Patients In Poor General Condition Research Articles

Prognostic impact of postoperative management by an intensive care unit intensivist after colonic perforation.

Postoperative management for colonic perforation is an important prognostic factor, but whether intensivists perform postoperative management varies between institutions. We investigated 291 patients with colonic perforation between 2018 and 2022. Patients were divided into those managed by an intensivists (ICU group; n = 40) and those not managed by an intensivists (non-ICU group; n = 251). We examined how management by intensivists affected prognosis using inverse probability weighting, and clarified which patients should consult an intensivists. The ICU group showed a significantly higher shock index (1.15 vs. 0.75, p < 0.01), higher APACHE II score (16.0 vs. 10.0, p < 0.001), and more severe comorbidities (Charlson Comorbidity Index 5.0 vs. 1.0, p < 0.001) and general peritonitis (85% vs. 38%, p < 0.001). Adjusted risk differences were - 24% (-34% to -13%) for 6-month mortality rate. Six-month mortality was improved by ICU intensivist management in patients with general peritonitis (risk difference - 22.8; 95% confidence interval - 34 to -11); APACHE II score ≥20 (-0.79; -1.06 to -0.52); lactate ≥1.6 (-0.38; -0.57 to -0.29); shock index ≥1.0 (-40.01; -54.87 to -25.16); and catecholamine index ≥10 (-41.16; -58.13 to -24.19). Intensivists were involved in treating patients in poor general condition, but prognosis was extremely good. Appropriate case consultation with intensivists is important.

Technical refinements of the scapular tip-free flap for mandibular reconstruction.

The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

The prognosis-based classification model in resectable pancreatic cancer

AimPancreatic ductal adenocarcinoma treatment is mainly based on the anatomical resectability classification. However, prognosis-based classification may be more reasonable. In this study, we stratified resectable pancreatic ductal adenocarcinoma according to preoperative factors and reconsidered treatment strategies. MethodsWe retrospectively evaluated 131 patients who underwent upfront surgery for resectable pancreatic ductal adenocarcinoma between 2007 and 2019. Recurrence within 1 year after surgery was defined as early recurrence, and the risk factors for early recurrence were identified using preoperative factors. Subsequently, we calculated the scores and stratified the participant groups. ResultsFifty-five (42 %) patients who relapsed within 1 year showed significantly poorer survival than those without recurrence (median overall survival, 14.0 vs. 80.6 months; p < 0.01). Multivariate analysis revealed that a tumor diameter of ≥24 mm (p < 0.01) and preoperative serum carbohydrate antigen 19-9 level of ≥380 U/mL (p = 0.04) were the independent risk factors for early recurrence. Early recurrence score was created using these factors, stratifying the participant group into three groups of 0–2 points, and the prognosis was significantly different (median overall survival, 49.3 vs. 31.2 vs. 16.0 months; p < 0.01). ConclusionWe stratified the upfront surgical cases of resectable pancreatic ductal adenocarcinoma. The group with a score of 0 had a good prognosis, and upfront surgery was possibly not futile on patients in poor general condition. The group with a score of 2 had a poor prognosis and may require stronger preoperative treatment.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Covid-19 and Dengue Coinfection: Case Report

The concurrence of COVID-19 with dengue present a similarity in the early stages of both diseases could cause delays in the diagnosis of dengue infection,SARS-CoV-2 or both. This adds an additional difficulty to the diagnosis and suggests that a positive result of IgM or IgG serology would not be sufficient for the definitive confirmation of dengue. Clinical case: 13-year-old female patient in poor general condition who debuts with a clinical picture of 5 days of evolution consisting of fever, anosmia, ageusia, unquantified fever peaks, chills, abdominal pain and vomiting that does not stop.

