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To remove a bent femoral nail is always a challenging task for a surgeon. In the last 20 years several case reports and descriptions of techniques are to be found in literature, the goal being to weaken the nail at the apex and then straightening it in situ in most cases. Those reports all have one parameter in common: the necessity to remove the nail relates to a refracture of the femur.We report the case of a patient who presented with the explicit wish to have a bent femoral nail removed and a femoral angulation corrected because of pain in the ipsilateral hip. A femoral fracture had been treated by a Küntscher nail in 1982. A refracture with severe bending of the nail had occurred a short time later, which was treated conservatively without a second surgical procedure.We can show that a planned removal of a bent and well-osseointegrated Küntscher nail can be achieved without complications and that thereby a multiplane angulation in the femur can be corrected, paving the way for a future arthroplasty in this specific case.Einen verbogenen Femurnagel zu entfernen, ist eine anspruchsvolle Aufgabe. Es finden sich mehrere Kasuistiken in der Literatur, meist mit dem Ziel, den Nagel zu schwächen und dann in situ zu begradigen.Im Folgenden wird über einen Patienten berichtet, der aufgrund einer multiplanaren Femurdeformität mit einliegendem Marknagel Hüftschmerzen entwickelt hatte. Eine Femurfraktur war 1982 mittels Marknagel versorgt worden. Eine Refraktur, bei der sich der Nagel verbog, wurde konservativ behandelt.Wir können zeigen, dass die Entfernung eines so verbogenen Marknagels komplikationslos durchgeführt werden kann.

Offshore windfarms are constructed in the German North and Baltic Seas. The off-coast remoteness of the windfarms, particular environmental conditions, limitations in offshore structure access, working in heights and depths, and the vast extent of the offshore windfarms cause significant challenges for offshore rescue. Emergency response systems comparable to onshore procedures are not fully established yet. Further, rescue from offshore windfarms is not part of the duty of the German Maritime Search and Rescue Organization or SAR-Services due to statute and mandate reasons. Scientific recommendations or guidelines for rescue from offshore windfarms are not available yet. The present article reflects the current state of medical care and rescue from German offshore windfarms and related questions. The extended therapy-free interval until arrival of the rescue helicopter requires advanced first-aid measures as well as improved first-aider qualification. Rescue helicopters need to be equipped with a winch system in order to dispose rescue personnel on the wind turbines, and to hoist-up patients. For redundancy reasons and for conducting rendezvous procedures, adequate sea-bound rescue units need to be provided. In the light of experiences from the offshore oil and gas industry and first offshore wind analyses, the availability of professional medical personnel in offshore windfarms seems advisible. Operational air medical rescue services and specific offshore emergency reaction teams have established a powerful rescue chain. Besides the present development of medical standards, more studies are necessary in order to place the rescue chain on a long-term, evidence-based groundwork. A central medical offshore registry may help to make a significant contribution at this point.

Increasing incidences of osseous metastatic malignancies and higher life expectancy in patients are resulting in a raise of occipitocervical metastases. Those patients with infaust prognosis have a significantly reduced quality of life. In Germany, between 800 and 1680 new cases per year are expected. Treatment algorithms include the evaluation of the general condition, the operability of visceral metastases, the tumor localization, the sensitivity to chemo-/radiotherapy, the fracture risk and the extent of neurological deficits and myelopathies.A systematic review on clinical studies or case series in posterior occipitocervical fusions due to metastases to the craniocervical transition yielded nine publications with 48 patients without neurological deficit. The mean survival time in the given follow-up was 6.44 months (n = 26; SD: 5,28; 95 % CI: 4.3-8.57). When measured, the clinical outcome was improved towards the VAS, the DENIS Pain Scale and the quality of life through the activities of daily living (ADL). We searched our clinical database for occipitocervical stabilizations in patients with craniocervical metastases. The prospectively collected data included the preoperative Tokuhashi score, SIN score, neurological status, length of hospitalization, perioperative course/loss of blood/complication rate, as well as the Karnofsky- index and pain measured by VAS preoperatively and in follow-up.Six patients were treated in this consecutive case series. The median age was 72 years (min./max.: 65/82), the average BMI 31.75 (min./max.: 19.3/38.1). The mean preoperative Karnofsky-index was 35 % (min./max.: 23.99/46.01; 95 % CI: 8.39) the mean preoperative Tokuhashi-score 7 (min./max.: 4/10), the mean preoperative VAS7 (min./max.: 4.8/9.2; 95 % CI: 1.68). There were no perioperative complications. In the follow-up, one patient showed a loosening of the screws in the osteolytic massae laterales and one patient suffered from a construct failure after fall.Metastases of the craniocervical transition are rare. The initial treatment of instability includes the application of a rigid Miami-J-collar or a Halo fixator. The decision for an operative procedure must accurately assess the individual patient characteristics to provide him a balanced concept between operational risk and clinical benefit. The assessment should be based on the life expectation and the expected quality of life in dependency of the respective therapeutic concept and its risks. The sole posterior stabilization of craniocervical instability through occipitocervical fusion leads to a reduction of pain, has a low perioperative risk, and may prevent a hospitalization. It is justified for selected patients to receive this treatment to help alleviate pain and to improve their quality of life. From our experience, rare cases of pain without instability should undergo conservative treatment in the first line. Due to the low availability of data on the manifestation and the clinical course of craniocervical metastases, there is a need for the collection of both the descriptive patient data include the radiographic findings as well as the clinical outcome and socio-economic factors using appropriate scoring systems.

