INTRODUCTION:Due to aging society, osteoporotic posterior ring fractures of the pelvis are gaining importance. Percutaneous iliosacral screw fixation can reduce pain if conservative therapy is not sufficient. One of the surgical complications is the malposition of the screws in neuroforamen. The aim of this study is to correlate the measured pedicle angle with the screw position in postoperative CT scans. MATERIALS AND METHODS:In this retrospective study (level of evidence: III), 97 patients with posterior ring fractures were treated with 137 percutaneous iliosacral screws. The inclination angles of the S1 pedicle were measured in the preoperative pelvic CT scan of each patient. Patients were divided up into pedicle angles from 10 - 19.9° (Group 1), 20 - 29.9° (Group 2), 30 - 39.9° (Group 3) and 40 - 49.9° (Group 4). We correlated the pedicle inclination angle to radiologically described screw position in the L5/S1 neuroforamen and the need for revision because of screw malposition. RESULTS:A total of 10 pedicle inclination angles were from 10 - 19.9° (7.3%), 96 from 20 - 29.9° (70.1%), 28 from 30 - 39.9° (20.4%) and three from 40 - 49.9° (2.2%). Of the 137 screws used, 19 were intraforaminal (13.9%). There were no intraforaminal screws in the Group 1, eight in Group 2, 10 in Group 3 and one in Group 4. Five of the screws needed revision (3,6%). There were no revisions in Groups 1 and 4, two in Group 2 and three in Group 3. Groups 3 and 4 had a higher percentage of intraforaminal screw positions. Patients with steeper angles S1 pedicles showed a significantly higher probability of intraforaminal screw location and revision (p<0.01). DISCUSSION:Complications such as intraforaminal screw position and revision surgery are more frequent in patients with steeper S1 pedicles, making this a detrimental prognostic marker.

Introduction Osteoporotic posterior ring fractures of the pelvis are common injuries in the elderly, but the treatment of these fractures still remains controversial. Percutaneous iliosacral screw fixation is one surgical option if conservative treatment cannot provide sufficient pain reduction. The aim of this study is to provide short-term results of elderly patients with percutaneous screw fixation. Methods 30 patients with posterior ring fractures were treated between 12/2009 and 01/2014 with percutaneous iliosacral screw fixation. Patients' mean age was 78.4 years. Concerning short-term outcome, we focused on initial pain level and postoperative pain reduction together with intra- and postoperative complications. Results The average hospital stay was 23.7 days, with surgical treatment performed after an average of 9.2 days. 90% of our patients were female. All 30 patients had a lower level of pain at discharge compared with admission or immediately prior to surgery. The difference in pain level at admission compared with the pain level upon discharge showed a mean reduction from 6.8 to 1.8 with a statistically significant change (P≤0.001). 24 of 30 patients had no registered complications, one screw malpositioning with postoperative nerve irritation occurred. Discussion Conventional percutaneous iliosacral screw fixation is a successful operative treatment for elderly patients with persistent lower back pain after unstable posterior ring fractures of the pelvis. Intra- and postoperative complications are rare, so this treatment can be regarded as a safe procedure. Level of evidence IV (retrospective study).

Background The aim of this study was to provide subjective and objective results of surgical treatment of unstable elbow dislocations with the hinged external fixation technique. Methods Twenty-six patients were available for re-examination after treatment. Parameters used to quantify the subjective functional results were the Mayo Elbow Performance Score, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire, and the stability of the elbow joint. In addition, we measured the medial and lateral joint space by varus and valgus stress ultrasound examinations of the elbow. Results The mean Mayo Elbow Performance Score was 93.5 (±8.3 standard deviation), and the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire showed an average of 7.3 points (±8.9 standard deviation). We saw 18 patients with stable joints and 8 patients with slight instability. In the ultrasound stress test, we saw a significant difference of the affected joint under varus stress (7.8 ± 1.7 mm) compared with the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (4.8 ± 0.9 mm; treated elbow) than contralaterally under valgus stress (3.3 ± 0.7 mm) (P < .001). Conclusion Closed reduction and hinged external fixation of unstable elbow dislocations resulted in good and very good results. We could identify a slight difference in the stability of the affected elbow compared with the contralateral side in all patients without clinical relevance.