Delayed Discharge after Thoracic Surgery under the Guidance of ERAS Protocols

Enhanced recovery after surgery (ERAS) protocols have been applied in thoracic surgery and are beneficial to patients. However, some issues about ERAS are still pending. A total of 1,654 patients who underwent thoracic surgery under the guidance of ERAS protocols were enrolled in this study. We set the length of postoperative stay (LOPS) as our key research indicator. Patients were divided into routine discharge group and delayed discharge group based on LOPS. Causes of delayed discharge were analyzed to improve management of postoperative recovery. Male, old age, underlying disease (coronary artery disease, chronic kidney disease, old cerebral infarction, chronic obstructive pulmonary disease, and arrhythmia), intensive care unit (ICU) stay, type of insurance, and lower forced expiratory volume in one second (FEV1) are the independent impact factors causing delayed discharge. Increased nonchylous drainage (INCD) and prolonged air leakage were the two leading causes for delayed discharge. Patients should have personalized recovery goal under the same ERAS protocols. We should accept that patients in poor general condition have a prolonged LOPS. More stringent ICU stay indications should be developed to increase postoperative patients' ERAS protocols compliance. Further research on chest tube management will make a contribution to ERAS protocols.

Technique of endovascular repair of iatrogenic subclavian artery injury following subclavian vein catheterization

The iatrogenic subclavian artery injury is a rare but potentially serious complication of subclavian vein cannulation. The use of endovascular techniques is an alternative to surgical repair especially in patients with concomitant diseases in whom immediate, potentially large surgery would be associated with a high risk of perioperative complications. This article discusses technical aspects of endovascular repair of iatrogenic injury of subclavian artery with implantation of covered stents based on two cases. Author’s experience and data from literature suggests that endovascular management including covered stent implantation is safe and effective treatment and should be considered as a method of choice especially among patients in poor general condition and/or major comorbidities.

Rodeando al enemigo: Colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante.

Nicolás Avellaneda (1) (ORCID 0000-0002-6802-7125), Augusto Carrie (1) (ORCID 0000-0003-4226-7240), Federico Veracierto (1) (ORCID 0000-0003-3363-8935).&#x0D; &#x0D; Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno” (CEMIC). Galván 4102, C1431 CABA, Argentina.&#x0D; &#x0D; &#x0D; &#x0D; Introducción.&#x0D; &#x0D; &#x0D; La enfermedad de Crohn presenta una incidencia aumenta en los últimos años en los países industrializados, y la afectación ileocecal es la mas frecuente en esta patología.&#x0D; En una primera instancia los pacientes puede recibir tratamiento médico, pero un porcentaje significativo de estos pueden evolucionar hacia complicaciones de la enfermedad como estenosis o fístulas. Cuando estas se presentan, deben ser tratadas quirúrgicamente, representando un desafío para el equipo quirúrgico porque se trata de pacientes en mal estado general y con gran compromiso inflamatorio a nivel abdominal que dificulta la correcta identificación de los planos anatómicos.&#x0D; &#x0D; 2) Descripción.&#x0D; Se presenta el caso de un paciente de 84 años que ingresa por guardia en nuestra institución por presentar diagnóstico de enfermedad de Crohn de 10 años de evolución, mal estado general y deterioro nutricional severo. Al examen físico se palpa tumor a nivel de flanco derecho y fosa ilíaca derecha.&#x0D; Entero-RMN: Ileon terminal con fístula hacia colon derecho y transverso y cavidad intermedia con colección de 3 cm.&#x0D; Laboratorio: Glóbulos blancos: 12.000x10-9/L, Albúmina: 1,3 gr/dl.&#x0D; Se decide internar al paciente, se instaura tratamiento antibiótico, medidas de sostén y nutrición parenteral total.&#x0D; A las 3 semanas, el paciente presenta mejora en los parámetros nutricionales y en el estado general, por lo cual se programa tratamiento quirúrgico de la patología.&#x0D; Se realiza una laparoscopía exploradora donde se evidencia gran tumor inflamatorio que involucra ileon terminal, colon derecho y transverso. Se logra logra la movilización completa de las estructuras mencionadas, las cuales se exteriorizan por una mini laparotomía mediana supraumbilical, y se hace la resección en bloc del tumor inflamatorio, confeccionando una ileostomía terminal y abocando el colon transverso en tejido celular subcutáneo.&#x0D; Paciente presenta buena evolución postoperatoria, recibiendo el alta senatorial al séptimo día postoperatorio sin complicaciones.&#x0D; &#x0D; 3) Conclusiones.&#x0D; &#x0D; El tratamiento quirúrgico de la enfermedad de Crohn representa un desafío para el cirujano. Realizado por vía laparoscópica y luego de optimizar al paciente desde el punto de vista clínico y nutricional, se pueden obtener buenos resultados postoperatorios.