Demographic change not only affects patients with ophthalmological diseases but also ophthalmologists.The aim of this article is to evaluate the consequences of an aging society on health care provision. How can these challenges be overcome?Evaluation of publications from the German Federal Statistical Office about the current and projected population, analysis of own studies about health care provision, utilization, and delivery as well as the presentation and discussion of regulatory and organizational conditions.There is a continuous increase in chronic and age-related diseases. At the same time the prevalence of multimorbidity and the number of patients dependent on long-term care is rising, leading to an increase in the demand for ophthalmological care. Regarding health care providers we observed a cutback in qualified ophthalmological personnel, especially for remote areas thus causing difficulties in providing adequate eye care to the population.To deliver health care to a growing number of patients with a decreasing number of medical professionals is the major challenge of demographic change. This will have an enormous impact on ophthalmological health care in terms of maintaining high quality health services covering a nationwide area.

Epidemiological studies continue to receive growing attention in health services research.How can ophthalmological health services research benefit from the Study of Health in Pomerania (SHIP)?The SHIP is a population-based, epidemiological project conducted in the northeast of Germany. In 1997 a random sample of 6,265 eligible subjects was enrolled for the first SHIP cohort. Between 1997 and 2001 baseline examinations were performed, followed by 5-year follow-up from 2002 to 2006, from 2008 to 2012 and from 2014. A second independent sample of 8,016 eligible subjects was enrolled in 2008. Baseline examinations of this new cohort (SHIP-Trend) were conducted between 2008 and 2012 and the first follow-up is scheduled for 2015. Included in SHIP are a large variety of different assessments including eye examinations. All participants are subjected to non-mydriatic funduscopy and static vessel analysis (SVA).A total number of 4,420 subjects participated in the interdisciplinary baseline examinations of SHIP-Trend. Standardized fundus photography was performed with a non-mydriatic camera in 3,934 subjects.Estimations of the prevalence of major eye diseases may provide valid indicators for healthcare provision within healthcare research. New concepts of prevention with a strengthened integration of ophthalmological diagnostics can be identified from the widespread spectrum of different healthcare examinations. Regional differences in the efficiency of healthcare provision can be evaluated with comparative studies between different German populations.

Horse riding is associated with a high rate of injuries. The possibilities of prevention are limited because of deficient knowledge about the causes and mechanisms of equine-related accidents. In the present study 198 equine-related accidents were analyzed and based on these data risk groups were identified and guidelines to improve safety in horse riding were formulated.In this 2-center study the accidents of 169 riders over a period of 12 months were analyzed. Data on equine-related patterns of injury and the resulting treatment were collated from the clinical records. Additionally, a questionnaire was completed on the day of trauma by the patients, which covered age, gender, the cause and mechanism of injury and the use of safety equipment at the time of the accident.There were 169 (85.5%) female and 29 (14.5%) male riders with a median age of 27.2 years (range 5-74 years). Of the riders 55 (27.8%) were aged 18 years or younger, 134 (67.7%) riders were treated as outpatients while 64 (32.3%) required hospitalization, 51 (25.8%) required surgical treatment, 66 (33.3%) used a helmet and 14 (7.1%) a body protector at the time of accident.Equestrians wear helmets increasingly more when riding but the willingness to wear body protectors is disappointing. Protective headgear has been proven to reduce the risk of injuries but based on these data a positive effect of body protectors could not be shown. In this study safety vest users suffered from injuries of the upper body more often than those who did not wear a body protector. Children and adolescents often overestimate their skills; therefore, teaching and supervision of inexperienced young riders along with the use of protective equipment can prevent major injuries.

The demographic development will result in an increase of up to 30 % of distal radius fractures. There are various therapy options but what is new? Conservative therapy: conservative therapy is reserved for stable fractures only. Osteosynthesis by K-wires: due to low biomechanical stability in older patients, insufficient functional and radiological results were achieved. External fixator: external fixators are used in compound and complex fractures and show better results than K-wire osteosynthesis. Angular stable plate osteosynthesis: with angular stable plates it is possible to achieve good results with complex fractures and they are currently the method of choice. Intramedullary osteosynthesis: intramedullary nails result in a faster functional improvement than angular stable plates but have limitations. New is that 90% of osteoporotic distal radial fractures are treated with angular stable plates which have shown good results in single study groups.

Ex vivo culturing of limbal stem cells on human amniotic membranes can be accelerated if all amniotic epithelial cells have been removed beforehand. A common application of acellular amniotic membranes is their use in cultivating autologous oral mucosal epithelial cells for transplantation in cases of bilateral stem cell insufficiency. Amniotic epithelial cells can be eliminated with enzymatic-chemical or mechanical methods or with a combination of both.The efficacy of a waterjet cutter to eliminate amniotic epithelial cells from the amniotic membrane was investigated. Deep frozen placentas from healthy mothers were defrosted and a well-defined surface of the amniotic membrane (d = 15 mm) was treated with the waterjet in a standardized way. The waterjet used two different nozzles (pin-point and narrow stream nozzles). The applied system pressures with the pin-point stream nozzle (aperture 120 μm) were 30, 40 and 50 bar and the narrow stream nozzle was operated with pressures of 70, 80 and 90 bar on the amniotic membrane. A total number of 42 tissue samples were examined with an optical microscope using native trypan blue staining. For each type of nozzle and each application pressure two amnion samples were examined with a scanning electron microscope to analyze the efficacy of the mechanical epithelial cell elimination from the amniotic membrane. After medical imaging and histopathological examination the efficacy was graded using the following scale: 0 = no amniotic epithelial cells, 1 = no cells, low amounts of cell debris, 2 = single amniotic epithelial cells, large amounts of cell debris, 3 = loose cell layer, 4 = continuous sheet of epithelial cells.To eliminate epithelial cells from the surface of the amniotic membrane with the waterjet pinpoint stream nozzle (aperture: 120 μm) an application pressure of 30-50 bar was needed. The use of the narrow stream nozzle required a pressure of 70-90 bar.The preparation of amniotic membranes with the waterjet represents a precise option to mechanically eliminate amniotic epithelial cells from the amniotic membrane. The use of a waterjet cutter as an exclusively mechanical method without enzymatic-chemical substances may be a benefit, as cytotoxic effects on culturing limbal stem cells caused by chemical substances are not present.

