Granulocyte proteinases as mediators of unspecific proteolysis in inflammation: a review.

In severe inflammatory response, various blood and tissue cells, including polymorphonuclear granulocytes, release lysosomal proteinases, extracellularly and into the circulation. Such enzymes, as well as normally intracellular oxidizing agents produced during phagocytosis, enhance the inflammatory response by degrading connective tissue structures, membrane constituents and soluble proteins by proteolysis or oxidation. We first used polymorphonuclear elastase (E) as a marker of such release reactions. The liberated proteinase competes with susceptible substrates, including alpha 1-proteinase inhibitor (alpha 1PI) and alpha 2-macroglobulin, and is eliminated finally as inactive enzyme-inhibitor complexes by the reticulo-endothelial system. Using an enzyme-linked immunosorbent assay, we determined the plasma levels of E-alpha 1PI following major abdominal surgery, multiple trauma and pancreatogenic shock. Whereas the operative trauma was followed by up to 3-fold increase of the E-alpha 1-PI, postoperative septicemia was associated with a 10 to 20 fold increase. The increase of E-alpha 1-PI and a concomitant decrease of plasma factors, such as antithrombin III, clotting factor XIII and alpha 2-macroglobulin, were correlated. Multiple trauma causes a substantial increase of E-alpha 1-PI up to 14 hours after accident. The released elastase seems to correlate with severity of injury, but assessing the relationship to consumption of plasma factors is complicated by concomitant transfusions. In acute pancreatitis, peaks, of E-alpha 1-PI coincide with a massive consumption of antithrombin III and alpha 2-macroglobulin during shock.

Significance of arthroscopy in children with knee joint injuries.

Clinical and arthroscopic findings after knee joint injury were evaluated in 35 children aged 4-15 years. Arthroscopy revealed a rupture of the anterior cruciate ligament in 9 patients; two lesions were only partial. Eight children suffered from patellar dislocation. Eleven patients showed minimal synovial and cartilaginous lesions as the only cause of hemarthrosis, hydrarthrosis and clinical symptoms. Three had chondral lesions due to a dysplastic patella. The clinical diagnosis was confirmed in only 12 of 35 cases. Arthroscopic therapy was performed in 15 and open surgical intervention in 16 patients. Our results show that hemarthrosis and persisting symptoms after a knee trauma in children indicate a severe knee injury. The diagnostic procedure and treatment should be as ambitious as in adults.

[The PMN elastase plasma level, a biochemical parameter of the severity of trauma]. / Der PMN-Elastase-Plasmaspiegel, ein biochemischer Parameter der Traumaschwere.

Polytrauma patients with defined severity of trauma showed a significant release of lysosomal enzymes as measured by PMN leucocyte elastase-alpha 1 proteinase inhibitor complex in plasma. A positive correlation was found between the amount of liberated elastase and the severity of trauma (- indicated by means of extent of tissue trauma and blood loss). The concentration of elastase complexed with alpha 1 proteinase inhibitor may serve as an indicator for the severity of trauma and as an objective parameter supplementing the scales and scores used until now, which all are based upon subjective judgement.

[Treatment of the polytraumatized patient in a clinic]. / Die Behandlung des Polytraumatisierten in einem Klinikum.

433 patients (mean age 33.3 years) with multiple injuries were treated from 1978 to 8/1982. Classification of the injuries was done according the S(skeleton)A(abdomen)T(thorax)scheme. The overall mortality was 18%. The cause of death were CNS-injuries in 50% of the patients. Besides CNS-injuries single and multiple organ failure were limiting the prognosis. In all cases of organ failure the lung was affected. Two patterns of multiple organ failure were found. Significant factors were shock, massive blood transfusions and abdominal trauma--but as well as errors in the treatment. Still improvement of the survival rate of the polytraumatised patients must be achieved in the future. Besides aggressive shock therapy and prevention of posttraumatic pulmonary insufficiency through earliest respiratory support we emphasize a strict strategy of treatment priorities. Based upon an intensive training especially in trauma care the surgeon will be able to recognize complications earlier and thus increase the chance of survival of the polytraumatised patient.

[Rib cartilage transplant in arthrosis of the thumb basal joint]. / Rippenknorpeltransplantat bei der Daumensattelgelenkarthrose.