Rodeando al enemigo: colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante

1) Introduction. Crohn's disease has an increasing incidence in recent years in industrialized countries, and ileocecal involvement is the most frequent in this pathology. Firstly, patients can receive medical treatment, but many of them can present complications of the disease such as stenosis or fistulas. When these appear, they must be treated surgically, representing a challenge for the surgical team because this are patients in poor general condition and with a large abdominal inflammatory compromise that makes it difficult to correctly identify the anatomical planes. 2) Description. We present the case of an 84-year-old patient who is admitted to our institution in Emergency Service for presenting a diagnosis of Crohn's disease of 10 years of evolution, poor general condition and severe nutritional deterioration. Physical examination revealed a palpable tumor at the level of the right flank and right iliac fossa. Entero-MRI: Terminal ileum with fistula towards the right and transverse colon and intermediate cavity with a 3 cm collection. Laboratory: White blood cells: 12,000x10-9 / L, Albumin: 1.3 gr / dl. Decission is made to admit the patient, antibiotic treatment, support measures and total parenteral nutrition were instituted. At 3 weeks, the patient shows improvement in nutritional parameters and general condition, for which surgical treatment of the pathology is scheduled. An exploratory laparoscopy is performed where a large inflammatory tumor involving the terminal ileum, right and transverse colon is evidenced. Complete mobilization of the aforementioned structures is achieved, which are externalized by a supraumbilical median mini laparotomy, and enbloc resection of the inflammatory tumor is made, performing a terminal ileostomy and leaving the transverse colon in subcutaneous cellular tissue. Patient presented good postoperative evolution, receiving sanatorial discharge on the seventh postoperative day without complications. 3) Conclusions. Surgical treatment of Crohn's disease represents a challenge for the surgeon. Performed laparoscopically and after optimizing the patient from a clinical and nutritional point of view, good postoperative results can be obtained.

Transarterial Embolization in the Management of Intractable Haemorrhage

Introduction: The purpose of this study was to evaluate the effectiveness and long-term results of selective transarterial iliac embolization (STIE) in patients with intractable bladder haemorrhage (IBH). Methods: Twenty-five patients with a median age of 84 (range 65–94) years underwent STIE because of IBH between 2002 and 2020. The median follow-up time was 3 (mean 13.9) months. Patients were treated because of bleeding bladder or prostate cancer, radiation-induced haemorrhagic cystitis, and other conditions. Success was defined as technical success (feasibility to embolize bilateral hypogastric arteries or neoplastic arteries) and as clinical success (absence of further or additional therapy). Results: Twenty-five patients with a median age of 84 years with a median hospital stay of 7 days were embolized at our institution. In total, 60% required additional therapy. Only 20% had minor complications, but no complication major was seen; 60% needed an additional therapy because of continuous bleeding. Our 30-day, 90-day, 6-month, and 12-month mortality rates were 28, 44, 64, and 76%, respectively. Conclusions: STIE in IBH is a safe, well-tolerated, and feasible procedure for palliating haematuria patients in poor general condition. Major complications are very rarely seen. However, patients often need additional therapy after STIE.

A prospective cohort study on the safety and efficacy of bevacizumab combined with chemotherapy in Japanese patients with relapsed ovarian, fallopian tube or primary peritoneal cancer.