Telemedical home monitoring of glaucoma patients is not covered by health insurance in Germany. Various clinical studies have indicated that 24 h monitoring of intraocular and blood pressure of glaucoma patients allows a better evaluation of the individual disease condition. If the necessary parameters can be collected with telemedical home monitoring it will be possible to reduce the number of 24 h intraocular pressure profiles which necessitate hospital admission. Therefore inpatient 24 h profiles have been chosen as a health economical allocation base with a presentable economical value for the comparative examination. Assuming an at least identical or even higher clinical outcome of the telemedical glaucoma home monitoring inpatient 24 h profiles were chosen as a health economical allocation base to compare and contrast these methods.All procedures of the inpatient 24 h profiles at the ophthalmic clinic of Greifswald were measured using the stopwatch method. In a 1 day test run all activities of the medical staff were identified and documented in a list and afterwards measurements were carried out over 7 days with several stopwatches to allow the documentation of parallel activities. To determine the consumption of resources in telemedical home monitoring the self-documentation of all employees involved in the research project TT-MV were evaluated. Expert interviews helped to determine the economically relevant data about the applied medical technology, e.g. measuring devices, server and electronic health records.The number and complexity of the subprocesses of the inpatient 24 h intraocular pressure profiles were significantly higher compared to telemedical home monitoring. The total costs of the inpatient 24 h profiles were 571.21 € per patient including 291.21 € for medical care and 280 € for accommodation. In contrast the total costs of telemedical home monitoring were 288.72 € per patient. A direct cost comparison shows that telemedical home monitoring resulted in lower costs compared to hospital admission of glaucoma patients.Telemedical home monitoring of glaucoma patients is not only effective but also cost-efficient. As modern health care systems have to consider cost efficiency, a randomized, controlled longitudinal clinical study of both methods would be required.

To prevent complications through the use of contact lenses the efforts spent on documentation will have to be increased to meet the demands of quality management. How can ophthalmologists benefit from the use of software-based graphical documentation?To make a standardized documentation of contact lens complications possible a software module with a graphically intuitive visualization scheme of the Efron grading scale was developed. The Efron grading scale defines 16 different classes of findings scaled to 5 grades.The software module shows a schematic view of the eye which allows an easy sectoral assignment of all 16 Efron findings. The designated sector can simply be marked with a mouse click. A subsequently appearing context menu offers all 16 Efron findings together with the corresponding 5 grades. Finally the chosen Efron grade is graphically visualized in the corresponding sector.The software module supplies a feasible way for high quality documentation in the clinical routine with illustrative visualization. The practical application of software tools to assist clinical documentation can help to meet the challenges of quality management in contact lens utilization.

The local application of drugs is an efficient method for treating diseases of the external eye. However, some active substances can also cause a chronic toxic reaction at the ocular surface. No results from clinical experiments on the local tolerance of kanamycin which would meet the requirements of evidence-based medicine are as yet available.Thus, the cytomorphological processes of the treatment with kanamycin were examined in a prospective randomised placebo-controlled double blind cross-over study. The effect of the topical application (5 times a day for 7 days) of Kanamycin POS® eye ointment on the conjunctival epithelial barrier was studied in comparison with an eye ointment base (placebo) in 25 healthy subjects. To detect cytopathological microchanges of the epithelium, we carried out a standardised impression cytology (primary compatibility parameter). Biomicroscopy, Schirmer II test and non-invasive measurement of the break-up-time (tearscope) were also examined. The subjective compatibility parameters (itching, tearing, foreign body sensation, burning sensation, mucus) were measured on a 0 - 10 visual analogue scale.The cytological findings of 23 subjects were included in the final evaluation of the study. The impression cytology did not reveal a different effect of kanamycin ophthalmic ointment on the conjunctival ocular surface in comparison with the placebo. Only in one subject was a marked shift found in the nuclear-cytoplasmic ratio after application of verum. No signs of increased apoptosis ("snake-like chromatin") were found at the conjunctival epithelial barrier. The mean goblet cell count was 109 goblet cells per mm (2). No significant reduction of the goblet cell density was found in any treatment group. Among the subjective compatibility parameters, only the mean for itching constantly remained above the placebo group after application of kanamycin. Statistically significant differences were not found by the Wilcoxon test.In contrast to the clinical experience with the systematic application of kanamycin, the standardised evaluation of this study confirmed the very good topical tolerability of the tested kanamycin eye ointment. In view of the continuing clinically relevant aspect of the availability of a wide spectrum of antibiotics to avoid the development of resistance while at the same time keeping within what is reasonable economically, Kanamycin POS® for topical application supplements the options of ophthalmological antibacterial chemotherapy.

