance-inducing potential of cabozantinib. In parallel, c-Met expression and the pluripotency transcription factor SOX2 were downregulated, which might counteract development of full therapy resistance in long-term treated subclones. In single-treatment studies, cabozantinib increased efficacy of gemcitabine. Most importantly, cabozantinib strongly induced apoptosis and reduced viability in PDA cell lines, which are completely resistant toward gemcitabine. In primary, CSC-enriched spheroidal cultures cabozantinib downregulated CSC markers SOX2, c-Met and CD133 and induced apoptosis. These findings suggest that the clinical use of cabozantinib may be more effective than current chemotherapeutics.

Sulforaphane targets pancreatic tumour-initiating cells by NF-kappaB-induced antiapoptotic signalling.

BACKGROUND AND AIMS: Emerging evidence suggests that highly treatment-resistant tumour-initiating cells (TICs) play a central role in the pathogenesis of pancreatic cancer. Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) is considered to be a novel anticancer agent; however, recent studies have shown that many pancreatic cancer cells are resistant to apoptosis induction by TRAIL due to TRAIL-activated nuclear factor-kappaB (NF-kappaB) signalling. Several chemopreventive agents are able to inhibit NF-kappaB, and favourable results have been obtained--for example, for the broccoli compound sulforaphane-in preventing metastasis in clinical studies. The aim of the study was to identify TICs in pancreatic carcinoma for analysis of resistance mechanisms and for definition of sensitising agents. METHODS: TICs were defined by expression patterns of a CD44(+)/CD24(-), CD44(+)/CD24(+) or CD44(+)/CD133(+) phenotype and correlation to growth in immunodeficient mice, differentiation grade, clonogenic growth, sphere formation, aldehyde dehydrogenase (ALDH) activity and therapy resistance. RESULTS: Mechanistically, specific binding of transcriptionally active cRel-containing NF-kappaB complexes in TICs was observed. Sulforaphane prevented NF-kappaB binding, downregulated apoptosis inhibitors and induced apoptosis, together with prevention of clonogenicity. Gemcitabine, the chemopreventive agents resveratrol and wogonin, and the death ligand TRAIL were less effective. In a xenograft model, sulforaphane strongly blocked tumour growth and angiogenesis, while combination with TRAIL had an additive effect without obvious cytotoxicity in normal cells. Freshly isolated patient tumour cells expressing markers for TICs could be sensitised by sulforaphane for TRAIL-induced cytotoxicity. CONCLUSION: The data provide new insights into resistance mechanisms of TICs and suggest the combination of sulforaphane with TRAIL as a promising strategy for targeting of pancreatic TICs.

[Dyspnea and lung function. Results of a multicenter study]. / Dyspnoe und Lungenfunktion. Ergebnisse einer Multicenterstudie.

UNLABELLED: In seven pneumological centres 266 patients with different pneumological diseases were investigated. After having clarified several questions regarding the severity of the dyspnoea, cough intensity and the volume of sputum, as well as basic clinical investigation and after an x-ray of the thorax, the diagnosis was arrived at. Subsequently the lung function investigation with the flow-volume curve (including IVC, FVC, PEF, FEV1, MEF50%) and the body plethysmographic Rt and IGV were carried out. Different quality control procedures at and between the different centres ensured comparable results. All centres agreed to using methods well compatible with each other. The question as to which kind of parameters of lung function would agree best with the amount of the dyspnoea, was resolved. The causes for the large scatter of the results are described. Cough and sputum exercise an influence even on the degree of dyspnoea, but not by deteriorating the lung function. The results are shown for the entire collective (Part I) in respect of the different diagnoses (Part II). With different diagnosis the same significant correlations exist but the curves are positioned at different levels of the coordinate system. CONCLUSION: Significant correlations exist between the dyspnoea scale and function parameters. There are individual differences between the dyspnoea scale and disturbances of the function parameters. Carefully performed lung function analyse definitely important in any case.

Lung function testing: the dilemma of predicted values in relation to the individual variability.

