Clinical outcomes in latissimus dorsi transfer single- versus double-incision technique.

BACKGROUND/HYPOTHESIS: In patients with irreparable postero-superior rotator cuff lesions, a latissimus dorsi transfer (LDT) is performed. For this surgery, different techniques are used. In this study, we aim to compare the patient's functional outcome after treatment with modified L'Episcopo "single-incision" and modified Gerber "double-incision" technique for LDT. METHODS: 44 patients with irreparable postero-superior rotator cuff ruptures, refractory to physiotherapeutic treatment were included. 21 patients were treated using a modified L'Episcopo "single-incision", 23 patients with modified Gerber "double-incision" surgical approach. All patients had full-thickness tears of at least two complete tendons, and all had fully functioning deltoid and subscapularis muscles. Preoperatively, there were statistically significant differences between the two groups in all preoperative CMS sub-parameters except "power" and "pain". In the postoperative follow-up, a functional assessment using "Constant-Murley Score" (CMS) and "Age- and gender-related CMS" was conducted. STUDY DESIGN: Retrospective-comparative trial. RESULTS: There were no statistically significant differences between age, sex and time of follow-up between the two study groups (p > 0.05). The mean age was 59.2(± 6.3) years, and the mean follow-up time was 45.4(± 9.3) months for both groups taken together. Mean CMS improved for both groups together from 24.2 ± 8.2 points prior to surgery, to 62.8 ± 17.4 points after a mean follow-up time of 45.4 ± 9.3 months post surgery. The patients treated with "single-incision" surgery (n = 21) gained significantly (p < 0.001) more in CMS and all CMS-sub-scoring parameters except power and pain, compared to the patients treated with "double-incision" technique (n = 23). CONCLUSION: This survey shows appealing post-operative functional outcome in patients with irreparable postero-superior rotator cuff lesions treated with two different techniques for LDT. We believe that the presentation of these methods and their results might encourage shoulder surgeons to implement these techniques. Especially the "single-incision" LDT surgery might be a more accustomed technique for many shoulder surgeons well trained in the deltopectoral approach.

Prognostic factors in endovascular treated pelvic haemorrhage after blunt trauma.

BACKGROUND: Angioembolization is the method of choice for treating haemorrhage after blunt pelvic trauma. The aim of this study was to determine technical factors related to endovascular procedures which might be related to patient outcome. METHODS: This retrospective study included 112 consecutive patients (40 women and 72 men; mean age 57.2 ± 20.0). RESULTS: There were age peaks at 43 and at 77 years. Patients over 65 years had mainly "low-energy" trauma; younger patients were more likely to have polytraumas. Younger patients were more severely injured and had more surgical interventions, larger haematoma volumes, lower Hb levels and required more transfusions than older patients. Women were older than men, had fewer surgeries and waited longer for an angiography (p < 0.05 each). Logistic regression analyses identified the injury severity score (ISS) as relevant for survival before age, haematoma volume and Hb. Propensity score analyses showed that in addition to the need for transfusions, haemoglobin, and haematoma volume, the length of the coils and the number of microcoils used were relevant (p < 0.05 each). The location of haemorrhage in peripheral parietal arteries (superior and inferior gluteal artery) was an influencing factor for re-angiographies, which were associated with considerably longer hospital stays of more than 40 days. Fewer particles had generally been used in these patients. CONCLUSIONS: The use of too few coils and not using microparticles in angioembolization for pelvic haemorrhage are major influencing factors for the mortality or re-angiography rate. Special attention should be given to thorough peripheral embolization with microcoils, in particular for haemorrhage from the parietal branches of the internal iliac artery.

Functional and clinical outcome of total shoulder arthroplasty with oversized glenoid.