Pseudo-arthroses are disorders of fracture healing after conservative or operative treatment of fractures which are older than 6 months. Decisive for a targeted therapy is a differentiation between aseptic and septic or atrophic, oligotrophic or hypertrophic pseudo-arthrosis. The operative principals include revitalization of atrophic bone fragments, stabilizing reosteosynthesis for instability and the treatment of infection by transformation of a septic into a stabilized or aseptic pseudo-arthrosis.

The purpose of this study was to evaluate postoperative outcome and functional scores after single bundle anterior cruciate ligament (ACL) reconstruction with the use of quadriceps tendon autografts after a 16 (12-24) month follow-up.54 patients (9 women, 45 men, body mass index [BMI] 25.3 [18.1-36.3 kg/m (2)]) were included in this prospective series, treated between January 2004 and December 2005. Ligament stability was assessed with the Lachmann and pivot-shift tests and a KT 1000 arthrometer. Tegner index, Lysholm-Gilquist score and the International Knee Documentation Committee (IKDC) were employed to evaluate the functional outcomes. In addition, the single leg hop test was performed.Ligament arthrometry using the KT 1000 arthrometer demonstrated a mean side-to-side difference of 1.53 mm (0.2-4.1 mm). Regarding the Lachmann test, 17 patients (32%) showed 1+ laxity and no patient had an abnormal pivot-shift. The mean Tegner activity score was 4.22 (1-10), the mean Lysholm score was 80.8 (20-100) and the mean IKDC score 68.1 (29-87). Results of the single leg hop test revealed a mean decline of the treated leg to 87.7% (70-100%) of the contralateral side. The mean extension was reduced by 1.7 degrees (0-10 degrees) on the treated knee and the flexion by 2.1 degrees (0-10 degrees), compared to the contralateral knee.Single bundle anterior cruciate ligament reconstruction using quadriceps tendon demonstrates highly satisfactory results. Due to a moderate donor site morbidity and preservation of the medial stabilizing structures of the knee a wider use in primary cruciate ligament reconstruction may arise in the future.

Home monitoring will soon be established as an innovative way to provide telemedical care in ophthalmology. At present there are no fundamental technical restrictions for telemedical enhancements in ophthalmology, however a wider application range and depth could lead to harmonized and simplified device and interface development. This may help to initiate new concepts in ophthalmological home monitoring.

For medical professionals, home monitoring represents an innovative health service for remote patient care: The patient may remain in his or her domestic environment and continue normal activities. The physician can also, through technical and organizational integration, provide medical attendance from his or her usual working environment. All in all, in the near future home monitoring can help provide sufficient health services while also enabling medical resources to be used more effectively. The patient may benefit from individually optimized treatment and active integration into medical care. The better we manage the technical, organizational, medical, legal, and economic challenges of telemedicine, the better we can minimize the limitations of telemedical home monitoring. Other existing subjective concerns will be eliminated only if telemedical concepts are adapted to the specific needs of affected patients and physicians.

Data security must be considered seriously in the context of telemedical home monitoring because of the transmission and communication of patients' personal data. The contract governing medical treatment allows the ophthalmologist to process all data relevant to treatment. In Germany the legal framework for this purpose is provided by the Data Protection Act, various German hospital acts, and codes of medical professional conduct. In principle, these rules apply to telemedical home monitoring as well as to common physician-patient relationships. The patient must be informed extensively in an understandable manner and must give his or her written consent. However, the advanced options of new IT technologies demand the development of technical and organizational concepts that guarantee compliance with legal and regulatory affairs, assure data security, and prevent data abuse.

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patient's quality of life.

Pathological findings and clinical course of retinopathy of prematurity (ROP) are often documented with hand drawings. The use of software-based standardised symbols for ROP staging leads to improved documentation quality.We developed graphical symbols for all ROP stages as well as plus disease. All of the symbols were integrated into a java-based application as a particular ROP category of a complete symbol library for retinal changes. The symbols can be placed on a schematic retina with a mouse click. Using anchors each symbol can be individually adapted to the specific finding (size, position, shape).The use of standardised symbols in a software package allows the computer-aided manufacturing of graphically high-quality documentation in affordable time. The distinct assignment of all symbols to the ROP stages prevents misinterpretation and sketchy, illegible hand drawings.The digital documentation of pathological changes of ROP provides an easy, economic and standardised method to record retinal findings.