The method and the results of costal cartilage replacement for the trapezium are described. The idea was to find an alternative method for trapezium implant arthroplasty. From 1995, 47 patients were treated by this technique, 42 patients could be examined. There were good results in function and no case of shortening of the thumb. Except of two, all patients were satisfied.

[Securing the syndesmosis suture by syndesmosis hook in extreme stress caused by long-distance running. A case report]. / Die Sicherung der Syndesmosennaht durch den Syndesmosenhaken unter Extrembelastung durch einen Langstreckenläufer. Ein Fallbericht.

The elastic fixation of the distal tibiofibulary syndesmosis by means of Engelbrecht's hook allows weight bearing and free dorsal flexion. The example of an 40-year-old long distance runner (and surgeon) shows that this system can endure extreme stress: during the 9 months until the metal was removed, he took part in 14 contests with excellent results. He ran at least 100 km per week, together more than 3700 and classical marathons, 100 km runs and mountain marathons. When the metal was removed there was no sign of metallotic changes of the tissue at the interface between hook and plate.

[Rupture of the distal tibiofibular syndesmosis without ankle fracture]. / Die Sprengung der distalen tibiofibularen Syndesmose ohne Knöchelfraktur.

Rupture of the distal tibiofibular syndesmosis without fracture of the fibula may be a rare event, but in the presence of certain clinical signs, it should be investigated (pain and haematoma above the syndesmosis, pain at eversion and dorsal flexion, history of dislocation of the joint). The diagnostic procedure of choice is the arthrography of the ankle-joint. A so-called isolated posterior tibial fragment may lead to the diagnosis of a complex ligamentous injury.

[Multiple fractures of the lower extremities]. / Mehrfachfrakturen der unteren Extremität.

Between Jan 1st 1978 and June 30th 1981 we treated 98 patients with multiple fractures of the lower extremities. Of a total of 260 fractures 86,2% were operated following the rule of primary definitive treatment. The postraumatic osteomyelitis rated 8,2%; the lethality was 16,3% due to other concomitant injuries of polytraumatized patients. The different patterns of fractures required individual operative-planning. Since in patients with multiple fractures of the lower limbs mobilisation is difficult, early operation to achieve training-stability proved to be valuable.

[The injury pattern in horseback riding]. / Verletzungsmuster im Reitsport.

Injuries are relatively rare in horse riding compared to other sports, but when they occur they are rather severe and dangerous: about 40% of the injured suffer from fractures, for instance and only 15% from sprains. About 20% have to be admitted to the hospital. Roughly 30% of the injuries involve the arm and 7.5%-10% the spine. The head is injured in 20%, the brain in 8% and the lower extremity in only about 20%. That means that the majority of injuries involve the upper half of the body. One quarter of all lethal sport injuries are caused by horse riding.

[Treatment of the rupture of the distal tibiofibular syndesmosis with "Engelbrecht's syndesmosis hook"]. / Die Behandlung der Ruptur der distalen tibiofibularen Syndesmose mit dem "Syndesmosenhaken" nach Engelbrecht.

UNLABELLED: After completing the osteosynthesis of the lateral malleolus, the hook is positioned 3-5 cm cranial of the syndesmosis and fixed to the tibia with a screw. It is expected to allow undisturbed ligament healing of the syndesmosis with early formation or fibres under limited motion. No immobilisation is necessary and no early removing of the implant. RESULTS: Of 62 patients questioned, 53 were examined, after an average of 50 months (2-6 years p. o.). Using the Weber score, 51 had excellent or good results. Twelve patients reported discomfort while jumping, in five cases the ROM concerned dorsal extension, and in three cases plantar flexion was reduced. Four patients showed distinct radiologic signs of osteoarthrosis, and two patients slight signs.

[Closed elbow dislocation with rupture of the brachial artery]. / Geschlossene Ellenbogenluxation mit Durchtrennung der A. brachialis.

The case of a closed elbow dislocation with complete rupture of the brachial artery and its veins is described. This combination of injuries is rather rare and only 25 cases were found in the literature. The sharp lesion of the vessels was remarkable, probably due to the edge of the distally ruptured capsule. Immediate revision with suture of the vessels and an immobilization for three weeks gave a good result.

[Steroid-induced osteonecrosis of femoral condyles and bilateral Freyberg's disease]. / Kortisoninduzierte Osteonekrose der Femurkondylen und Morbus Freyberg beidseits.