To clarify the intestinal cancer risk in Crohn’s disease (CD).

BACKGROUND:: Exogenously applied insulin-like growth factor (rhIGF-1) may improve normal intestinal healing. This study examined the effect of rhIGF-1-coated sutures on anastomotic healing in experimental colitis.METHODS:: Acute colitis was induced in rats by dextran sodium sulphate (DSS). Inflammation was assessed by clinical Disease Activity Index (DAI), myeloperoxidase (MPO) measurement and histological examination. A distal colonic anastomosis was performed using sutures coated with rhIGF-1 dissolved in poly(D,L-lactide) (PDLLA) under general anaesthetic. Anastomotic healing was evaluated histologically, and by hydroxyproline measurement and bursting parameters after 1, 3 and 7 days, and compared with healthy, DSS and DSS + PDLLA controls.RESULTS:: DAI, MPO and histological inflammation scores were significantly increased in all animals treated with DSS. Bursting occurred less often within the anastomotic line on day 3 in the IGF group than in DSS controls (three versus eight of ten). On day 7, the IGF group had significantly increased histological healing scores (mean(s.e.m.) 12.5(0.7) versus 9.2(0.8) (P < 0.050)) and hydroxyproline content (4.6(0.3) versus 3.6(0.1) mg/g tissue; P < 0.050) compared with DSS controls.CONCLUSION:: IGF-1-coated sutures improve important aspects of anastomotic healing in rats with experimental colitis.

  Internal sphincter = smooth muscle   External sphincter = striated muscle   Mucosa of upper third of anal canal: no somatic sensation   Mucosa of lower two-thirds of anal canal: somatic innervation from inferior rectal nerves   Anal glands occur in the intersphincteric plane and open at the level of the dentate line within the anal canal Before any anorectal surgical procedure is performed, digital and sigmoidoscopic examinations are mandatory. Since these examinations may be painful in patients with local inflammation, it may be necessary to perform them with the patient under some kind of anaesthesia. Digital examination should always precede sigmoidoscopy and proctoscopy as it relaxes the sphincters and detects any obstruction that may cause injury during proctosig-moidscopy. It also provides helpful information on the strength and muscular symmetry of the sphincter muscles.

Although the CD40-CD40 ligand (CD40L) signaling pathway has been implicated in the pathogenesis of a variety of diseases, including inflammatory bowel disease, the nature of its contribution to intestinal inflammation remains poorly understood. The aim of this study was to determine whether CD40-CD40L contributes to the intestinal inflammatory response, tissue injury, and disease activity elicited by dextran sodium sulphate (DSS) through the modulation of leukocyte and platelet recruitment in the colonic microvasculature.Wild-type (WT), CD40(-/-), and CD40L(-/-) mice were fed DSS drinking water. On day 6, intravital videomicroscopy was performed to monitor leukocyte and platelet recruitment in colonic venules, with measurements obtained for tissue myeloperoxidase and histology. CD40 expression on colonic endothelium was measured using the dual-radiolabeled antibody technique.A comparison of the responses to DSS-induced colitis in CD40(-/-) and CD40L(-/-) mice to WT mice revealed a significant attenuation of disease activity and histologic damage, as well as profound reductions in the recruitment of adherent leukocytes and platelets in the mutant mice. Similar down-regulation of the blood cell recruitment responses to DSS was noted in WT mice treated with the CD40-CD40L pathway inhibitor Trapidil. CD40 expression in the colonic vasculature was greatly elevated during DSS-induced inflammation in WT mice, but not in CD40(-/-) mice.These findings implicate CD40-CD40L in the pathogenesis of DSS-induced intestinal inflammation, and suggest that modulation of leukocyte and platelet recruitment by activated, CD40-positive endothelial cells in colonic venules may represent a major action of this signaling pathway.