The aim of this study was to study and analyse distribution, range and intraday variation of ocular perfusion pressure (OPP) in patients with primary open-angle glaucoma (POAG) in the framework of telemedical home-monitoring.In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home-monitoring system for self-measurement of intraocular pressure and blood pressure. All measurements were transmitted via telephone modem to an electronic patient record that automatically calculated OPP. We present the temporal characteristics of OPP in 70 patients with POAG. After the measurement of blood pressure and intraocular pressure was performed, the individual ocular perfusion pressure was calculated by the formula: (OPP=[2/3 x (2/3 x DBP + 1/3 x SBP)]-IOP).In 3282 OPP measurements the percentage of values less than 50 mmHg was: left eye 2273/69.2%--right eye 2362/71.9 % and less than 40 mmHg: left eye 687/20.9 %--right eye 794/24.2%. 50/51 (left eye/right eye) patients had an individual OPP average of less than 50 mmHg and 10/10 (left eye/right eye) patients less than 40 mmHg. The diurnal OPP trend showed 4 phases (7-12, 12-18, 18-22, 22-7 hour). In the intervals from 22-7 hour and 7-12 hour ocular perfusion pressure values were low. Between 7-12 hour ocular perfusion pressure was significantly depressed as in the other phases (p0.05).Ocular perfusion pressure of glaucoma patients calculated using intraocular pressure (self-tonometry) and blood pressure demonstrates a feasible method to evaluate individual diurnal OPP fluctuations. However, this OPP could be described a bit more precisely as the really topical ocular perfusion. Many physiological conditions may not be included, e. g., autonomic circulation. Simultaneous measurement of blood pressure and intraocular pressure enable the detection and analysis of side effects and interactions between glaucoma and hypertension therapy. In clinical practice OPP telemonitoring presents a new way to examine ocular blood circulation in routine glaucoma work-up. The diurnal OPP variations were associated with the fluctuations of systemic blood pressure for the most of part.

Elevated intraocular pressure (IOP) is a clinically relevant factor in glaucoma progression. As a dynamic parameter the IOP depends on various internal and exogenic influencing factors. Therefore, we analysed intraindividual IOD variations between ambulant care and 24-h home-monitoring using self-tonometry.This study is based on paper-based glaucoma cards of 25 patients with primary open angle glaucoma. Additionally, all patients participated in a telemedical home-monitoring study with self-measurements of IOP and blood pressure stored in an electronic patient record. The glaucoma cards contained a total number of 409 IOP values with documentation periods from 0.5 to 10 years. In the teletonometry project all 25 patients were observed for 6 months with 1490 recorded IOP values. Statistical analysis was performed with SPSS software.Average IOP values for all 25 glaucoma patients were 16.3 +/- 2.9 mmHg for both eyes in glaucoma card documentation, whereas the electronic patient records showed IOP averages of 18.9 +/- 4.7 mmHg for right eyes and 18.2 +/- 4.4 mmHg for left eyes. Corresponding to the practice opening hours the glaucoma cards contained no IOP records from 12:00 pm to 01:30 pm as well as between 06:00 pm and 07:15 am. In these time periods 17 % of all IOP values recorded in 24-hour teletonometry were higher than 20 mmHg. However, statistical analysis and clinical evaluation of device parameters and measurement characteristics revealed sporadic measuring errors.The additional involvement of self-tonometry in telemedical 24-h home-monitoring is a feasible method to record and detect intraday IOP fluctuations. Compared to single IOP measurements documented in common paper-based glaucoma cards, the 24-h electronic patient record showed more frequent circadian IOP variations. As a result, self-tonometry and home-monitoring can be a useful link to fill the gap between singular ambulant IOP measurement and hospitalisation with 24-hour IOP profiles.

Conjunctivitis is a frequent disease mostly caused by infections. In the case of a single-sided manifestation and additional resistance to anti-infective therapy a widespread differential diagnosis has to be considered. The case report of a 41-year-old patient suffering from unilateral persistent conjunctivitis is presented. Initially, there was no biomicroscopic evidence for a penetrated ocular foreign body. The unilateral, chronic and sectoral conjunctivitis was resistant to topical application of antibiotics and steroids. After repeated in-depth anamnesis the patient recalled an inconsiderable trauma while he was working on a building site. High-frequency ultrasound was used to locate an intrascleral foreign body 3 mm behind the limbus corneae while slit lamp biomicroscopy and ophthalmoscopy failed to detect the foreign material. The precise localisation provided by the 20-MHz sector scanner optimised the management of operative intervention and consequently led to an uncomplicated extraction of the bulbar foreign body.

To develop a software package that improves the standardized clinical documentation of retinal findings. In the clinical routine, retinal findings are usually documented with sketchy freehand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to a change in location, size, or color of graphic primitives (e.g., ovals, rectangles, lines, textboxes). As a result, a feasible creation of standardized graphic documentation in retinal imaging is almost impossible.We developed a Java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as a findings sheet or digitally archived. Particularly for clinical ophthalmologists, we created a set of standardized symbols that can be digitally rendered for graphic documentation. All symbols were integrated into a graphics library and separated in specific categories: preoperative, postoperative, angiomas and tumors, and retinopathy of prematurity. The user can simply choose the required symbol from the library and place it onto the retina scheme using drag-and-drop functionality.The practicability of existing features for graphic documentation of retinal findings is not sufficient because freehand drawings are too time-consuming and also share the risk of false interpretation due to individual handwriting. In contrast to freehand sketching, our software tool not only allows faster graphic creation but also improves medical documentation using a standardized symbol library, which is also specifically categorized.Graphic symbols for retinal documentation have found universal acceptance by ophthalmologists for a long time, but their practical use is still not efficient in clinical routine. This report shows how the appropriate use of software technology can contribute to documentation quality and clinical practice.

Subtalar dislocation is considered a severe injury but occurs rarely and studies generally refer to relatively small patient collectives. We investigated the functional outcome in 22 cases to determine the long-term prognosis. Since associated foot injury is common, we compared the outcome for 12 cases of isolated subtalar luxation with 10 cases of collateral fractures of the adjacent bones of the hind foot and Talus. 19 cases of complex, partially open injuries after high energy trauma have got excluded because of the apparently poor long-term results. The Kitaoka-hind-foot-Score (AOFAS) after mean follow up of 8.3 years indicated a significantly better outcome for isolated luxation. Nearly 50 % of isolated luxations had a excellent outcome (73 %, mean score 89), luxations with associated fractures had mainly good and fair results (73 %, mean score 74). Analysis of the gait pattern by dynamic plantar pressure measurement demonstrated lower pressures in the isolated luxation group and higher pressures in the group with associated fractures in the lateral region of the forefoot with shorter phases of weight bearing.