BACKGROUND: The Epoca-Reconstruction-(Reco)®-Glenoid has been developed to treat patients with cuff-tear-arthropathy. The glenoid component of this system has a hemispheric shape that canopies the humeral head. This design is believed to provide a stable fulcrum and restore normal deltoid function. The purpose of this study was to analyse strengths and disadvantages of the Epoca-Reco®-Glenoid in cuff-tear-arthropathy patients. Changes in functional outcome using Constant-Murley-Scoring(CMS), CMS sub-scoring parameters and radiological outcome were analysed. For this purpose, a classification for radiologic lucency was proposed. Diverging results, influencing factors and alternative treatment options have been discussed to analyse weaknesses and enhance future development of this arthroplastic model. MATERIALS AND METHODS: 23 patients aged 68 ± 8.4 years with irreparable cuff-tear-arthropathy refractory to physiotherapeutic treatment were treated with Reco-Glenoid Total-Shoulder-Arthroplasty (TSA). Pre-operative standardized evaluations included history, physical examination, radiographs, computer tomography and clinical scorings. The post-operative controls included physical examination with CMS, video documentation and radiological evaluation. RESULTS: After a median follow-up time of 38 ± 18 months, the CMS had been significantly improved (p < 0.001) from (17.4 ± 5.8) to (43.2 ± 19.2) points. Significant improvement in pain, activities of daily life, range of motion (p < 0.001) and power (p = 0.006) was achieved. Significantly, inferior results in functional outcome and higher lucency rates were observed in female patients and in patients treated with small glenoid components. The follow-up rate was 100 %. CONCLUSION: The semi-constraint reconstruction glenoid prosthesis model in cuff-tear-arthropathy patients significantly improves shoulder function, however, it yields controversial results, with satisfactory results in male and poor results in female patients. Revision rate of the female cohort and loosening of the glenoid component in this short-term follow-up is of concern. Further investigations taking BMD, osteopenic conditions and influence of surface area in smaller individuals into consideration are recommended, to determine whether this is the underlying cause of the inferior results in females.

A randomized study of the effectiveness of suprascapular nerve block in patient satisfaction and outcome after arthroscopic subacromial decompression.

PURPOSE: The purpose of this study was to evaluate the efficiency of the suprascapular nerve (SSN) block in pain reduction after arthroscopic subacromial decompression operations and its influence on patient satisfaction. Furthermore, we wanted to evaluate whether better perioperative pain management could positively influence postoperative shoulder function. METHODS: In this prospective, randomized, double-blinded clinical trial, 3 groups of patients--each with 15 participants--were treated with SSN block (10 mL of 1% ropivacaine), placebo, or a subacromial infiltration of local anesthesia (20 mL of 1% ropivacaine). Preoperative and postoperative pain was evaluated with a visual analog scale. Functional outcome was measured by the Constant-Murley score, and patient satisfaction was measured anecdotally by interview 2 days, 2 weeks, and 6 weeks after surgery. RESULTS: The SSN group reported significantly lower levels of postoperative pain, required significantly less analgesia, had better range of motion, and had higher levels of postoperative satisfaction in comparison to the subacromial infiltration group and placebo group. CONCLUSIONS: Patients treated with SSN blocks had less pain overall, which led to a decreased need for analgesics in comparison to the subacromial infiltration and placebo groups. Furthermore, patients in the SSN-blocked group achieved better postoperative ROM and were significantly more satisfied after surgery.

Break Reaction Time after Conservatively Treated Ligament Ruptures of the Ankle.

BACKGROUND: Ankle sprain lesions are the most common ligament lesions in humans. One particularly dangerous consequence of this pathology is an inability to quickly and sufficiently depress the brake pedal when driving a car. The high incidence of the lesion, in the context of a society that is highly automobile-dependent, makes the question "When can a patient safely drive a car again?" of particular socioeconomic importance. HYPOTHESIS/PURPOSE: Though orthopaedic physicians are often confronted with this question, finding an answer in the sparse literature on the topic proves difficult. This study aims to provide a definitive answer to this question. STUDY DESIGN: Prospective Case Control Study. METHODS: 30 patients with grad II and III ligament injuries of the right ankle (18 women, 12 men) and 30 healthy volunteers (19 women, 11 men) participated in this study. Brake reaction time (BRT) was assessed using a previously reported custom-made driving simulator. BRT was assessed two, four and six weeks after injury. Simultaneously the American Orthopedic Foot and Ankle Society Ankle Hindfoot Score (AOFAS-AHS) was assessed. RESULTS: Two weeks after the incident, the patients' BRT measured 690.6±186.2ms. Four weeks after the incident, the BRT improved to 551.8±137.3ms (p<0.001). Compared to the healthy controls' BRT (553.6±118.6ms), there were no significant differences 4 weeks after the injury (p=0.473). At this time, the BRT of both groups was also well below (i.e. faster) than the recommendations of road authorities (700-1500ms). An AOFAS-AHS score of more than 80 points correlated with a sufficient BRT. CONCLUSIONS: Four weeks post injury, patients generally had a sufficient BRT to drive in traffic safely. Some patients could achieve sufficient BRTs at an earlier stage. All patients with sufficient BRTs had an AOFAS-AHS score of ≥81 points. The AOFAS-AHS score can therefore be regarded as an adequate screening tool to evaluate which patients are ready to safely operate motor vehicles earlier.