this prospective cohort study aimed to assess the safety and efficacy of bevacizumab combined with chemotherapy in Japanese patients with relapsed ovarian, fallopian tube or primary peritoneal cancer. in this study, 40 Japanese patients with relapsed ovarian, fallopian tube or primary peritoneal cancer selected to receive bevacizumab with chemotherapy were enrolled. Patients in poor general condition were excluded. Each patient was monitored prospectively for adverse events, administration status, disease status and survival. Treatment was continued until intolerable adverse events or disease progression. The primary endpoint was safety. bevacizumab plus platinum-based chemotherapy was performed for 30 patients (median cycle; 16.5), while bevacizumab plus non-platinum chemotherapy was performed for 10 patients (median cycle; 5.5). Among bevacizumab-related adverse events, hypertension occurred in 80% of patients, proteinuria in 83%, mucositis in 25%, bleeding in 20%, thromboembolic events in 5.0% and fistula in 2.5%. Gastrointestinal perforation or other life-threatening lethal adverse events were not observed. Response rate and median progression-free survival were 73% and 19.3months for patients with bevacizumab plus platinum-based chemotherapy, and 30% and 3.9months for patients with bevacizumab plus non-platinum chemotherapy, respectively. There was no correlation between response rate and occurrence of adverse events such as hypertension or proteinuria. bevacizumab combined with chemotherapy was tolerable and effective for Japanese patients with relapsed ovarian cancer, fallopian tube cancer or primary peritoneal cancer. Hypertension and proteinuria are frequently occurred and managed properly for continuing treatment.

Outcomes of Treatment for Elderly Patients With Trigeminal Neuralgia: Percutaneous Balloon Compression Versus Microvascular Decompression.

The study aimed to evaluate the surgical outcomes of percutaneous balloon compression (PBC) and microvascular decompression (MVD) in the treatment of elderly patients with trigeminal neuralgia (TN). A total of 30 patients who underwent PBC surgery (PBC group) and 30 patients who received MVD surgery (MVD group) were included. The treatment efficacy, Barrow Neurological Institute (BNI) pain intensity score, inflammatory response, the rates of complication and recurrence were analyzed respectively. The total efficacy was 93.33% in the PBC group and 90.00% in the MVD group (P > 0.05), respectively. The pain relief rate was 90.00% and 86.67% after PBC and MVD surgery, respectively (P > 0.05). The levels of IL-1β, TNF-α, and IL-6 were significantly decreased at post-operative 3 days and 5 days compared with pre-operation in the 2 groups (P < 0.05). The post-operative complication rates regarding masticatory muscle weakness and facial numbness in the PBC group were higher than MVD group (P < 0.05). Nevertheless, the incidences of herpes simplex and keratohelcosis were similar between the 2 groups (P > 0.05). The recurrence rates were also similar between the 3 groups (P > 0.05). Percutaneous balloon compression and MVD are effective in the treatment for elderly TN, which can effectively improve the post-operative cure rate of pain prognosis and reduce the inflammatory response. However, PBC is a minimally invasive, safe and effective method for patients in poor general condition and refused treatment with craniotomy.

Full Endoscopic Discectomy, Debridement, and Drainage for High-Risk Patients with Spondylodiscitis

To evaluate the efficacy and clinical results of full endoscopic debridement and drainage (FEDD) for high-risk patients with spondylodiscitis. Fourteen patients who underwent FEDD at our institution between November 2015 and September 2017 were retrospectively reviewed. All patients had single-level infectious spondylodiscitis and were high-risk candidates for surgery. Their general condition was evaluated according to the American Society of Anesthesiologists grading system. The Charlson Comorbidity Index was used for comprehensive assessment of comorbidity status. Outcomes were evaluated by numeric rating scale (NRS) pain score, Oswestry Disability Index, modified Macnab criteria, and radiographic images at follow-up. All 14 patients experienced immediate relief of back pain after FEDD, with no procedure-related complications. The causative bacteria were identified in 10 of the 14 patients (71.5%). Half of the 14 patients had an American Society of Anesthesiologists score of ≥3. The average Charlson Comorbidity Index was 5.1 ± 1.6 points. Compared with the preoperative NRS score of 8.2 ± 0.9, the NRS scores at 1 week and 12 months after surgery were 3.4 ± 1.1 and 1.4± 1.2, respectively. A significant improvement in Oswestry Disability Index was observed after surgery (preoperative, 30.1 ± 3.9; 12 months postoperatively, 17.6 ± 6.2; P< 0.05). Satisfaction rate was 85.7% based on the Macnab criteria (excellent or good outcome). None of the patients developed any significant kyphotic deformity after FEDD. FEDD may be an effective alternative to extensive open surgery in patients with infectious spondylodiscitis, especially those who are high-risk candidates for surgery (elderly patients with multiple comorbidities and patients in poor general condition).