Self-tonometry, a supplementary measurement of the intraocular pressure in ophthalmology by glaucoma patients using an automatic tonometer, will become more and more important in the future. As long as the self-tonometry has to work in the contact modus with the ocular surface, home application of a topical anaesthetic by the glaucoma patient will be a requirement for a successful measurement. So far no severe problems within this controlled self-medication have been seen. Nevertheless, public health authorities believe patient health is put at high risk by the application of local anaesthetics during self-tonometry. As there are no clinical studies of the health care, we evaluated the local tolerability of a topical anaesthetic in line with self-tonometry employing a modified tonometer OCUTON S.A total of 100 glaucoma patients participated in a prospective clinical study of the routine clinical service in which each was monitored for 1 year. The telemonitoring involved self-tonometry for at least 6 months in every case and Ocuton S Proparakain-POS 0.5% eyedrops (proxymetacaine-HCl) were applied by the probands before every measurement of the intraocular pressure with a modified self-tonometer. Information regarding the local tolerability of the topical anaesthetic was analysed using a standardised questionnaire. The intensity of the following subjective symptoms was listed in separate visual analogue scales for: lacrimation, burning, foreign body sensation, mucus aggregation, pruritus and pain.Information from 83 glaucoma patients on local tolerability of proparacaine eyedrops could be analysed. For several reasons no data could be gathered from 17 probands, which were refusal to complete the questionnaire, cancelled participation and, in two test persons, there emerged an allergic reaction (local eyelid redness and swelling) which necessitated a change to a different topical anaesthetic. In all other participants the application was carried out without any significant local or systemic symptoms or side-effects. Immediately after application of the eyedrops 36.1% of the test persons suffered a minor conjunctival hyperaemia which eased off within 1 h in 20.4% of these patients. Of the interviewed glaucoma patients 91.5% judged the single symptoms on the visual analogue scale between zero and medium intensity. The severest effects, according to the subjective evaluation, were felt in symptoms of burning with a score of 94 and lacrimation graded 96. The least intensity was established in the symptom of mucus aggregation where 72.3% rated this symptom in the visual analogue scale between 0 and 10. The other symptoms pruritus, feeling of pressure and foreign body sensation hardly differed in subjective ratings.A self-medication with topical anaesthetics on undamaged ocular surfaces for self-tonometry purposes can be performed by glaucoma patients without a high risk potential. However, the application presupposes that routine ophthalmological examinations are carried out according to the ophthalmological associations' recommendations. Therefore, medical care concepts which integrate self-tonometry into routine ophthalmological services and comply with the complex requirements of a modern glaucoma management should be applied more often.

At the University Eye Hospital of Greifswald, we have developed a digital patient record that allows close monitoring of glaucoma, diabetes and hypertension. The record stores contemporary, long-term profiles containing intraday variation and interaction of intraocular pressure, blood pressure and serum glucose levels even at night.All patients are equipped with a home monitoring system. They subsequently transmit self-measurements via the "telemedical interface" to the server. Physicians use a web front-end to access electronic patient records; this provides a PDF export filter for printing. We intend to include a total number of 120 patients from Mecklenburg-Vorpommern who suffer from glaucoma possibly combined with hypertension/diabetes. This long-term investigation was designed as a randomised cross-over study in two groups.Especially for this project an electronic patient record was developed and implemented. The components of the home monitoring system were modified and connected to a custom-built "telemedical interface". To date the study includes 120 patients, 60 of whom constantly measure and transmit their values to the electronic patient record, while the others are treated without home monitoring. All self-measurements are presented in a tabular form. In addition, dynamically generated graphics provide a diagrammatic view of all values. On demand, a detailed protocol for every single measurement report allows a comprehensive evaluation of the quality of the self-measurements. Ocular perfusion pressure is calculated automatically from intraocular pressure and blood pressure. The presented system documents continuously all information that is relevant for treatment and provides fast access for all attending physicians.Central data collection and unlocalised access improve information exchange between involved physicians. Flexible measurement periods allow the detection of pressure spikes even at night. In addition, this may help to classify glaucoma (normal-pressure glaucoma) and its causal connection to blood pressure. The patients benefit from individualised therapy adaptation and early therapeutic intervention in case of critical parameters.

A constantly aging population leads to an increasing number of elderly patients. As a result, the treatment of chronic illnesses becomes a significant part of daily routine. Today's concepts in social services and healthcare require time consuming and barely cost-effective efforts for the special needs of geriatric care. The use of telemedicine offers a possible solution, because telemedical methods may help to realize improved monitoring systems for optimized and effective patient management. This report provides an overview of the scenarios and advantages of telemedicine in general. In addition, we provide information on practical experiences in a project on telemedical glaucoma management in Mecklenburg-Vorpommern.

