Gerwin A. Bernhardt

Quality of Life After Volar Plate Fixation of Articular Fractures of the Distal Part of the Radius

BACKGROUND Outcome measurement following surgery is increasingly the focus of attention in current health-care debates because of the rising costs of medical care and the large variety of operative options. The purpose of the present study was to correlate quality of life after volar locked plate fixation of unstable intra-articular distal radial fractures with functional and radiographic results as well as with quality-of-life data from population norms. METHODS Fifty-four consecutive patients with intra-articular distal radial fractures and a mean age of sixty-three years were managed with a volar locked plate system. Range of motion, grip strength, and radiographs were assessed at a mean of six years postoperatively. The wrist-scoring systems of Gartland and Werley and Castaing were adopted for the assessment of objective outcomes. The Disabilities of the Arm, Shoulder and Hand and Short Form-36 questionnaires were completed as subjective outcome measures, and the results were compared with United States and Austrian population norms. RESULTS Functional improvement continued for two years postoperatively. At the time of the latest follow-up, >90% of all patients had achieved good or excellent results according to the scoring systems of Gartland and Werley and Castaing. The results of the Short Form-36 questionnaire were similar to the United States and Austrian population norms. The mean Disabilities of the Arm, Shoulder and Hand score was 5 points at two years, and it increased to 13 points at six years. The twenty patients with radiocarpal arthritis had significantly poorer results in the physical component summary measure of the Short Form-36 questionnaire (p = 0.012). CONCLUSIONS The results of the present single-center study show that, following distal radial fracture fixation, wrist arthritis may affect the patients subjective well-being, as documented with the Short Form-36, without influencing the functional outcome. Well-designed longitudinal clinical trials are needed to confirm the findings of the present investigation in terms of quality of life after surgical treatment of intra-articular distal radial fractures.

Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: a prospective study of observer variability.

BACKGROUND An acromiohumeral interval narrower than 6 mm has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study assessed interobserver and intraobserver variability in the radiographic measurement of the acromiohumeral interval. MATERIAL AND METHODS Five board-certified orthopedic surgeons independently reviewed 58 blinded, standardized anteroposterior shoulder radiographs. The acromiohumeral interval was measured in millimeters. The 5 investigators classified each image a second time in random order. RESULTS After the same 58 radiographs had been evaluated by the 5 investigators at both examination time points, no significant differences were noted in the interobserver and intraobserver measurements (P < .05). The respective maximum interobserver and intraobserver differences were 4 and 3 mm (range, 0-4 mm). CONCLUSION The assessment of the acromiohumeral interval using standardized anteroposterior radiographs is a reliable and reproducible method of measurement. LEVEL OF EVIDENCE Level 1; Investigating a diagnostic test.

Treatment of Patients with Pyogenic Liver Abscess

Background: Pyogenic liver abscess (PLA) remains a serious disease with a mortality of 6–14%. Methods: Clinical data of 76 patients with PLA were analyzed. Treatment options comprised antibiotics, percutaneous puncture/drainage, endoscopic papillotomy/stenting and/or surgery as indicated. Results: Fifty-eight patients (76%) had single and 18 patients multiple PLA (right lobe: 65%; both lobes: 22%). The most frequent etiologies were: biliary (38%), hematogenous and posttraumatic (11%). Factors associated with the need for surgery included gallbladder empyema, biliary fistulas, malignancy, perforation, multicentricity, vascular complications and foreign bodies (e.g. infected ventriculo-peritoneal shunt, toothpick). Conclusions: Microbiological testing provides important information for treatment monitoring and modification. Complementary assessment of risk factors for a complicated course is crucial for timely identification of patients requiring additional treatment.

