Franziskushospital Aachen

Avoiding suture tension in peripheral nerve coaptation seems to be a clinical dogma since 30 years, although experimental data are weak and clinical practice shows good functional outcome after peripheral nerve repair by direct coaptation under "reasonable" tension, defined by local anatomic feasibility and the use of specific suture material. In this article, we focus on the microsurgical technique of nerve stump coaptation and the distribution of tension through epineural sutures with various suture materials; we also analyze the impact on the different nerve tissue layers, the limit of this approach and its combination with other tissue releasing techniques like paraneurolysis, adjacent joint flexion, or bone shortening.

Backround: Some children with obstetric brachial plexus palsy (OBPP) present later on with an ulnarly deviated wrist. The aim of this study was to present a retrospective analysis of a subgroup of OBPP children with ulnarly deviated wrists and to describe their morphologic wrist deformity in terms of clinical and radiological appearance. Methods: We present a retrospective analysis of the records of 27 children with an ulnarly deviated wrist as a consequence of OBPP. Radiographs of the affected wrist were performed when the ulnar deformity became clinically manifest and merited investigation, at a mean age of 15 (range: 6.5-27) years. Available clinical and radiological data were analyzed and categorized. Results: The ulnar-deviated position was associated with impaired active and passive pronosupination in all patients. Fifteen fixed supination deformities and 3 anterior radial head dislocations were noted clinically. Plain radiographs were completed in 24 patients and could be analyzed in 18, showing variations in ulnar variance (7 neutral, 7 ulna minus, and 4 ulna plus) along with 6 subluxations of the distal radioulnar joint (DRUJ). Of the patients treated surgically (n = 7), only the 2 patients treated with wrist fusion had an actual improvement in ulnar wrist deformity. Conclusion: Radiologically visible ulnar head hypoplasia, overgrowth of the distal ulna, or a shortened ulnar diaphysis and an incongruent DRUJ were present in all examined OBPP patients with a clinically evident ulnarly deviated wrists. The radiological findings highlight the morphologic adaptation behind this clinical condition and could allow further investigation into suitable treatment strategies.

Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). Acomparison of three different treatment models (6months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29h (A) and 18h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A:11%, B:0%, C:0%; p = 0.035). There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

While fetal thymus size has been shown to be a prognostic maker in pregnancies with fetal growth restriction, there is no data on fetal thymus size in pregnancies complicated by maternal diabetes. Therefore, the objective of our study was to evaluate the influence of maternal diabetes on fetal thymus size. We retrospectively assessed 161 pregnancies of diabetic mothers and 161 uncomplicated pregnancies matched by gestational age (control group). Diabetic mothers were allocated to three different groups: 1. diet-controlled gestational diabetes, 2. Insulin-dependent gestational diabetes, and 3. pre-existing diabetes. The anteroposterior thymic and the intrathoracic mediastinal diameter were measured and we calculated the quotient as thymic-thoracic ratio (TT-ratio). Furthermore, we defined the thymus-head ration (TH-ratio) as the quotient of the anteroposterior thymic diameter and the circumference of the fetal head. TT- and TH-ratios were significantly smaller in pregnancies with maternal diabetes (P < 0.001 and P < 0.001, respectively). In all three diabetes groups, both ratios were lower when compared to the control group (P < 0.001). TT- and TH-ratios were significantly smaller in pregnancies with maternal diabetes (P < 0.001 and P < 0.001, respectively). In all three diabetes groups, both ratios were lower when compared to the control group (P < 0.001).

Jeder wiederherstellungschirurgische Eingriff generiert aus seiner Gewebe und technischen Spezifizitat einen besonderen Nachbehandlungsbedarf, der neben ublicher, auf physiotherapeutischen Konzepten beruhender Therapie auch eigene Anregungen des Chirurgen beinhalten muss – vermittelt als Inhalt eines guten interdisziplinaren Austauschs zwischen Operateur und Therapeut(en).

Aus der Perspektive der betroffenen Eltern wird beschrieben, wie der Umgang, die Kontakte und Aufklarungsgesprache mit Eltern verbessert werden konnen. Die Autorin ist Mutter eines Sohnes mit einer geburtstraumatischen Plexusparese. Sie ist Vorsitzende von Plexuskinder e.V., einem bundesweiten Selbsthilfeverein, der betroffenen Kindern und Erwachsenen und ihren Angehorigen Informationen, Ratschlage und Unterstutzung bietet.

In diesem Kapitel kommen drei Betroffene mit ihren eigenen Lebensgeschichten und ihrer individuellen Betrachtungs- und Verarbeitungsweise zu Wort, um auch anderen Patienten Mut zu machen und den Behandler zu motivieren, stets ein offenes Ohr fur seinen Patienten zu haben.

Peripheral nerve surgeries, especially the surgical treatment of brachial (and lumbar) plexus injuries, are not defined surgical specialties and are provided by only few colleagues in each country all over the world. They include neurosurgeons, orthopedic surgeons, and hand and plastic surgeons, and they meet regularly and frequently at international meetings where they share their knowledge on surgical techniques and also exchange with researchers working on nerve regeneration and bioartificial nerve grafts.