HFR Freiburg Kantonsspital

Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment.

We reviewed retrospectively 11 patients who had been treated surgically by open autologous osteochondral grafting for symptomatic chondral or osteochondral defects of the dome of the talus between 1996 and 1999. The mean ages of the eight men and three women were 34.2 and 25.9 years, respectively, with a mean time to follow-up of 24 months. The results of functional outcome were prospectively obtained using the MODEMS AAOS foot and ankle follow-up questionnaire, the AOFAS ankle-hindfoot scale and the Hannover scores for the ankle. The grafts were harvested from the ipsilateral knee. Good to excellent results were obtained for the ankle without adverse effects on the knee. We believe that autologous osteochondral grafting should be considered for the patient with a symptomatic osteochondral defect of the talus.

PURPOSE: The purpose of this study is to evaluate clinical and radiological outcomes of patients treated with autologous matrix-induced chondrogenesis (AMIC) for full-thickness chondral and osteochondral defects of the femoral condyles and patella. METHOD: A retrospective evaluation of clinical and radiographic outcomes of patients treated with AMIC for chondral and osteochondral full-thickness cartilage defects of the knee was performed with a mean follow-up of 28.8 ± 1.5 months (range, 13-51 months). RESULTS: Significant improvements in clinical outcome scores (IKDC, Lysholm, Tegner, and VAS pain score) were noted. The largest improvements were seen in the osteochondral subgroup (mean age 25.9 years), whereas patients treated for chondral defects in the patellofemoral joint and on the femoral condyles improved less. Patients in all groups were generally satisfied with their results. MRI evaluation showed that tissue filling was present but generally not complete or homogenous. CONCLUSIONS: AMIC is a safe procedure and leads to clinical improvement of symptomatic full-thickness chondral and osteochondral defects and to regenerative defect filling. The value of AMIC relative to other cartilage repair procedures and to the natural course remains undefined. LEVEL OF EVIDENCE: Case series, Level IV.

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

OBJECTIVES: Chondroitin sulfate 800 mg/day (CS) pharmaceutical-grade in the management of symptomatic knee osteoarthritis consistent with the European Medicines Agency guideline. METHODS: A prospective, randomised, 6-month, 3-arm, double-blind, double-dummy, placebo and celecoxib (200 mg/day)-controlled trial assessing changes in pain on a Visual Analogue Scale (VAS) and in the Lequesne Index (LI) as coprimary endpoints. Minimal-Clinically Important Improvement (MCII), Patient-Acceptable Symptoms State (PASS) were used as secondary endpoints. RESULTS: 604 patients (knee osteoarthritis) diagnosed according to American College of Rheumalogy (ACR) criteria, recruited in five European countries and followed for 182 days. CS and celecoxib showed a greater significant reduction in pain and LI than placebo. In the intention-to-treat (ITT) population, pain reduction in VAS at day 182 in the CS group (-42.6 mm) and in celecoxib group (-39.5 mm) was significantly greater than the placebo group (-33.3 mm) (p=0.001 for CS and p=0.009 for celecoxib), while no difference observed between CS and celecoxib. Similar trend for the LI, as reduction in this metric in the CS group (-4.7) and celecoxib group (-4.6) was significantly greater than the placebo group (-3.7) (p=0.023 for CS and p=0.015 for celecoxib), no difference was observed between CS and celecoxib. Both secondary endpoints (MCII and PASS) at day 182 improved significantly in the CS and celecoxib groups. All treatments demonstrated excellent safety profiles. CONCLUSION: A 800 mg/day pharmaceutical-grade CS is superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in symptomatic knee osteoarthritis (OA) patients. This formulation of CS should be considered a first-line treatment in the medical management of knee OA.

