Serial clinical and MRI examinations after arthroscopic rotator cuff reconstruction using double-row technique.

PURPOSE: Rotator cuff reconstruction using arthroscopic double-row technique enables a better repair of the anatomical footprint at the tendon insertion. Objective of this serial study was to illustrate structural and functional results during recovery following double-row reconstruction. METHODS: Forty-five patients with mid-sized ruptures of the supraspinatus tendon were assessed prospectively and underwent arthroscopic surgery using the double-row technique. Rupture localization, size, form, and extent of retraction were recorded intraoperatively. Clinical and MRI follow-up examinations were carried out for all patients after 6, 12, 26, and 52 weeks. A A standard protocol was used during the follow-up examinations to determine tendon integration, signal changes in the tendon, extent of bone marrow edema near the enclosed absorbable suture anchors, muscle changes. The clinical results were correlated with the MRI appearance. RESULTS: After 26 weeks, the Constant score (CS) showed a highly significant increase for the first time with a value of 78 (p < 0.001). Tendon integration according to Sugaya showed a left shift over time, with higher CS-values for lower Sugaya classifications. Significant improvements in strength were first measured between the 26-week and 52-week follow-ups (9->19/p < 0.001). Highly significant improvement (p < 0.001) of the tendon signal and the fatty infiltration was found in the same time interval. The hypotrophy showed slight improvement, while a highly significant reduction of the bone marrow edema was found between weeks 12 and 26 (p < 0.001). There were no re-ruptures after week 26. CONCLUSIONS: The present serial study showed that it took 26 weeks to reach a significant clinical improvement concerning CS. With regard to tendon healing, no further deterioration of the structural results occurred between week 26 and week 52 postoperative. There were slightly but not significant better clinical results according to the the Sugaya classification. However, parameter "strength" was significantly increased between weeks 26 and 52. This was consistent with a significant decrease in the signal intensity at the repaired tendon site, an additional improvement in the fatty infiltration, and the atrophy according to Thomazeau in the same time interval. LEVEL OF EVIDENCE: I.

In vitro effects of different sources of fibrinogen supplementation on clot initiation and stability in a model of dilutional coagulopathy.

OBJECTIVES: To analyse which fibrinogen source may improve coagulation using an in vitro 33% dilutional coagulopathy model. BACKGROUND: Uncritical volume resuscitation in the context of trauma haemorrhage contributes to the iatrogenic arm of the acute trauma-induced coagulopathy through dilution and depletion of coagulation factors, with fibrinogen reaching critical levels first. MATERIALS AND METHODS: By using an experimental model of 33% dilutional coagulopathy, we have analysed which fibrinogen source may exert superior effects on improving haemocoagulative capacities and correcting depleted fibrinogen levels. As fibrinogen sources, we supplemented (i) fresh frozen plasma (FFP), (ii) fibrinogen concentrate low-dose (Fiblow ) and (iii) fibrinogen concentrate high-dose (Fibhigh ), the latter both in the presence and absence of additional FXIII. RESULTS: The dilution was associated with decreased haemoglobin and haematocrit levels. Fibrinogen supplementation with fibrinogen-containing formulations led to increased fibrinogen levels (FFP: 172·2 ± 17·4 mg dL-1 ; Fiblow : 211·5 ± 20·61 mg dL-1 ; Fibhigh : 255·8 ± 21·4 mg dL-1 ) than in a diluted-only sample (155·5 ± 19·7 mg dL-1 ). Extrinsically activated assay with tissue factor (EXTEM) clot formation times, α-angles and maximum clot firmness significantly improved in the groups of Fiblow + FXIII (79 ± 12·2 s; 74·3 ± 2·4°; 62 ± 2·3 mm), Fibhigh (70·8 ± 10·6 s; 76·2 ± 2·7°; 64·3 ± 2·3 mm) and Fibhigh + FXIII (69·8 ± 11·5 s; 77·5 ± 2·7°; 64·33 ± 2·5 mm) compared with the dilution groups (104·2 ± 19 s; 69·7 ± 2·9°; 56·5 ± 3·1 mm). In contrast, rotational thromboelastometric trace (ROTEM) measures of samples supplemented with FFP largely remained unchanged. CONCLUSION: Fibrinogen concentrates corrected and improved haemodilution-induced changes in blood clotting in vitro. High-dose fibrinogen supplementation was associated with correction and improvement in clot dynamics and stability.