Quality of life after pertrochanteric femoral fractures treated with a gamma nail: a single center study of 62 patients

BackgroundIntramedullary nailing of pertrochanteric femoral fractures has grown in popularity over the past 2 decades likely because this procedure is associated with a low risk for postoperative morbidity and a fast recovery of function. The evaluation of outcomes associated with pertrochanteric nailing has mainly been based on objective measures. The purpose of the present study is to correlate patients’ health-related quality of life results after intramedullary nailing of pertrochanteric fractures with objective outcome measures.MethodsWe conducted a single-center study including 62 patients (mean age 80 ± 10 years) with pertrochanteric fractures treated with a Gamma 3 Nail. Health related quality of life was measured using the Short Form-36. These results were compared to both US and Austrian age and sex-adjusted population norms. The objective outcome measures studied at one year postoperatively included Harris Hip Score, range of motion, leg length, body mass index, neck-shaft angle and grade of osteoarthritis.ResultsAccording to the Harris Hip Score 43 patients (67%) had excellent or good results. There was no significant difference in the average neck-shaft angle comparing affected hip to non-affected hip at 12 months postoperatively. The average osteoarthritis score, for both the injured and uninjured hip, did not differ significantly. We found significant differences between the bodily pain, social functioning and mental health subscales and two summary scores of the Short-Form 36 in comparison to Austrian population norms. Complication rate was 8%.ConclusionsThe results of this study confirm that intramedullary nailing with the use of a Gamma Nail is a safe treatment option for stable and unstable pertrochanteric fractures. Despite good functional and radiographic results we noticed a substantial fall off in patients’ quality of life up to 12 months after operation.

Quality of life after volar locked plating: a 10-year follow-up study of patients with intra-articular distal radius fractures.

BackgroundThis study aimed to present functional results and patient’s health related quality of life (HRQOL) data ten years after volar locked plate fixation (VPF) of unstable intra-articular distal radial fractures (DRF).MethodsThirty-nine patients with a mean age of sixty-one years were operatively treated with VPF after intra-articular distal radial fractures. They were evaluated two, six, and ten years postoperatively according to the Gartland and Werley score. For subjective evaluation the Short Form 36 (SF-36) and the Disability of Arm, Shoulder and Hand (DASH) questionnaires were adopted.ResultsOverall, wrist function did not differ significantly two, six and ten years after the operation. Over 90% patients achieved “good” or “excellent” results ten years after surgery according to the Gartland and Werley score. Ten years postoperatively the results of the SF 36 did not differ significantly from the two- and six-year follow-up. Overall findings from the SF-36 did not differ significantly from the data of Austrian and American norm populations. Only in the subscale of mental health (MH) the ten-year follow-up did show significantly poorer results (p = 0.045) compared to the Austrian norm population. The median DASH scores did not show significant differences during the ten-year follow-up period.ConclusionThe ten-year results of this single-center study suggest that operative treatment of intra-articular DRF with volar locked plates is a useful and satisfactory therapy option, both in terms of function and HRQOL.

Incidental finding of sclerosing angiomatoid nodular transformation of the spleen

ZusammenfassungGRUNDLAGEN: Die Prävalenz von Tumoren in der Milz ist gering, die meisten sind von benigner Natur und vaskulären Ursprungs. 2004 wurde erstmals eine vaskuläre Läsion beschrieben, die sklerosierende angiomatoide noduläre Transformation (SANT), eine benigne Läsion mit guter Abgrenzung und multinodulärem angiomatoiden Erscheinen. Wir berichten über einen Fall dieses seltenen Tumors in der Milz, welcher zufällig bei einem Patienten mit einem Tumor in der Bauchspeicheldrüse gefunden wurde. FALLBERICHT: Ein 69-jähriger Patient mit einem Pankreasschwanztumor verdächtig auf ein Karzinom wurde unserem Krankenhaus zugewiesen. Die radiologische Abklärung zeigte eine 4 cm große zentrale Milzläsion verdächtig auf eine Metastasierung des Pankreastumors. Es wurde eine distale Pankreatektomie mit Splenektomie durchgeführt und der histologische Befund ergab eine sklerosierende noduläre angiomatoide Transformation der Milz. Der operative und postoperative Verlauf war komplikationslos. SCHLUSSFOLGERUNGEN: SANT der Milz sind sehr seltene Tumoren und sollten als Differentialdiagnose zu anderen vaskulären Tumoren der Milz in Betracht gezogen werden.SummaryBACKGROUND: The prevalence of tumors in the spleen is rare; most tumors are benign and of vascular origin. In 2004 a vascular lesion was first described, the sclerosing angiomatoid nodular transformation (SANT), which is a benign lesion with good circumscription and multinodular angiomatoid appearance. We report a case of this rare tumor in the spleen which was incidentally found in a patient with a tumorous lesion in the pancreatic tail. CASE REPORT: A 69-year-old patient was referred to our hospital with a tumor in the pancreatic tail which was suspicious for cancer. Radiologic work-up revealed furthermore a 4 cm in diameter large lesion central in the spleen suspicious for metastasis of the pancreatic tumor. The patient underwent surgery and a distal pancreatectomy with splenectomy was performed. Histologic specimen obtained a sclerosing angiomatoid nodular transformation in the spleen. The operative and postoperative course was uneventful. CONCLUSIONS: SANT of the spleen are very rare tumors and should be considered as an important differential diagnosis to other vascular lesions.