Objectives: To analyse the association between female hormonal factors and the development of systemic autoimmunity associated with RA in women at increased risk for RA, namely first-degree relatives of patients with RA (RA-FDRs). Methods: In an ongoing cohort study of RA-FDRs, we analysed all women with available ACPA status. The primary outcome was ACPA positivity. The predictors of interest were female hormonal factors, such as oral contraceptives, breastfeeding, post-menopausal status, early post-menopausal period and total number of ovulatory years. Results: A total of 768 female RA-FDRs were analysed, of which 42 (5%) had developed ACPA positivity. ACPA-positive women were older (52 vs 44 years, P = 0.001). Hormonal factors significantly and independently associated with the presence of ACPA were the post-menopausal (P < 0.001) and the early post-menopausal periods (P = 0.040). Conclusions: In women at increased risk of RA, characteristic systemic autoimmunity was associated with menopause, suggesting that the acute decline in ovarian function might contribute to the development of autoimmunity associated with RA and potentially to the increased risk of RA in women.

We reviewed retrospectively 11 patients who had been treated surgically by open autologous osteochondral grafting for symptomatic chondral or osteochondral defects of the dome of the talus between 1996 and 1999. The mean ages of the eight men and three women were 34.2 and 25.9 years, respectively, with a mean time to follow-up of 24 months. The results of functional outcome were prospectively obtained using the MODEMS AAOS foot and ankle follow-up questionnaire, the AOFAS ankle-hindfoot scale and the Hannover scores for the ankle. The grafts were harvested from the ipsilateral knee. Good to excellent results were obtained for the ankle without adverse effects on the knee. We believe that autologous osteochondral grafting should be considered for the patient with a symptomatic osteochondral defect of the talus.

Computer-assisted image guidance allows precise preoperative planning and intraoperative localization of surgical instruments. The technique recently was validated for the insertion of pedicle screws. In the laboratory, the precision of a surface-matching algorithm was evaluated for registration and accuracy and safety of screw placement into the vertebral bodies of S1 and S2 for fixation of the sacroiliac joint. Using six plastic pelves, 24 screw holes were made through the sacroiliac joint into the vertebral body of S1, and 12 holes were made through the sacroiliac joint into S2. The accuracy of the hole position was evaluated using a postoperative computed tomography examination. The safety factor was assessed by analysis of the remaining bone stock around the holes calculating a theoretical cylindrical volume being outside bone with increasing bore hole diameters. The registration was accurate with a mean error less than 1.4 mm in the posterior parts of the pelvis. The drilling followed precisely the preoperatively planned trajectories; perforation of the cortex of the sacrum was not observed. The safety factor of the S1 vertebral body is higher than that of S2 allowing larger diameter screw insertion into S1. This technique provides a safe and precise guide for transcutaneous or open insertion of iliosacral screws in cases of iliosacral dislocation or sacral fracture.

OBJECTIVE: The objective of this study was to test the clinical value of MR imaging for diagnosing cephalopelvic disproportion and for predicting labor outcome in women at risk for dystocia. SUBJECTS AND METHODS: Antepartum fetal sonography and maternal MR imaging pelvimetry measurements were performed at term in 38 pregnant women at risk for dystocia with a single fetus in cephalic presentation. Various methods used to diagnose cephalopelvic disproportion were evaluated in a blinded manner for their accuracy to predict both the presence of cephalopelvic disproportion and the mode of delivery (vaginal vs cesarean). RESULTS: None of the methods tested yielded both high sensitivity (15-100%) and high specificity (24-92%) for determining the presence of cephalopelvic disproportion and high levels of accuracy for predicting labor outcome (overall predictability, 50-74%). CONCLUSION: To achieve increased reliability of MR imaging pelvimetry in the diagnosis and treatment of dystocia and in predicting labor outcome, new methods assessing fetal-pelvic compatibility, including measurements of the pelvic outlet and the shape and configuration of the pelvis, need to be established and prospectively tested before firm recommendations for clinical use can be made.