Both leukocytes and platelets accumulate in the colonic microvasculature during experimental colitis, leading to microvascular dysfunction and tissue injury. The objective of this study was to determine whether the recruitment of leukocytes and platelets in inflamed colonic venules are codependent processes. The rolling and adherence of leukocytes and platelets in colonic venules of mice with dextran sodium sulfate (DSS)-induced colitis were monitored by intravital videomicroscopy. DSS elicited an increased recruitment of both rolling and adherent leukocytes and platelets. DSS-colitic mice rendered thrombocytopenic with anti-platelet serum exhibited profound reductions in leukocyte adhesion. Neutropenia, induced with anti-neutrophil serum, significantly reduced the adhesion of leukocytes and the accumulation of platelet-leukocyte aggregates while greatly enhancing the number of platelets that roll and adhere directly to venular endothelial cells. The enhanced platelet adhesion associated with neutropenia was mediated by platelet P-selectin interactions with endothelial cell P-selectin glycoprotein ligand (PSGL-1). DSS colitis was also associated with an increased expression of PSGL-1 in the colonic vasculature. These findings indicate that the recruitment of leukocytes and platelets in inflamed colonic venules are co-dependent processes.

There is evidence that inducible nitric-oxide synthase (iNOS)-derived NO contributes to the pathophysiology of intestinal inflammation. The aims of this study were to assess the role of iNOS in the development of dextran sodium suffate (DSS)-induced colonic inflammation and to define the contribution of tissue-specific iNOS expression to this inflammatory response. Study groups included: 1) wild-type (WT) mice; 2) NVT double right arrow WT bone marrow chimeras with normal iNOS function; 3) WT double right arrow iNOS(-/-) chimeras (with functional blood cell MOS, but iNOS-deficient tissue); 4) iNOS(-/-)double right arrow WT chimeras (with iNOS-deficient blood cells, but normal tissue iNOS activity); and 5) iNOS-deficient mice. In WT mice and WT double right arrow WT chimeras, DSS-induced colonic inflammation was characterized by bloody diarrhea and a high disease activity index. However, WT double right arrow iNOS(-/-) and iNOS(-/-)double right arrow WT chimeras and iNOS(-/-) mice exhibited an attenuated disease activity index, with parallel changes in histopathology. Colonic myeloperoxidase (MPO) was comparably elevated in DSS-treated WT mice (30.1 +/- 1.7) and WT double right arrow WT chimeras (29.0 +/- 11), whereas MPO was significantly reduced in iNOS(-/-) mice and iNOS(-/-)double right arrow WT chimeras (9.5 +/- 1.7 and 15.6 +/- 2.2, respectively). WT double right arrow iNOS(-/-) chimeras exhibited the lowest MPO activity (3.7 +/- 0.6). Our findings implicate both blood cell- and tissue-derived MOS in DSS-induced colonic inflammation, with tissue-associated iNOS making a larger contribution to the recruitment of inflammatory cells.

Transendothelial migration of circulating leukocytes into the colonic wall is a key step in the development of the inflammatory infiltrate in inflammatory bowel disease (IBD). The platelet-endothelial cell adhesion molecule-1 PECAM-1 (CD31) is expressed in the tight junction area of endothelial cells, where it is supposed to support the transmigration process. The aim of this study was to determine the role of PECAM-1 in experimental IBD and to show whether blockade of PECAM-1 has therapeutic effects. Chronic colitis was induced in female BALB/c mice by cyclic oral administration of dextran sodium sulfate (DSS) 3% (wt/vol). Expression of PECAM-1 was visualized by immunohistochemistry. In the treatment group animals received 1 mg/kg anti-PECAM-1 (2H8) ip daily starting on day 26. On day 30 leukocyte adhesion and migration was measured during N(2)O-isoflurane anesthesia in the distal colon by intravital microscopy. Disease activity index (DAI), histology, and MPO levels were compared with healthy and diseased controls. PECAM-1 was expressed in colitic mice. Chronic DSS colitis was characterized by a marked increase in rolling, adherent, and transmigrated leukocytes compared with healthy controls. Immunoblockade of PECAM-1 reduced leukocyte transmigration significantly and also diminished leukocyte rolling and sticking in an indirect manner. It also resulted in a significantly diminished DAI and MPO levels, as well as an amelioration of the histological inflammation score. PECAM-1 plays an important role in transendothelial leukocyte migration in DSS colitis. PECAM-1 could be a novel target for antibody-based treatment in IBD.