[Results of a prospective multicenter trial for treatment of acromioclavicular dislocation]. / Ergebnisse einer prospektiven Multicenterstudie zur Behandlung der Schultereckgelenksprengung.

OBJECTIVE AND METHODS: The treatment of the acromioclavicular joint dislocation is a topic of constant debate. Objective of the study was to analyze if operative treatment of Rockwood types 3 and 5 acromioclavicular joint dislocations is superior to nonoperative treatment. Treatment outcomes of 100 patients (91 male, 9 female, median age 33.7 +/- 8.6) from 4 different hospitals/departments of trauma surgery were analyzed. Clinicofunctional, radiological, as well as subjective parameters were taken into consideration. RESULTS: Clinicofunctional outcome of the operative treatment of acromioclavicular joint dislocation was very good in 91.2 % of patients. 87.7 % of the operated patients had a subjectively stable joint. The patients operated on for the acromioclavicular joint dislocation were capable of exercising after 13 weeks post surgery. versus 25.3 weeks in nonoperatively treated patients. The operated patients had a Rowe score and Constant score as high as 90.7 and 91.8 respectively, reflecting an excellent treatment outcome. CONCLUSION: Operative anatomic reconstruction of the injured acromioclavicular joint leads to very good clinicofunctional outcomes. The operative technique plays only a minor role in achieving these outcomes. The rate of complications is low for all operative techniques listed here. Demanding patients and multimedia education of patients are the reasons for a majority of operated patients in this study (97 %).

Practice management of acute trauma haemorrhage and haemostatic disorders across German trauma centres.

PURPOSE: Early detection and management of trauma haemorrhage and coagulopathy have been associated with improved outcomes. We assessed infrastructure, logistics and management practice of trauma-associated haemorrhage and coagulopathy across German trauma centres. METHODS: A web-based survey of 20 questions was developed using the open source survey application LimeSurvey®. It was disseminated among surgeons and anaesthetists in Germany. RESULTS: 145 Questionnaires were returned of which 106 were completed and analysed. Two-thirds of the respondents declared they worked in level I trauma centres. Only 61 % followed a treatment algorithm. Over 90 % used standard laboratory and coagulation tests for decision-making. 56.6 % declared they additionally used extended coagulation assays (TEG/ROTEM). Packed red blood cells, fresh frozen plasma, platelet concentrates, prothrombin complex concentrates, tranexamic acid, calcium, fibrinogen and vitamin K were used by more than 85 % of the respondents for the initial treatment. In all hospitals, irrespective of care level, the first blood product was administered in less than 30 min upon patient arrival (49 % <15 min, 48.1 % <30 min). New oral anticoagulants (NOACs) were identified as an increasing problem in today`s trauma care (>95 %) and 65 % of the respondents necessitated reliable tests for early risk stratification. 57.6 % necessitated interdisciplinary training programs to improve clinical skills. CONCLUSIONS: There is variation in the local infrastructure, logistics and management of trauma haemorrhage and coagulopathy across German trauma centres. More than one-third of the respondents declare they do not consistently follow a treatment algorithm. NOACs are considered as an increasing problem in acute trauma care.

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy.