We report seven cases in which open or closed reduction of a shoulder dislocation associated with a fracture of the humeral neck led to displacement of the neck fracture. Avascular necrosis of the humeral head developed in all six patients with anatomical neck fractures. All five anterior dislocations also had a fracture of the greater tuberosity and both posterior dislocations had a fracture of the lesser tuberosity. The neck fracture had not initially been recognised in three of the seven cases. In five cases attempted shoulder reduction led to complete displacement of the head segment, which was treated by open reduction and minimal internal fixation. In the other two cases, shoulder reduction caused only mild to moderate displacement which was accepted and the fracture was treated conservatively. We conclude that biplane radiography is essential before reduction of a shoulder dislocation. Neck fractures must always be ruled out, especially where there are tuberosity fractures. In our series, careful closed reduction under general anaesthesia with optimal relaxation and fluoroscopic control did not prevent iatrogenic displacement. Prophylactic stabilisation of the neck fracture should be considered before reduction of such a fracture-dislocation. It may be, however, that the prevention of displacement by prophylactic stabilisation does not always prevent late avascular necrosis; we observed this in one case.

Elevated interleukin (IL)-1β levels, NLRP3 inflammasome activity, and systemic inflammation are hallmarks of chronic metabolic inflammatory syndromes, but the mechanistic basis for this is unclear. Here, we show that levels of plasma IL-1β are lower in fasting compared to fed subjects, while the lipid arachidonic acid (AA) is elevated. Lipid profiling of NLRP3-stimulated mouse macrophages shows enhanced AA production and an NLRP3-dependent eicosanoid signature. Inhibition of cyclooxygenase by nonsteroidal anti-inflammatory drugs decreases eicosanoid, but not AA, production. It also reduces both IL-1β and IL-18 production in response to NLRP3 activation. AA inhibits NLRP3 inflammasome activity in human and mouse macrophages. Mechanistically, AA inhibits phospholipase C activity to reduce JNK1 stimulation and hence NLRP3 activity. These data show that AA is an important physiological regulator of the NLRP3 inflammasome and explains why fasting reduces systemic inflammation and also suggests a mechanism to explain how nonsteroidal anti-inflammatory drugs work.

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

BACKGROUND: Adding bevacizumab to chemotherapy improves response rates and progression-free survival (PFS) in metastatic breast cancer (mBC). We aimed to demonstrate decreased toxicity with metronomic chemotherapy/bevacizumab compared with paclitaxel/bevacizumab. METHODS: This multicenter, randomized phase III trial compared bevacizumab with either paclitaxel (arm A) or daily oral capecitabine-cyclophosphamide (arm B) as first-line treatment in patients with HER2-negative advanced breast cancer. The primary endpoint was the incidence of selected grade 3-5 adverse events (AE) including: febrile neutropenia, infection, sensory/motor neuropathy, and mucositis. Secondary endpoints included objective response rate, disease control rate, PFS, overall survival (OS), quality of life (QoL), and pharmacoeconomics. The study was registered prospectively with ClinicalTrials.gov, number NCT01131195 on May 25, 2010. RESULTS: Between September 2010 and December 2012, 147 patients were included at 22 centers. The incidence of primary endpoint-defining AEs was similar in arm A (25 % [18/71]; 95 % CI 15-35 %) and arm B (24 % [16/68]; 95 % CI 13-34 %; P = 0.96). Objective response rates were 58 % (42/73; 95 % CI 0.46-0.69) and 50 % (37/74; 95 % CI 0.39-0.61) in arms A and B, respectively (P = 0.45). Median PFS was 10.3 months (95 % CI 8.7-11.3) in arm A and 8.5 months (95 % CI 6.5-11.9) in arm B (P = 0.90). Other secondary efficacy endpoints were not significantly different between study arms. The only statistically significant differences in QoL were less hair loss and less numbness in arm B. Treatment costs between the two arms were equivalent. CONCLUSION: This trial failed to meet its primary endpoint of a reduced rate of prespecified grade 3-5 AEs with metronomic bevacizumab, cyclophosphamide and capecitabine.

