Results of total aponeurectomy for Dupuytren's contracture in 61 patients: a retrospective clinical study.

INTRODUCTION: Many surgical techniques have been advocated to treat Dupuytren's contracture. Partial fasciectomy is often performed to treat the whole spectrum of Dupuytren's disease. METHOD: We have reviewed the effectiveness of total aponeurectomy performed on 61 patients [10 women and 51 men (male:female ratio 5.1:1) with a mean age of 63.0 (range 42-79 years) and a mean follow-up of 3.45 years (range 1.03-6.39 years)]. RESULTS: Post-operative complications including haematoma, seroma or necrosis were found in 13.8% of the patients. Recurrence of contracture occurred in 10.8% of the patients and 4.6% of the operated patients presented with a nerve lesion. Nerve irritation occurred in 6.2% of the patients. The mean DASH-score was 3.85 (range 0-52.5). Family pre-disposition was an important risk factor for Dupuytren's disease with 44.3% of patients having a positive family history. CONCLUSION: We suggest that total aponeurectomy is a promising alternative to partial fasciectomy with low risk for a recurrence and slightly increased risk for a nerve lesion.

The effects of partial retinal lesions on activity and size of cells in the dorsal lateral geniculate nucleus.

The nasal parts of the adult cat retina were photocoagulated. In the dorsal lateral geniculate nucleus (dLGN) the projection of the remaining innervation was shown by anterograde transport of 3H-proline after eye injections. The neuronal activity was measured from single cells across the border region between innervated and deafferented parts of layer A of the dLGN contralateral to the lesions. A gradual decrease from normal light-excitability to total inexcitability was observed over a range of 300 micron. The perikaryal cell sizes measured in the same part of the dLGN displayed a concomitant decrease. Blockage of the afferent impulses by chronic application of tetrodotoxin did not change the results, suggesting that it is the loss of connections, not the loss of activity, that produces the transneuronal atrophy in the adult cat dLGN.

Percutaneous dilatational tracheostomy--early results and long-term outcome of 326 critically ill patients.

OBJECTIVE: To analyze perioperative and postoperative complications and long-term sequelae following percutaneous dilatational tracheostomy (PDT). DESIGN: A prospective clinical study of patients undergoing PDT. SETTING: Seven intensive care units at a University hospital PATIENTS: 326 intensive care patients (202 male, 124 female; age: 11-95 years) with indications for tracheostomy. INTERVENTIONS: Using tracheoscopic guidance, 337 PDTs were performed according to Ciaglias' method. In 106 decannulated patients, tracheal narrowing was assessed by plain tracheal radiography. RESULTS: Two procedure-related deaths were seen (0.6%). Perioperative and postoperative complications occurred with 9.5% of the PDTs. One of 106 patients, who were followed-up for at least 6 months, showed a clinically relevant tracheal stenosis. Subclinical tracheal stenosis of at least 10% of the cross-sectioned area was recognized in 46 of 106 patients (43.4%). In the univariate analysis, the degree of stenosis was influenced by the age of the patient (p = 0.044), the duration of intubation prior to PDT (p = 0.042) and by the duration of cannulation (p = 0.006). These parameters had no statistical significance in a multiple regression model. CONCLUSION: When performed by experienced physicians, percutaneous dilatational tracheostomy under fiberoptic guidance is a safe method. The risks of early complications and of clinically relevant tracheal stenoses are low. Subclinical tracheal stenoses are found in about 40% of patients following PDT.

Morphological fine tuning of retinotopy within the cat lateral geniculate nucleus.

The course of optic tract fibres from small parts of the cat retina to the terminal projections in the dorsal lateral geniculate nucleus (dLGN) was demonstrated with anterograde tracer substances. Fibres headed towards the same projection columns enter the dLGN at its ventral border parallel to each other and widely scattered. Within the dLGN the fibres converge into a well defined, narrow projection area. Fibre courses and orientation of the projection columns are not identical. Only roughly presorted in the tract, the fibres are extensively rearranged within the dLGN to produce the high precision of retinogeniculate topography.

Modified syringe design prevents plunger-related contamination--results of contamination and flow-rate tests.

The usual mechanism for syringe contamination is spread of micro-organisms along the inside of the barrel. Two or more full strokes of the plunger will inevitably transport a contaminant from the inside wall into the sterile compartment. We modified syringes by replacing the plunger with a modified version that has an additional central O-ring seal. Conventional and modified syringes were tested for their susceptibility to contamination using standard microbiological and radioisotope methods, and the flow-rate stability of the modified syringe design was assessed in a model with commercially available infusion pumps. Although conventional syringes consistently became contaminated with the second full excursion of the plunger, no contamination was observed in modified syringes, even after 100 aspiration/injection cycles. With respect to flow-rate stability, the new syringe design complies with DIN (German Institute for Standardization) standards.

[Combined interventions in heart and thyroid surgery--an example of interdisciplinary cooperation]. / Kombinationseingriffe an Herz und Schilddrüse--Beispiel für eine interdisziplinäre Zusammenarbeit.