Management of hemorrhage in severe pelvic injuries.

BACKGROUND: Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. METHODS: In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. RESULTS: Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. CONCLUSION: Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Normal glenoid rim anatomy and the reliability of shoulder instability measurements based on intrasite correlation.

PURPOSE: To evaluate the glenoid shape and to evaluate if the contralateral glenoid can be used as size reference. METHODS: Two independent investigators prospectively analysed shoulder computer-tomographies of 90 patients. The glenoids were positioned in a true "en face" view and evaluated for size and shape. The intraindividual correlation of these parameters between left and right side were assessed. RESULTS: In the 90 computer tomographically evaluated shoulder pairs a significant intraindividual correlation of size and shape was seen (P < 0.001). The intraindividual difference in glenoid surface area averaged 1.8% of the total glenoid surface. The shape of the inferior hemisphere correlated 100%. We found all the inferior glenoids to be circular. CONCLUSION: Our study clearly shows that the inferior glenoid in healthy individuals has the shape of a circle. The high side-to-side correlation of the glenoid surface area can be applied when measuring bony defects by evaluation of the contralateral side.

Preoperative administration of esomeprazole has no influence on frequency of refluxes.

STUDY OBJECTIVE: To examine the effect of esomeprazole in a fixed time setting on gastric content volume, gastric acidity, gastric barrier pressure, and reflux propensity. DESIGN: Randomized, controlled, double-blind trial. SUBJECTS: 21 healthy, ASA I physical status volunteers. INTERVENTION: Esomeprazole was given 12 hours and one hour before investigation. Before the study, a multichannel intraluminal impedance catheter, pH monitoring data logger (PHmetry) catheter, and an intragastric-esophageal manometry catheter were placed nasally after topical anesthesia. MEASUREMENTS: Gastric acidity and gastric content volume were determined by PHmetry after aspiration of gastric contents over a nasogastric tube. Gastroesophageal reflux and intragastric-esophageal barrier pressure were investigated by multichannel intraluminal impedance measurement, PHmetry, and intragastric-esophageal manometry. MAIN RESULTS: The pH of gastric contents was significantly (P < 0.001) higher after esomeprazole (mean [25th-75th percentile], 4.2 [3.9-4.8] vs 2.0 [1.9-2.7]), and gastric content volume was significantly (P < 0.001) lower (5.0 mL [3.0-12.0] vs 15 mL [10.0-25.0]) in comparison to placebo. No significant difference between esomeprazole and placebo was found with respect to number of refluxes per person, duration of reflux, or barrier pressure. CONCLUSION: Esomeprazole in a fixed time setting can markedly increase the pH of gastric contents and decrease gastric content volume, but has no influence on the frequency, duration of refluxes, or gastroesophageal barrier pressure.

Gemcitabine with cyclosporine or with tacrolimus exerts a synergistic effect and induces tolerance in the rat.

BACKGROUND: This study investigated the effect of the antineoplastic agent gemcitabine (dFdC) in combination with cyclosporine (CsA) or with FK506 on acute heart allograft rejection in a rat model. METHODS: Transplantations were performed in the fully allogeneic Lewis-to-Brown Norway strain combination. dFdC, CsA, and FK506 single-drug therapy and combinations of dFdC with CsA and FK506 were administered at various dosages starting on day 1 to prevent and on day 4 to treat acute rejection until day 20. Animals who did not reject their graft were intraperitoneally injected with 108 splenic donor-type lymphocytes. In addition, Lewis and third-party skin grafts were transplanted to these animals. RESULTS: Mean graft survival times under CsA, FK506, and dFdC monotherapy were 18.3/63.7 days (1 mg/5 mg per kg), 41.7 days, and 24.7/38.7 days (100 microg/150 microg per kg), respectively. CsA and FK506 in combination with dFdC prolonged graft survival to more than 100 days (CsA) and more than 95.2 days (FK506). Graft survival after treatment of an ongoing rejection was 21.5/38.3 days for CsA (1 mg/5 mg per kg) and 17.7/59.2 days for dFdC (100 microg/150 microg per kg). The combination of CsA+dFdC prompted indefinite survival of five of six hearts. Lymphocyte inoculation did not induce graft rejection. Notably, none of the Lewis, but all third-party, skin grafts were rejected immediately. Histomorphologic analysis of grafted hearts, however, demonstrated typical features of chronic rejection. CONCLUSIONS: The combination of CsA and FK506 with low-dose dFdC exerts a synergistic effect in the prevention and treatment of acute allograft rejection in this model. Although chronic rejection could not be prevented, strain-specific tolerance was achieved. Therefore, combining standard immunosuppressants with dFdC is a novel, promising strategy for prevention and treatment of acute allograft rejection.