OBJECTIVE: Plunging when drilling can be a detrimental factor in patient care. There is, although, a general lack of information regarding the surgeon's performance in this skill. The aim of this study was to determine the effect that using sharp or blunt instruments had on the drill bit's soft tissue penetration, using a simulator. MATERIALS AND METHODS: Surgeons taking part in an International Trauma Course were invited to participate. Two groups were defined: experienced and inexperienced surgeons. Twelve holes were drilled in the following order: 3 holes with a sharp drill bit in normal bone (SNB), 3 holes with a sharp drill bit in osteoporotic bone (SOB), 3 holes with a blunt drill bit in normal bone, and 3 holes with a blunt drill bit in osteoporotic bone. Mean values and Student t tests were used for statistical analysis. RESULTS: Thirty-seven surgeons participated, 20 experienced and 17 inexperienced surgeons. Mean plunging depths for SNB, SOB, blunt drill bit in normal bone, and blunt drill bit in osteoporotic bone were, respectively, 5.1, 5.4, 21.1, and 13.9 mm for experienced surgeons and 7.6, 7.7, 22, and 15.9 mm for inexperienced surgeons. Drilling with SNB and with SOB was statistically different, with inexperienced surgeons plunging 2.5 mm (P = 0.31) and 2.6 mm (P = 0.042) deeper, respectively. There was a difference (P < 0.001) between sharp and blunt drill bits in all drilling conditions for both the groups. CONCLUSIONS: Our study showed a significant difference in plunging depth when sharp or bunt drill bit was being used. Surgeons, regardless of their experience level, penetrate over 20 mm in normal bone and over 10 mm in osteoporotic bone.

This classic discusses the original publication "A method of resurfacing osteoarthritic knee joints" by Dr K.H. Pridie (1959), where this pioneer surgeon described a newly developed method for the treatment of osteoarthritic joint surfaces of the knee, which he named subchondral drilling. This short and concise 11-line publication appeared in the Proceedings of the Congress of the British Orthopaedic Association. It has generated 464 citations since 1959, becoming part of the hundred most-cited publications in knee research. Pridie introduced in clinical experimentation the entity of Marrow Stimulation Techniques to liberate mesenchymal stem cells from cancellous bone. He was aware that the results induced, in terms of quality of the regrown tissue, was limited and "only" fibrocartilage. His idea might have been raised from the work of numerous animal researchers who confirmed repeatedly since 1905 that cartilage needed an osseous perforation to heal. Although the past 60 years brought modifications from the technique described in the original article, the concept of marrow stimulation introduced by Pridie remains the most frequently used in cartilage repair surgery today.

Background : In the late course of chronic pancreatitis (CP), weight loss is often seen because of reduced caloric intake and a reduction of pancreatic enzyme secretion, resulting in maldigestion. Most of these patients can be managed by dietary recommendations and pancreatic enzyme supplementation. However, approximately 5% of these patients are reported to be candidates for enteral nutrition support during their course of CP. Although small bowel access for enteral feeding can be easily obtained by percutaneous endoscopic gastrojejunostomy (PEG/J) or direct percutaneous endoscopic jejunostomy (DPEJ), to date there are no data regarding clinical outcome and safety of long‐term jejunal feeding in CP. Methods : From January 1999 to October 2002, 57 patients receiving enteral nutrition by PEG/J or DPEJ were retrospectively analyzed during a follow‐up period of 6 months. There were 38 females and 19 males, with an average age of 46.6 years. Results : Small‐bowel access was obtained by PEG/J in 53 patients and by DPEJ in 4. Duration of enteral feeding was 113 days. Average body weight significantly increased from 64.8 kg at day 1 to 69.1 kg at day 180 ( p &lt; .001). The percentage of patients with abdominal pain decreased from 96% to 23%. One patient sustained a colon mesentery injury after DPEJ tube placement. Conclusions : Long‐term nutrition support by PEG/J or DPEJ in patients with symptomatic, chronic pancreatitis increases patients' body weight and decreases the degree of malnutrition, abdominal pain, and other gastrointestinal symptoms. The underlying mechanisms for these observations are unclear and require further investigation. Small‐bowel rest with reduced pancreatic gland stimulation might be a key component. Moderately to severely malnourished patients who do not respond to oral dietary interventions and who are candidates for elective pancreatic surgery might also be candidates for long‐term preoperative jejunal feeding to reduce malnutrition‐associated perioperative complications. In experienced hands, we feel that long‐term jejunal feeding is safe, with minimal major complications.