TAPP repair in a giant bilateral scrotal hernia - limits of a method.

1. Goker H, Haznedaroglu IC, Ercetin S et al. Haemostatic actions of the folkloric medicinal plant extract Ankaferd Blood Stopper. J. Int. Med. Res. 2008; 36: 163–70. 2. Kurt M, Kacar S, Onal IK, Akdogan M, Haznedaroglu IC. Ankaferd Blood Stopper as an effective adjunctive hemostatic agent for the management of life-threatening arterial bleeding of the digestive tract. Endoscopy 2008; 40(Suppl. 2): E262. 3. Kurt M, Disibeyaz S, Akdogan M, Sasmaz N, Aksu S, Haznedaroglu IC. Endoscopic application of Ankaferd blood stopper as a novel experimental treatment modality for upper gastrointestinal bleeding: a case report. Am. J. Gastroenterol. 2008; 103: 2156–8. 4. Kurt M, Akdogan M, Onal IK et al. Endoscopic topical application of Ankaferd Blood Stopper for neoplastic gastrointestinal bleeding: a retrospective analysis. Dig. Liver Dis. 2010; 42: 196–9.

Management of colorectal liver metastases after complete response to neoadjuvant chemotherapy. A case of computertomography-guided wire marking of the liver tumor

Dear Editor, The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at time of diagnosis and another 50% develop metastatic disease to the liver over the course of their disease. Unfortunately, only 10–25% of patients are candidates for liver resection. Owing to new chemotherapeutic agents (irinotecan and oxaliplatin) and new targeted agents such as bevacizumab and cetuximab, response rates, respectability rates, and survival times have improved. Furthermore, some patients who undergo neoadjuvant chemotherapy with these new chemotherapy regimens have complete response of the liver tumors and the tumor is no longer visible by computertomography (CT) scan or intraoperatively. The question is now what to do with those patients? We present a case of a 50-year-old female who underwent a right hemicolectomy for caecal cancer and a left oophorectomy due to metastasis in an outside hospital. At that time, the patient had a synchronous liver metastasis in segment IV b of the liver. After an uneventful postoperative course, eight cycles of xelox plus bevacizumab were administered to the patient. Follow-up CT revealed complete response and no tumor was visible. The patient was then referred to our center for further investigations. CT scan and magnetic resonance imaging showed no visible tumor. Furthermore, F-fluorodeoxyglucose positronemission tomography (F-FDG PET) was performed and revealed enhanced FDG uptake in segment IV b representing a biologic active lesion. After extensive discussion with our oncologist and interventional radiologist, we decided to mark the former metastatic lesion by hook wire as used in breast surgery. With the aid of the CT scan before neoadjuvant chemotherapy, which showed the exact position of the metastatic lesion in the liver, the tumor was measured out and preoperatively a CT-guided hook wire under antibiotic prophylaxis was placed at the position of the presumptive metastatic lesion. Afterwards, the patient was brought in the operating room and an atypical liver segment resection with appropriate safety margin around the pike of the wire was performed. Routinely performed intraoperative ultrasonography of the liver was unremarkable; no tumor lesion could be found. Furthermore, the histological specimen was tumor-free representing also complete pathologic response. The operative and postoperative course was uneventful and the patient was discharged after 1 week length of hospital stay. After close surveillance and a follow-up time of 5 months, the patient is free of tumor. The described case is to our knowledge the first in the literature with a CT-guided wire marking of a non-visible colorectal liver tumor after complete response due to neoadjuvant chemotherapy. The number of patients with colorectal liver metastases receiving surgical resection is increasing. Clinically, the first measurement of efficacy of Int J Colorectal Dis (2009) 24:125–126 DOI 10.1007/s00384-008-0548-3