Bipolar anastomosis technique with removable instruments: an easy, fast, and reliable technique for vascular anastomosis.

The interrupted suture technique is most commonly used for microsurgical vascular anastomosis. For several reasons (e.g., exposure of suture material to blood, time needed), many attempts have been made to find other solutions. This article describes a new means of performing a microsurgical vascular anastomosis. The aim of this study was to show the feasibility and possible advantages of this new technique. The basic components at work here are a modified cuff and electrically generated heat used to unite the vessel walls. In this way, both endothelial layers are adapted without manipulating the inside of the vessel or leaving behind foreign matter. Various energy/coagulation time settings were used to perform arterial anastomoses (n = 42) in an isogeneic abdominal aorta interposition model in the rat. The quality of anastomosis was evaluated at days 1, 10, 21, and 120. Immediately after the welding process all anastomoses (n = 42) were patent. No stenosis was found at any observation time. Anastomosis time ranged from 3 to 18 minutes (average, 11 minutes). This new technique permits a vascular anastomosis to be performed easily and reliably with a high patency rate. With this technique, the authors are convinced that a skilled surgeon can create a high-quality anastomosis in a fraction of the time needed to sew an anastomosis.

Bipolar anastomosis technique (BAT) enables "fast-to-do", high-quality venous end-to-end anastomosis in a new vascular model.

The interrupted suture technique is most commonly used for microsurgical venous anastomosis. Needle-stitch trauma and intraluminal suture, however, potentially cause vascular wall damage, thrombosis, intimal hyperplasia or even stenosis. Therefore, the present study aimed to show the feasibility and reliability of a modified cuff technique (bipolar anastomosis technique (BAT)) for venous end-to-end anastomosis in a new chicken throat vascular model. In ex vivo experiments, freshly resected chicken jugular veins (N = 96) were used to find ideal BAT time to current settings for venous end-to-end anastomosis. Thereafter, the left jugular vein of chickens (N = 40) was dissected in vivo and subsequently anastomosed using BAT. The quality of anastomosis was evaluated by Doppler sonography immediately, at two hours and at two, six, 12, 16, and 29 weeks after surgery. Additional histological examination took place at two hours (N = 8) and at two (N = 6), six (N = 6), 12 (N = 6), 16 (N = 6) and 29 (N = 6) weeks after surgery. Immediately after surgery (N = 40) and at two hours (N = 38) venous anastomoses were found to be patent in Doppler sonography. Anastomotic rupture caused death in two animals within one hour after surgery. Thrombotic occlusion was found in one animal at six weeks after surgery. In the remaining animals (N = 37) only minimal stenosis which decreased to almost normal levels was sonographically found. The average time needed for anastomosis using BAT was less than two minutes. BAT allows fast venous end-to-end anastomosis in a chicken throat vascular model.

The influence of postural changes on gastroesophageal reflux and barrier pressure in nonfasting individuals.

UNLABELLED: There is controversy regarding optimal body positioning (i.e., head-up, head-down) in awake nonfasting individuals to minimize the risk for pulmonary aspiration of gastric contents as the result of gastroesophageal reflux (GER). In the present study, we investigated GER and intragastric-esophageal barrier pressure by means of multichannel intraluminal impedance measurement and intragastric-esophageal manometry in awake, nonfasting volunteers randomly positioned in a 20 degrees head-up position, the supine position, and a 20 degrees head-down position. No significant difference among positions was found with respect to number of GER episodes per person (0/1/1) or intragastric-esophageal barrier pressure (15.6/19.6/19.4 mm Hg). We conclude that specific body positioning is useless in the prophylaxis of GER in awake nonfasting individuals. IMPLICATIONS: Tilting of nonfasting individuals to the head-up or head-down position recommended for prevention of regurgitation of gastric contents does not influence the frequency of gastroesophageal reflux.