The anatomic closeness of heart and thyroid gland makes it feasible to operate on both organs simultaneously if required. Between January 1988 and February 1994 we did simultaneous procedures on heart and thyroid gland in 14 patients. We did not see any procedure-specific complications. The cumulative risk of the combined operation seems to be less than in the two stage procedure, because of the better exposure of the thyroid. The main advantage for the patient is the avoidance of a second intervention. Because of the high frequency of thyroid diseases liable for operation endocrinological diagnostics should be performed in all patients undergoing cardiac surgery. The indication for a simultaneous intervention should be made generously in order to avoid a second operation.

[Reuse of previously implanted defibrillators]. / Zur Wiederverwendung von gebrauchten implantierbaren Defibrillatoren.

Implantable defibrillators are part of the therapeutical armamentarium for the treatment of tachycardia. About 2000 of these systems are implanted in Germany per year. Device costs range between 45,000 and 55,000 DM. The medium device life-time is 5 years. Questions about reuse of the systems after the patient's death arise. From ethical point of view these plans have to be opposed.

[Pacemaker and defibrillator lead extraction techniques - literature review and own results]. / Verfahren zur Extraktion von transvenösen Herzschrittmacher- und Defibrillatorsonden : Literaturübersicht und eigene Ergebnisse.

In the past, the application of continuous traction used to be the alternative to open surgical removal of impacted pacemaker leads. Today's state-of-the-art methods for lead extraction follow the principles of traction (by locking stylets) and countertraction (by outer sheaths). Technical advances with respect to outer sheath design - including the use of lasers or bipolar electrocautery - led to a higher success rate, particularly as far as the removal of endocardial defibrillator leads is concerned. From 1997 to 1999, we treated 31 patients (pts) who required lead extraction more than 6 months after lead implantation. In 16 pts pacemaker leads and in 15 pts endocardial defibrillator leads had to be removed. All but one infected lead could be extracted using the "Cook-Byrd-Method" described here. Incompletely extracted leads were more common in the patient group without infection. This may be the result of different levels of "aggressiveness" when removing leads in infected and non-infected cases, and a reflection of the different risks. We report on the technical principles of lead removal. Published methods and results are reviewed and compared. The laser sheath, recently favored by some authors, are not necessarily quicker, better and safer. New electrosurgical dissection sheaths seem to be promising in one study with just a small sample size. The results of the EXCL study (Electrosurgical Extraction of Cardiac Leads) will provide us with new data. Complete lead removal is mandatory, especially in systemically infected pacemaker systems, while it remains most important to prevent harm to the individual patient. The "aggressiveness" of each procedure should be related to the potential risk. However, the costs associated with each method may not be neglected.

[Clinical experience with combined automatic implantable cardioverter-defibrillator and pacemaker systems]. / Klinische Erfahrungen einer kombinierten antitachykarden und antibradykarden Herzschrittmachertherapie.

Patients who need an implantable Cardioverter/Defibrillator (ICD) often require a cardiac pacemaker (PM) to treat underlying symptomatic bradycardia. In some cases the simultaneous therapy has caused interactions between the systems with defaults on both sides.Four patients with an ICD of the newer generation received a single or dual chamber pacemaker system. In all cases bipolar pacemaker electrodes were used. They were positioned together with the ICD-electrode in the right ventricular apex without regard to the distance between them. In order to exclude possible interference between systems special tests were performed during the operative procedure with respect to the system implanted first. In a follow-up period of 4-14 months all patients had episodes of ventricular tachycardia or ventricular fibrillation that were terminated successfully. Two patients with a bradycardia related arrhythmia after shock delivery showed a correct pacemaker stimulation. Subsequent to the start of pacemaker therapy improvement in stress capacity could be documented, partly on the basis of echocardiography.Combined ICD and PM therapy can thus be generally regarded as compatible. For AV-sequential pacing at least three electrodes and two aggregates are necessary. The development of an ICD with the option for a dual-chamber stimulation would simplify the therapy, along with a greater acceptance on part of the patients.

Efficacy of 3-D-imaging in minimally-invasive screw fixation of proximal phalanx fractures: A cadaveric study.

The current study evaluated whether 3-D fluoroscopic imaging is capable of adequate visualisation, reduction and effective guidance of implant placement during a minimally-invasive screw-fixation (MISF) procedure in the treatment of proximal phalanx fractures. A comparison with conventional intraoperative 2-D imaging was performed in a cadaveric model. Conventional 2-D and 3-D imaging series were performed following the creation of proximal phalanx fractures, reduction and fixation, pre- and post-operatively. For both imaging modalities, attention was paid to A) correct reduction, B) screw-placement and, if present, C) intra-articular offset of fracture edges.The results revealed no related overall advantage of the 3-D imaging system over normal 2-D fluoroscopy at the proximal phalanx region. The authors conclude that, given the cost of 3-D imaging technology, as well as the increased time required for image acquisition, its routine use in the treatment of phalanx fracture cases is not justifiable at present.

Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years.