We report on a patient with steroid-induced osteonecrosis of the femoral condyles after therapy of an acute lymphatic leukemia. Because of continuing bilateral knee pain, we performed osteochondral autografting of the right femoral condyle in two steps. During the follow-up period, the patient developed bilateral Freyberg's disease, which was also successfully treated by surgery. The MRIs which we performed as a follow-up 3 years later showed complete incorporation and vitality of the transplanted cylinders. No further clinical symptoms occurred.

[Multiple organ failure--the most important complication in polytraumatized patients]. / Das Mehrfach-Organversagen--die wichtigste Komplikation beim polytraumatisierten Patienten.

In 4 1/2 years 78 out of 433 polytrauma-patients came to death in our hospital ( = 18%), half of them because of their brain-trauma. 15 fatalities occurred in connection with pulmonary failure only, 19 in multiple organ failure. Pulmonary failure is of central importance in MOF. Two types of MOF are described: the rapid pattern directly following severe shock with slightly better prognosis and a delayed pattern caused by concomitant sepsis. The hope of further improving these results is connected with five demands: 1. an elaborate scheme of treatment: taking the priorities into account; 2. sufficient treatment of shock; 3. controlled use of the respirator as early as possible and as long as necessary; 4. avoiding any sepsis; 5. close monitoring of system function.

Multiple organ failure in polytrauma patients.

To determine limitations in survival and problems of single and multiple organ failure (SOF, MOF) following trauma in Bavaria, we reviewed 433 consecutive patients with multiple injuries treated at the Klinikum Grosshadern from 1978 through 1982. Most patients were young and were injured in traffic accidents. The overall mortality was 18% (78 deaths): 38 deaths were due to CNS injuries (49%), six from miscellaneous causes (7%), 15 associated with SOF (19%), and 19 associated with MOF (25%). There were 50 patients with SOF and 34 with MOF. Two MOF patterns were found: a rapid single-phase (15 patients) due to trauma and shock; and a delayed two-phase MOF (19 patients) due to trauma, shock, and sepsis. Mortality for the MOF group was 56%. The lung was the predominant organ to fail represented in all SOF and MOF cases. Cimetidine and pirenzipin prevented stress bleeding in all but four patients. Significant factors leading to MOF were shock, massive blood transfusions, sepsis, and errors in treatment. The temporal sequence of organ failure was lung, clotting system, kidney, and liver. Sepsis was ultimately the cause of death in eight MOF patients (42%). Earlier pulmonary and cardiovascular support beginning at the scene of the accident, and prevention and better treatment of head injury, respiratory failure, and sepsis are critical factors for increasing survival after injury.

[Fractures of the proximal femur in patients over 70 years--choice of procedure and results]. / Frakturen am proximalen Femur bei über 70jährigen--Verfahrenswahl und Ergebnisse.

From 1978 till oct. 1981 110 patients between 70 and 99 years old were operated upon fractures of the proximal femur. Out of those 43 presented with fractures of the femoral neck, 46 with pertrochanteric, and 17 with subtrochanteric. In fractures of the femoral neck we generally perform alloplastic replacement of the femoral head or total hip arthroplasty. By means of a 24 hour preparing period (volume and electrolyte replacement, digitalis) and intraoperative administration of dopamine the systemic reaction to bone cement could be avoided. Pertrochanteric fractures are treated by Ender- rods immediately. Subtrochanteric fractures are the greatest technical problem. We now use long-stem-prosthesis as compound-osteosynthesis. Physiotherapy is applied aggressively. The patients are trained to walk from the second day p.op. on. Perioperative lethality rated 17%. Within the group of age 70 till age 80 only four died (7,5%), over 80 years 15 (30% of this group). Following hip-replacement there were 13 deaths, after Ender-rods only 4 lethalities. 83% of all patients could be discharged after a mean of 19 days, 86% of those ambulatory.

[Glucose determination in diluted whole blood using an enzyme electrode]. / Glukosemessung in verdünntem Vollblut mit einer Enzymelektrode.

The construction and operation of a measuring device containing an enzyme electrode is described. Glucose oxidase is enclosed in an acrylamide film by means of photopolymerization. The maximal increase of the anodic current of the H2O2 being formed in the enzyme reaction serves as measuring signal. The device gives for diluted serum and blood correlation coefficients above 0,99 according to the methods given in the German Pharmacopeia 7. The measuring time for each specimen is roughly 90 s, the serial variation coefficient 2%.