Hepatobiliary transporter expression and post‐operative jaundice in patients undergoing partial hepatectomy

Post‐operative hyperbilirubinaemia in patients undergoing liver resections is associated with high morbidity and mortality. Apart from different known factors responsible for the development of post‐operative jaundice, little is known about the role of hepatobiliary transport systems in the pathogenesis of post‐operative jaundice in humans after liver resection.

Inguinal Hernia Repair under Local Anaesthesia in Patients with Cirrhosis

The prevalence of chronic liver disease and liver cirrhosis has continued to rise in recent years, especially with the epidemic of obesity, alcohol abuse, and viral hepatitis [1]. In end-stage liver disease, portal hypertension leads to refractory ascites, accounting for elevated intraabdominal pressure with peritoneal distension resulting in a higher prevalence of abdominal wall hernias. In the June 2011 issue of the World Journal of Surgery, Oh et al. [2] described their results of open nonmesh inguinal hernia repair in patients with cirrhosis compared to the results of noncirrhotic patients. Although this study includes the largest number of cirrhotic patients to date and so is of great value, it nonetheless raises some questions. First, it is not clear what follow-up examinations were included and whether imaging techniques such as sonography or magnetic resonance imaging were used in addition to the clinical examination. Second, the use of antibiotics is questionable as they are only recommended in high-risk patients undergoing mesh repair [3]. It remains unclear why they used antibiotics in nonmesh repairs. Third, mesh repair is recommended for all patients because of the lower recurrence rates [3]. The relatively small recurrence rate in the series by Oh et al. [2] of 2.3% might be due to the expertise of a single surgeon, so these results cannot be generalized. Fourth, in the methods section, the authors stated that the anesthesia type was determined by the anesthesiologists after individual patient evaluation. As patients with cirrhosis are at high operative risk for increased postoperative morbidity and mortality, it would be interesting to know how many cirrhotic patients were not eligible for routine hernia repair or were American Society of Anesthesiologist (ASA) class IV and V patients and therefore had to be excluded. General anesthesia (GA), on the one hand, could be life-threatening for high-risk patients. On the other hand, spinal anesthesia (SA) might be impossible because of the higher risk of spinal bleeding. It would be interesting to know if these authors have experience in the conservative treatment of hernias with a watch-and-wait follow-up and if they have data on the quality of life of those patients compared to that of the operatively treated patients. An alternative option to conservative treatment would be to use local anesthesia (LA) for patients initially ineligible for GA or SA. High-risk patients especially are eligible for inguinal hernia repair with LA [4]. Data in the literature for cirrhotic patients undergoing hernia repair in LA are limited [5]. It would be interesting to know whether Oh and his group have any experience with inguinal hernia repair with LA. We recently operated on a patient who had severe groin pain and Child-Pugh class C liver cirrhosis with refractory ascites. The patient had been rejected several times by surgeons and anesthesiologists because of his poor general status. We performed an open mesh repair as described earlier [4]. The postoperative course was uneventful, and he was discharged 1 day after surgery. At the latest followup, 6 months after surgery, he was free of pain, and no recurrence could be detected. Oh et al. [2] showed that inguinal hernia repair in patients with cirrhosis can be done safely even in a nonmesh manner. I suppose that if more operations were G. A. Bernhardt (&) Division of General Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria e-mail: gerwin.bernhardt@lkh-voitsberg.at