INTRODUCTION: Arthrodesis of the distal interphalangeal joint (DIPJ) is an accepted operative procedure to treat osteoarthritis, instability and joint deformity. There is a wide spectrum of recommended operative techniques including cerclage wires, headless screws, bio-resorbable pins and lag screws. Lag screw fixation remains one of the most accepted methods of fixation; however, problems can occur in particular subsidence of the screw head leading to loss of compression and prominence of the screw head in the finger tip necessitating removal. We describe here a new technique of DIPJ arthrodesis that avoids these problems. METHODS AND PATIENTS: The technique is described here in detail, and clinical results are given for 18 joints (17 patients) followed-up at a mean 24 months (range 6-44). RESULTS: Mean post-operative DASH score was 15. There were no cases of non-union; only four complications were seen, one case of nail growth disturbance and one of early screw breakage necessitating revision. Two infections necessitated early hardware removal although both arthodesis were united. CONCLUSION: The technique is simple and reliable giving consistent clinical results.

[Self-active physical thrombosis prophylaxis in the patients' bed with the Phlebostep: acceptance and measurement of venous blood flow in immobilized patients]. / Eigenaktive physikalische Thromboseprophylaxe im Patientenbett mit dem Phlebostep : Akzeptanz und venöse Flussmessung beim immobilisierten Patienten.

BACKGROUND: Despite the broad use of low molecular weight heparin, deep vein thrombosis is still a relevant risk for immobilized patients in orthopedic surgery. Patients can reduce this risk by active training exercises with a muscle pump. The aim of this study was to test the acceptance and effect of a self-developed training device to accelerate venous return as well as a technical optimization. The device was installed for in-patients in orthopedic and traumatology departments. PATIENTS AND METHODS: A simple pillow-like device was developed, which can be positioned against the foot end of the patient's bed (Phlebostep). The device gives a sound-based feedback to the patient while pushing actively against it with complete ankle flexion. A digital integrated counter device allows direct feedback to the physician and nursing staff at any time. Initial testing including duplex sonography for venous flow measurements were done on 10 orthopedic in-patients. Prior testing on 7 healthy volunteers was carried out to define the effect of various amounts of pressure on the Phlebostep on the venous blood flow. Additionally, a questionnaire on the general acceptance and user-friendliness was filled out by 84 patients who had used the Phlebostep. RESULTS: The optimal pressure force was defined as 35 mmHg for further measurements. The venous flow measurements in the 10 postoperative patients revealed an increased venous blood flow in the affected leg by an average of 99.9%. Analysis of the questionnaire from the 84 patients showed a high degree of acceptance. CONCLUSION: In addition to the technical feasibility, this study showed that use of the Phlebostep resulted on average in a doubling of venous return. The increase of venous flow offers an additional effective device for thrombosis prophylaxis through patient's own active movements and is clearly superior to the use of devices such as antithrombosis stockings alone. The Phlebostep found a high degree of acceptance with the patients.

[Direct coronary bypass operation in complicated coronary dissection]. / Direkte koronare Bypassoperation bei komplizierter koronarer Dissektion.

Improvement of interventional techniques, sophisticated patient selection, and individual experience has decreased the probability of emergency operative revascularization of increasing numbers of PTCA cases in recent years. This rate is now between 0.5 to 3%, including highrisk dilatations. Dissection is the most common complication of PTCA, while perforation is rare. Patients with high risk for PTCA-procedures (age, concomittant diseases, female gender) are, in general, risk patients for operative revascularization. The postoperative course of emergency bypass surgery after PTCA-complication (infarction rate, mortality) is dependent on duration and severity of the myocardial ischemia and preoperative circulatory function. Complete revascularization in cases of multi-vessel disease and the use of the internal mammary artery as a graft vessel is being achieved in increasing numbers.

[Changes in heart surgical strategies: a word of caution]. / Herzchirurgische Strategien im Wandel: Ein Wort der Vorsicht.

The introduction of minimally invasive coronary artery bypass surgery has expanded the technical armementarium for operative treatment of coronary artery disease. Minimal access surgery using partial sternotomy or anterior intercostal minimal thoracotomy can be combined with videoscopic techniques or port-access-methods. Either atrio-aortal cannulation, femoro-femoral or jugular-femoral connections to the pump are possible for extracorporal circulation (ECC). Even endoluminar occlusion of the aorta and application of cardioplegia into the aortic root can be considered and applied. Extracorporal circulation has developed into a safe standardized method. As far as pathophysiology is concerned, the decision to use ECC or not is of much more importance than the grade of invasiveness. Fundamentally we therefore need to distinguish between minimally invasive methods with and without ECC. Video-assisted coronary surgery in hearts under hypothermia and fibrillation with ECC is also recommended occasionally. Minimally invasive coronary artery procedures on beating hearts without ECC have to be done in a stabilized and bloodless operative field to allow the construction of high standard anastomoses between bypass grafts and coronary arteries. In practice, silicon occluders, epicardial and myocardial suture occlusion and fixation, mechanical stabilization devices, and pharmacologic induction of bradycardia are used. In principle a skilled surgeon should be familiar with all these methods to select the most suitable solution for the special clinical problem. A final judgement about each method is not possible up to now. High patients numbers have to be recruited in the groups and subgroups due to low mortality (1%) and morbidity (5%), otherwise statistical significance of the results cannot be gained.