Monocytopoiesis was analyzed in patients with severe, acute inflammations induced by surgical interventions as well as in others with mild, chronic inflammations in connection with gastric or duodenal ulcers. The state of acute inflammation was assumed to be associated with a high and steeply rising monocyte demand as opposed to the constant and relatively small monocyte recruitment in chronic inflammation. In chronic mild inflammatory reactions DNA synthesis activity of promonocytes was increased by a factor of about two; the promonocyte pool was normal. In patients who underwent surgical operations changes in the following parameters were observed during the first 15 h after start of surgery: (1) average increase in 3H-TDR labelling index by 38%; (2) average enlargement of promonocyte pool by 34%, (3) and relase of immature cells from the bone marrow into the blood. Increase in DNA synthesis activity as well as expansion of the promonocyte pool causes an enhanced monocyte production rate. The 'shift to the left' in monocyte egress is equivalent to a reduced stem-cell-to-blood transit time. These variations permit short-term adaptation of monocytopoiesis to varying demands.

BACKGROUND: The general outcome of posterior wall acetabular fractures is still the source of discussion. Posterior wall fractures are recognized throughout the literature as being difficult to treat. The aim of the present study was to analyze in our own patients the relevance of the classical prognostic criteria for the outcome of isolated posterior wall fractures and those with associated lesions. MATERIALS AND METHODS: A prospective cohort of 33 consecutive patients treated operatively between 1996 and 2006 in a single level 1 trauma center for a posterior wall fracture of the acetabulum was analyzed retrospectively. Included were posterior wall acetabular fractures or associated posterior wall fractures, such as the combinations of posterior column with posterior wall, transverse with posterior wall, or T-shaped fracture with posterior wall fracture. Outcome measurement of the postoperative survival of the hip joints until the primary outcome reoperation (total hip replacement or fusion) and secondary outcome diagnosis of symptomatic osteoarthritis were performed. RESULTS: Twenty-six of the 33 patients with posterior wall fractures also had a dislocated joint. Twelve had isolated and 21 associated fractures. Six patients were reoperated with a THA (four patients within 2 years and one after 10 years), and one arthrodesis was done to treat a hematogenous septic arthritis in a degenerative hip joint. Secondary arthritis was observed in 10 patients. CONCLUSIONS: No difference was found between the outcome in cases of isolated posterior wall acetabular fracture and the outcome in those with associated lesions. The classical prognostic criteria were not found to be relevant to the outcome for our group.

BACKGROUND: Knowledge about prognostic factors in surgically treated patients with oropharyngeal squamous cell carcinoma (SCC) is limited. The purpose of this study was to identify influential factors on survival in a large cohort of patients with surgically treated oropharyngeal SCC. METHODS: Retrospective analysis of survival estimates in patients with surgically treated oropharyngeal SCC using tumoral positivity for human papillomavirus (HPV) and risk-of-death categories according to a study from 2010 as stratification factors. RESULTS: The 5-year overall survival (OS) and disease-specific survival (DSS) rates after surgery alone were higher in HPV-associated oropharyngeal SCC (OS 80% vs 62%; P = .01; DSS 92% vs 76%; P = .03). Patients in the low-risk category had higher survival rates (OS 91%; DSS 99%) than patients in the intermediate-risk group (OS 63%; DSS 83%), and high-risk group (OS 61%; DSS 75%). CONCLUSION: Nonsmokers with HPV-positive oropharyngeal SCC have a better prognosis than smokers with HPV-positive oropharyngeal SCC and also than patients with HPV-negative tumors when treated by surgery alone.

Correction to: S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit AsthmaPneumologie 2017; 71(12): 849-919DOI: 10.1055/s-0043-119504