Quantitated lung function parameters are usually interpreted in relation to so-called "normal ranges' obtained from healthy study groups. The aim of this paper is the critical review of formulas and the evaluation of intraindividual variation in modern lung function testing. To which extent is the total variation of lung function parameters in cross-sectional studies (usually serving as basis for the normal range) attributed to the intraindividual variation between repeated measurements? This question raises a further question: are lung function values in the normal range really normal? To assess spirometric and body plethysmographic parameters 26 healthy subjects from three medical centers underwent 30-72 measurements over a period of 2 months for the determination of variations due to (1) intraindividual variation over time and (2) interindividual variation. For each subject, predicted values of different lung function parameters published by Quanjer et al. [Eur Respir J 1993; 6:5-40.1], of intrathoracic gas volume by Ulmer et al. [Die Lungenfunktion; Stuttgart, Thieme, 1991] and of total airway resistance by Ruehle and Matthys [Pneumologie 1976;153:223] were applied. When converted into percent predicted and adjusted for differences in medical centers, the intraindividual standard deviation was estimated to be about half of the interindividual standard deviation. We conclude that the normal range of lung function parameters derived from the standard deviation within populations is too wide for the assessment of individual values. Interpretation of individual lung function measurements should primarily be based on the "individual normal range' derived from former lung function measurements of the individual and only secondly on the "predicted value'.

Reproductive anatomy and gametogenesis in Shipleya inermis (Cestoda: Dioecocestidae).

Study of the reproductive anatomy in 65 strobilae of the dioecious cestode Shipleya inermis Fuhrmann, 1908 (Acoleata: Dioecocestidae) showed that a common genital duct, probably arising through fusion of the vas deferens and the proximal portion of the vaginal duct, compensated functionally for the loss of a patent vagina. Gonochorism was characteristic, but rudimentary genital organs of the opposite sex were present in 26% of males and 9% of females; two strobilae (3%) were hermaphroditic. Hermaphrodites had normally developed male organs and were capable of cross-fertilization as males; their female organs were much reduced in size but were functional, and eggs or fertilized ova in the uteri indicated that self-fertilization occurred. Gametogenesis was traced, mainly in chromosomal preparations. The diploid chromosomal complement in embryos and germ-line cells consisted of four pairs of homologues (2n = 8, n = 4, FN = 14). Based on observation in female cestodes of one pair of chromosomes having non-homologous or non-pairing segments due to influence of heterochromatin, the authors suggest that females produce gametes of two types relative to heterochromatic DNA, while males are homogametic, and that sex-determining effects are associated therein. In males, meiosis included chromosomal pairing and recombination, after which heterochromatin was eliminated from germline cells through fragmentation. Other biological characteristics of S. inermis in the hosts, Limodromus spp. (Charadriiformes), are briefly discussed.

Maseria vespertilionis n.g., n.sp. (Dorylaimina : Muspiceidae), a nematode from nearctic bats (Vespertilionidae).

Maseria vespertilionis n. g., n. sp. (Dorylaimina : Muspiceidae) is described from nearctic bats (Vespertilionidae). In addition to the type host, Eptesicus fuscus (P. de Beauvois), in Oregon, M. vespertilionis was recorded from Myotis volans (Allen) in Oregon, and from M. lucifugus (Le Conte) in Oregon and Alaska. The nematode was found only in subcutaneous tissues near the plantar surface of the rear feet of the host. The genus Maseria is distinguished from other genera in Muspiceidae by various morphological characteristics, among which the presence of a Demanian system is important. The lesions produced in the feet of the host are described, and other biological characteristics of the nematode are discussed.

Report of the topic study group on graduate education in medical technology.

The reported study indicates that individuals are motivated for personal reasons to obtain advanced education. Tangible benefits of more challenging employment opportunities and greater financial rewards were achieved by some of the respondents. There is apparently a deficiency in financial support of graduate education for this group of health professionals because many of the individuals reported attending graduate school on a part-time basis. However, it is possible that some part-time students elected this route to keep in contact with current laboratory practice. In addition, the external degree program was a welcome and only possible route for one-fifth of the sample. A tendency to be interested in leaving the health field is noted with concern.