Using hexapod kinematics (Stewart platform), an external fixator was developed that can be adjusted in all six spatial degrees of freedom by means of six linear adjusting elements. With such a system, any desired three-dimensional bone movements, for example, fracture reduction or deformity correction, can be effected exactly, without having temporarily to compromise any stability already achieved or to rearrange the construction during treatment. Since the introduction of the hexapod principle by Stewart in 1965, computerized control has been deemed necessary for its application. This paper describes the mathematical basis and the software developed for clinical use. Mathematical procedures are needed for the calculation of the inverse and forward kinematics of the hexapod, and for the description of three-dimensional movements.

We report a very rare case of a simultaneous rupture of the right patellar and left quadriceps tendon in an otherwise healthy 37-year-old patient, who jumped off a kickboard. Suture of both tendons was performed on the day of trauma. We describe our postoperative treatment and report the follow-up examination one year after the trauma. Beside functional questionnaire, Lysholm score and physical examination and x-ray, quadriceps isokinetic testing was performed.

Multivisceral resections have been performed on 35 patients with primary and 45 with recurrent rectal cancer. Lethality was 3.7%, morbidity was 9%. Macroscopic adhesions were confirmed histologically as tumorous in 66% of the additionally resected organs. Tumor invasion, tumor recurrence and surgical radicality were found as statistically significant prognostic factors. In radically resected primary tumors 5-yr-survival was 49%. Multivisceral resection in rectal cancer is possible with low morbidity and lethality and potentially curative in primary tumors. In recurrent tumors multivisceral resections are frequently palliative.

The major advantage of biodegradable synthetic wound dressings compared to other synthetic materials and biological tissue derivatives is avoidance of the necessity to change the dressing. The copolymer films used in this study were made of lactic and caproic acid. They pose no problems concerning immunology or transmission of diseases. Moreover, the substances released by degradation may possibly influence the process of wound healing. The material proved to be non-toxic and was used successfully as a carrier for cell culture with keratinocytes. The permeability for bacteria is determined by degradation. Evaluation of the bacteriological studies indicates secure protection against secondary contamination of the films for at least 15 days, however. Concerning application, dressing properties, wound healing and wound retraction, no disadvantages were found in comparison with the results of the competition's film Opsite. Based on these findings, the films are now used in a clinical study as a wound dressing for split-skin donor sites.

Over a period of almost 6 years, 18 out of 320 burn patients treated in the burn centre had sustained additional severe trauma; for the most part the trauma was due to a motor vehicle accident or a fall. The risk of overlooking such additional injuries can be minimized by systematic examination and a team approach, the same as in normal multiple-trauma patients. Apart from the burn, life-threatening complications such as intra-abdominal bleeding or haemopneumothoracic injuries are to be treated immediately. In order to facilitate appropriate burn wound care and optimize mobilization, early internal or external fixation of unstable orthopaedic injuries should be performed as soon as possible. In our experience, operations carried out within 48 h after the injury have neither led to complications in wound healing nor to osteomyelitis.

Most of the temporary dressings used in the treatment of burns do not meet the objectives of a skin substitute concerning application, safety and comfort. Removal is often painful and traumatic and increases the risk of infection. Biodegradable polymers of lactic and caproic acid were developed as part of a research programme (BMFT/FRG 01 KG 8809/7), and chemical and physical properties were investigated. Films made of the copolymer material were characterized by structure, transparency, permeability, tensile strength, flexibility and degradation. The transparent films appeared increasingly opaque during hydrolysis. The water vapour permeance could be varied between 40 and 250 (40-136) ml/m2 per h (according to the method of measurement). The mechanical properties are characterized by a maximum elongation of2000% at 37 degrees C and a very low elastically modulus. When the results were compared with those of three established film dressings, no restriction was found in the aptitude of the material as a wound dressing.

Anteroposterior X-ray views of both acromio-clavicular (AC-) joints with 10 kg weights in each hand are generally accepted for the diagnosis of Tossy I to III AC-joint separations. An analogue diagnosis can be made by standardized ultrasound examination. Ten individuals without AC-instability (Tossy I), eleven with Tossy II- and eight with Tossy III-instability were examined both radiographically and by B-mode ultrasound. AC-joint width was uniformly calculated by using an index (AC-index = AC-joint width of uninjured side/AC-joint width of injured side). The sonographically measured mean AC-index for Tossy I-stability was 1.0; sonographically 0.49 and radiographically measured 0.5 for Tossy II-injury; and sonographically 0.21 and radiographically measured 0.2 for Tossy III-instability. Statistical analysis resulted in significant differences for all mean AC-indices of the three groups (p0.0001). We conclude that ultrasound examination of AC-joint instability is as reliable as radiographic measurement. Standard X-rays of the shoulder remain mandatory to exclude fractures only. The decision for operative stabilisation of the AC-joint can be based on the side-effect free and cost-effective ultrasound examination of the grade of AC-joint instability (AC-index0.3 equivalent Tossy III).