Einleitung: Über ihre Rolle in der Hämostase und der Thrombose hinausgehend, scheinen Thrombozyten bei der Initiierung und Aufrechterhaltung der Entzündung von Bedeutung zu sein. Aktivierte Thrombozyten setzen Entzündungsmediatoren frei und tragen zur Expression von Adhäsionsmolekülen bei. Ziel der Untersuchungen war die Charakterisierung der Rolle der Thrombozyten in der experimentellen Kolitis.

Unsere Ergebnisse zeigen eine physiologische basale Expression von PSGL-1 im Gefäßbett verschiedener Organe. In zwei unterschiedlichen Entzündungsmodellen, der Sepsis und Colitis der Maus, fand sich eine signifikante Erhöhung dieser Expression. Daraus folgern wir, dass nicht nur P-Selektin, sondern auch sein endothelständiger Ligand PSGL-1 eine wichtige Rolle im Pathomechanismus der akuten Entzündungsreaktion spielt. PSGL-1 konnte damit als ein potentielles Zielmolekül für eine anti-inflammatorische Therapie identifiziert werden.

Purpose. Due to the persistant organ shortage for kidney transplantation, donor selection has changed in the past years. Although hypertension and diabetes mellitus are known to be risk factors for renal insufficiency, kidneys from donors with these diagnoses in their history have been accepted for kidney transplantation even with an increased risk of poor graft function. Herein we have reported our experience with kidney transplantation using grafts from donors with both, a history of type 11 diabetes and hypertension. Methods. Between 2000 and 2005, ten patients were grafted using donors with history of type 11 diabetes mellitus and hypertension. Mean donor age was 58 +/- 7.5 years and recipient age, 52.2 +/- 15.7 years. Mean HLA mismatch was 0.8 (A); 1.2 (B) and 0.9 (DR). Cold ischemia time was 17.4 +/- 4.1 hours. Immunosuppression was based on CYA (n = 7), tacrolimus (n = 2) or sirolimus (n = 1). Results. Six patients (60%) showed good initial function, and four (40%) had delayed graft function (DGF). One patient died at ten weeks due to multiorgan failure. Two (20%) biopsy-proven rejections were diagnosed, one of which was resistant to therapy. Six months after kidney transplantation, 7 (77%, n = 9) showed good graft function (creatinine 1.3 to 2.4 mg/dL), but one patient displayed long-lasting DGF with poor function. Conclusion. Grafts from donors with a history of diabetes mellitus and hypertension are suitable for kidney transplantation. Elevated rate of DGF (40%) would justify allocation of these organs to local transplant centers to shorten ischemia time and thereby reduce DGF and achieve better long-term results. Identification and detailed evaluation of these donors prior to allocation (eg, HbA(1c), biopsy) may help transplant centers to accept these kidneys.

Surveillance of intestinal cancer in Crohn’s disease (CD) has often been advocated. To date, no clear evidence exists whether CD patients are at special risk for intestinal cancer. An increased incidence of small bowel adenocarcinoma is suggested. However, recent figures also suggest an increased risk of CD associated colorectal cancer. We report our experience with 10 cases of CD complicated by intestinal adenocarcinoma.