Reinforced cementoplasty using dedicated spindles in the management of unstable malignant lesions of the cervicotrochanteric region

In long bones, cementoplasty alone does not provide sufficient stability, which may cause secondary fractures. This study reviewed the safety and efficacy of reinforced cementoplasty (RC) (percutaneous internal fixation using dedicated spindles combined with cementoplasty) for unstable malignant lesions of the cervicotrochanteric region (CTR) of the proximal femur. Eighteen consecutive patients (nine women [50%] and nine men [50%]; mean age 55.1 ± 16.2years; range 22-85) underwent RC for 19 unstable lesions of the CTR (16/19 [84.2%] bone metastases, 3/19 [15.8%] multiple myeloma lesions). All the patients were considered unsuitable for surgery. Clinical outcome was judged with a mean follow-up of 8.8 ± 7.2months (range 1-27). The primary endpoints were occurrence of secondary fractures during the follow-up period and local pain relief measured by a visual analogue scale (VAS). No secondary fracture occurred. Mean VAS improved from 5.9 ± 3.1 (range 0-10) to 2.3 ± 2.4 (range 0-7) at 1month (p = 0.001) to 1.6 ± 1.7 (range 0-5) at final follow-up (p = 0.0002). One symptomatic cement pulmonary embolism was recorded. RC is an original minimally invasive technique providing pain relief and effective bone stability for unstable malignant lesions of the cervicotrochanteric region in patients unsuitable for open surgery. • Reinforced cementoplasty (RC) combines intralesional spindling with cementoplasty. • RC provides effective bone stability and pain relief. • RC is a suitable minimally invasive option for patients in poor general condition.

Chronic lymphocytic leukemia

Currently, several novel drugs are available for chronic lymphocytic leukemia (CLL) in Western countries. Of these drugs, those that inhibit the B-cell receptor (BCR) signaling pathway are the most promising. Ibrutinib inhibits BTK in the BCR pathway and can be administered orally. The results of several clinical trials suggest that ibrutinib is highly effective against relapsed/resistant (RR) and treatment-naïve CLL. Furthermore, ibrutinib shows equivalent efficacy on CLL with the 17p deletion. Idelalisib, which also blocks the BCR pathway, inhibits PIK3delta and induces CLL cell death. Clinical trials have shown outstanding efficacy of idelalisib against RR-CLL, especially when administered with antiCD20 antibodies. This drug is also effective against CLL with the 17p deletion. ABT-199 is another novel drug; it inhibits BCL2 signaling, not the BCR pathway, and can be administered orally. The efficacy of ABT-199 against RR-CLL has been demonstrated in a number of clinical trials. These drugs have only mild toxicity and can be used for patients in poor general condition. Unfortunately, none of these drugs have yet been approved in Japan. Rapid resolution of the 'drug lag' problem is necessary.

Bouche et infections virales

Exclude herpes infection in the presence of acute oral ulcers of unknown origin, particularly in patients in poor general condition. Remember that asymptomatic HSV-1 shedding in saliva may result in an oral-genital transmission. Perform an anogenital examination and a screening for other sexually transmitted diseases when oral warts are diagnosed. Search for immunosuppression and monitor the patient (screening for a potential associated carcinoma) when there is rapid growth of oral warts. Consider all the clinical signs (systemic, skin, other mucosa, immunity...) when a patient has an enanthem or oral ulcerations. Ask for a HIV test when an oral Kaposi's sarcoma, a hairy leukoplakia or major aphthae are diagnosed.

Efficacy of Continuous Brachial Plexus Block for Intractable Cancer Pain in a Terminal Patient

We report a case of terminal cancer in which continuous peripheral nerve block provided effective relief for cancer-related pain that was difficult to control with pharmacotherapy. A 70-year-old woman with thyroid cancer, paraplegia due to multiple bone metastases, and cauliflower-like proliferation of skin metastasis on the left upper arm was receiving inpatient palliative care. Intractable pain during treatment of the tumor and when changing body position due to metastatic tumor and pathological fracture of the left humerus was difficult to control with pharmacotherapy. Continuous interscalene brachial plexus block was therefore performed, resulting in effective pain relief over the subsequent 38 days before death. Ultrasound-guided continuous peripheral nerve block can be performed at the bedside in patients in poor general condition who cannot tolerate neuraxial block, and should be considered in cases of terminal cancer patient suffering from intractable pain despite pharmacotherapy.