Different methods of internal and external fixation are used to treat aseptic posttraumatic nonunion of the femur and tibia. The advantages and disadvantages of the different methods will be demonstrated by analysing the clinical course and the outcome of our patients. Utilizing these data, a therapeutic concept tailored to the individual situation is recommended.Depending on the form of reaction we distinguish between vital and non-vital nonunions. The classification is made according to the clinical course, x-ray-findings and in special cases the results of scintigraphy. Due to anatomic differences in vascularisation and soft tissue coverage nonunion of the femur and the tibia are discussed separately. Stabilisation is achieved by intramedullary nail, plate or external fixator. As new methods the internal plate fixator was used for the femur and the Ilizarov ring fixator for the tibia. If there has been a mistake in the choice of the method of the primary stabilisation a change of method is done. If the indication for the initial method of stabilisation was correct, the therapy of nonunions is limited to the correction of technical mistakes. Additionally, a biologic stimulation is required for the therapy of non-vital nonunion.The clinical data of 77 patients treated from 1985-1993 were analysed retrospectively. Vital nonunions of the femur (11) healed after 9.5 months on the average, those of the tibia (49) after 10 months. The duration of treatment of non-vital nonunions was much longer and required 20 and 16 months, respectively. The treatment of two non-vital nonunions of the tibia could not be completed. For the femur only intramedullary nail (4) and plate (8) were used, for the tibia mainly the fixator (43), of these in 18 cases the Ilizarov-apparatus. Differences in the duration of treatment due to the choice of implant could not be recognized. Complications were pin problems (14) and one lesion of the peroneal nerve in the fixator group and superficial wound infection (2), nerve irritation (1) and fracture (1) in the group treated with intramedullary nailing.Due to the good soft tissue coverage and vascularisation internal fixation is favored for the treatment of femoral nonunions. The fixator should only be used if distraction osteogenesis is necessary because of a bony defect. Due to the problematic soft tissue situation and poorer vascularisation on the external fixator is preferred in the treatment of tibial nonunions if a change of method is indicated. For this purpose, we currently use predominantly the Ilizarov-apparatus because of its biomechanical properties and the convincing results. Initial problems with its use could markedly be reduced with growing experience.

The treatment of nonunions complicated by infection and bone loss is divided into two stages. Having calmed down the infection by stabilizing, removal of infected and necrotic tissue and local antibacterial measures, the bone loss has to be filled up. Bridging the gap by means of autogenous cancellous bone grafting is complicated by a high rate of refractures depending on the length of bone loss. Therefore after changing the method and using the Ilizarov procedure it is of interest, whether this method offers advantages. Our experience is to be reported and discussed.According to the clinical course two groups of patients with nonunions of the tibia complicated by infection and bone loss were compared. 25 previously evaluated patients of the years 1980/81 whose tibial bone loss was bridged by cancellous bone grafting (1st group) were compared with 16 patients who were treated by the Ilizarov method from May 1990 to October 1993 (2nd group). The average age was nearly the same (32.6/32.9 years). In the first group the average of bone loss measured 4 cm, in the second 7.8 cm. The number of initial operations to eliminate infection and the duration of fixator application from the beginning of bridging bone loss were compared as well as early and late complications, especially the rate of refracture and reinfection.1.2 operations were needed to eliminate infection in the first group, in the second only one was necessary. The handling of the Ilizarov device is more difficult and needs training. The higher rate of early complications at the beginning decreased with increasing experience. The average of fixation time could be reduced by about ten days per cm of bone loss using the Ilizarov technique. By segmental transport new cortical bone is generated which surpasses cancellous bone grafting in regard to stability. This seems to be an important reason that refracture did not occur in the second group. Furthermore, reinfection could be avoided up to now obviously due to sufficient segmental resection of infected and necrotic tissue. Limited stores of autogenous cancellous bone are not to be feared. The total number of operations can be reduced. At the docking side early single cancellous bone grafting is recommended.

The Ilisarov ring fixator is an extremely versatile external fixation device. There is a wide range of indications for its use, e.g. fractures, pseudarthroses and non-unions, large defects, deformities and limb shortening. The device consists of rings or half-rings, which are connected to each other by threaded rods or plates and to the bone by wires under tension. This design allows neutral fixation, compression or distraction of the bone fragments. Because of its low axial stiffness at low loads and increased stiffness at higher loads, this fixator promotes osteogenesis and reduces strain on the tissues in functional treatment. Surgical intervention for its application is minimally invasive. This is a useful addition to the orthopaedic surgeon's armamentarium, providing proper attention is paid to preoperative planning, the principle rules of frame design and wire insertion technique, and postoperative management.

We report three cases of chronically dislocated joints of the lower extremities that were treated by the Ilisarov method. As the results show, it is possible to reduce such dislocations step by step, causing less operative trauma.

In 338 consecutive human kidney transplants since 1972 uretero-neocystostomy was performed in a typical manner. The technique is a modification of Leadbetter's ureterosigmoid anastomosis and it is used for all cases of ureteral reimplantation at our institution. The rate of operative complications belonging to the urinary tract is 4.8%. In 29% out of 31 reexamined patients a vesico-ureteral reflux to the transplant appeared. We believe that the demonstrated method is useful for reconstruction of the urinary tract in renal transplants.

In cases of urinary fistulae as well as lymphoceles the only ultrasound-guided percutaneous nephrostomy has led to a good result. In cases of ureterostenosis and distal fistulae the renal function could be preserved by percutaneous nephrostomy. The anterograde pyelography was exact in demonstrating localization of the stenosis which led to a better operative procedure. The interventional ultrasound therefore represents an important option in the treatment of operative complications after kidney transplantation.

Most of the temporary dressing used in the treatment of extensive burn wounds pose immunological permeability, or transparency problems. All available dressings must be removed, and removal is often painful and traumatic. The development of biodegradable wound dressings made of copolymers of lactic and caproic acid was part of a research program (BMFT/FRG). Four parameters determine the properties of the copolymers: Purity, mole ratio of monomers, molecular weight, and sequence. Films of these copolymers can be made transparent, permeable, and flexible. They are degraded by hydrolysis and the normal ways of metabolism.