Laparoscopic cholecystostomy in treatment of obstructive jaundice

Cholecystostomy is considered to be a treatment option when conservative treatment of acute cholecystitis failed in elderly and critically ill patients. The aim of this paper is to present a cholecystostomy in the treatment of obstructive jaundice before the definitive operation for the underlying cause of jaundice. The patient in poor general condition with the obstructive jaundice was diagnosed to have a pancreatic head tumor. He had undergone the laparoscopic cholecystostomy. After improvement of the general condition and lower total bilirubin level, the patient had undergone to definitive procedure. It is shown that laparoscopic cholecystostomy can be a successful way for adequate bile drainage in a patient with poor general condition before the definitive treatment of obstructive jaundice.

Evaluation of efficacy and safety of robotic stereotactic body radiosurgery and hypofractionated stereotactic radiotherapy for vertebral metastases.

Aim of the studyThe purpose of this study was to evaluate the efficacy and safety of applying CyberKnife (CK) radiosurgery in patients with spinal metastases.Material and methodsTwenty-eight patients with vertebral metastases treated using the CK system were included in the study. Eleven patients suffered from pain, and in 1 case neurological symptoms were observed. The remaining patients were free from clinical symptoms of metastatic disease. The doses applied ranged between 8 and 40 Gy delivered in 4 fractions of 8–15 Gy.ResultsIn the first follow-up evaluation (mean 4.5 months after the treatment), pain was stable in 5 of 8 evaluable cases and in 3 regression occurred. The last follow-up examination (mean 11 months after stereotactic radiosurgery) revealed stable ailments in 3 of 6 evaluable cases, improvement in 3 and new complaints in another 4 patients. In 17 patients imaging studies were conducted after a mean time of 11 months after CK treatment. Stabilization was confirmed in 11, regression in 4 and progression in 2 cases. Median overall survival was 20.6 months. Median progression-free survival was 12.6 months. No side effects attributable to the treatment were observed, but during follow-up transient or permanent deterioration in neurological status as a consequence of disease progression was diagnosed in 4 patients. Delivery time of a single fraction ranged between 0.5 and 1.5 hours.ConclusionsRobotic stereotactic radiosurgery as part of multimodality therapy for metastatic spinal tumours is safe and effective. Because of long irradiation times, this kind of treatment is not suitable for patients in poor general condition.

Distal clavicle fracture

Reposition and fixation of unstable distal clavicle fractures with a low profile locking plate (Acumed, Hempshire, UK) in conjunction with a button/suture augmentation cerclage (DogBone/FibreTape, Arthrex, Naples, FL, USA). Unstable fractures of the distal clavicle (Jäger and Breitner IIA) in adults. Unstable fractures of the distal clavicle (Jäger and Breitner IV) in children. Distal clavicle fractures (Jäger and Breitner I, IIB or III) with marked dislocation, injury of nerves and vessels, or high functional demand. Patients in poor general condition. Fractures of the distal clavicle (Jäger and Breitner I, IIB or III) without marked dislocation or vertical instability. Local soft-tissue infection. Combination procedure: Initially the lateral part of the clavicle is exposed by a 4 cm skin incision. After reduction of the fracture, stabilization is performed with a low profile locking distal clavicle plate. Using a special guiding device, a transclavicular-transcoracoidal hole is drilled under arthroscopic view. Additional vertical stabilization is arthroscopically achieved by shuttling the DogBone/FibreTape cerclage from the lateral portal cranially through the clavicular plate. The two ends of the FibreTape cerclage are brought cranially via adjacent holes of the locking plate while the DogBone button is placed under the coracoid process. Thus, plate bridging is achieved. Finally reduction is performed and the cerclage is secured by surgical knotting. Use of an arm sling for 6 weeks. Due to the fact that the described technique is a relatively new procedure, long-term results are lacking. In the short term, patients postoperatively report high subjective satisfaction without persistent pain.