PURPOSE: Early detection and management of post-traumatic haemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructures, logistics and clinical strategies may differ. METHODS: To assess local differences in infrastructure, logistics and clinical management of trauma-associated haemorrhage and coagulopathy, we have conducted a web-based survey amongst the delegates to the 15th European Congress of Trauma and Emergency Surgery (ECTES) and the 2nd World Trauma (WT) Congress held in Frankfurt, Germany, 25-27 May 2014. RESULTS: 446/1,540 delegates completed the questionnaire yielding a response rate of 29%. The majority specified to work as consultants/senior physicians (47.3%) in general (36.1%) or trauma/orthopaedic surgery (44.5%) of level I (70%) or level II (19%) trauma centres. Clinical assessment (>80%) and standard coagulation assays (74.6%) are the most frequently used strategies for early detection and monitoring of bleeding trauma patients with coagulopathy. Only 30% of the respondents declared to use extended coagulation assays to better characterise the bleeding and coagulopathy prompted by more individualised treatment concepts. Most trauma centres (69%) have implemented local protocols based on international and national guidelines using conventional blood products, e.g. packed red blood cell concentrates (93.3%), fresh frozen plasma concentrates (93.3%) and platelet concentrates (83%), and antifibrinolytics (100%). 89% considered the continuous intake of anticoagulants including "new oral anticoagulants" and platelet inhibitors as an increasing threat to bleeding trauma patients. CONCLUSIONS: This study confirms differences in infrastructure, logistics and clinical practice for the detection and management of trauma-haemorrhage and trauma-associated coagulopathy amongst international centres. Ongoing work will focus on geographical differences.

Investigations on the mode of action of ergotamine in the isolated femoral vein of the dog.

1 Experiments on spiral strips cut from the femoral vein of dogs suspended in Krebs-Henseleit solution were carried out.2 Ergotamine caused stimulation in concentrations about 350 times lower than noradrenaline (ED(50) of ergotamine = 2.2 x 10(-9) M; ED(50) of noradrenaline = 7.6 x 10(-7) M), but the maximal responses to ergotamine were only about one third those to noradrenaline.3 The pA(2) value of ergotamine against noradrenaline was 8.8.4 The effects of ergotamine can be blocked by prior administration of phentolamine. The pA(2) value for phentolamine against ergotamine was 6.8 and the pA(2) value for phentolamine against noradrenaline was 7.5.5 It is concluded that the stimulant action of ergotamine on smooth vascular muscle probably is mediated mainly via alpha-adrenoceptors.

Vasopressin, oxytocin and synthetic analogues: the use of bioassays.

Bioassay procedures have been the prerequisite for detection, purification, elucidation of the structure and the synthesis of neurohypophysial hormones. After a review of the history of these bioassays and of the standard preparations including international standards, the current international standards and the bioassay methods prescribed by the pharmacopoeias are described. Some important methodological details are also mentioned.

The nitric acid burn trauma of the skin.

Nitric acid burn traumata often occur in the chemical industry. A few publications addressing this topic can be found in the medical database, and there are no reports about these traumata in children. A total of 24 patients, average 16.6 years of age, suffering from nitric acid traumata were treated. Wound with I degrees burns received open therapy with panthenol-containing creams. Wound of II degrees and higher were initially treated by irrigation with sterile isotonic saline solution and then by covering with silver-sulphadiazine dressing. Treatment was changed on the second day to fluid-absorbent foam bandages for superficial wounds (up to IIa degrees depth) and occlusive, antiseptic moist bandages in combination with enzymatic substances for IIb degrees -III degrees burns. After the delayed demarcation, necrectomy and mesh-graft transplantation were performed. All wounds healed adequately. Chemical burn traumata with nitric acid lead to specific yellow- to brown-stained wounds with slower accumulation of eschar and slower demarcation compared with thermal burns. Remaining wound eschar induced no systemic inflammation reaction. After demarcation, skin transplantation can be performed on the wounds, as is commonly done. The distinguishing feature of nitric-acid-induced chemical burns is the difficulty in differentiation and classification of burn depth. An immediate lavage should be followed by silver sulphadiazine treatment. Thereafter, fluid-absorbent foam bandages or occlusive, antiseptic moist bandages should be used according to the burn depth. Slow demarcation caused a delay in performing surgical treatments.

Pharmacological basis of the treatment of orthostatic disorders with ergot alkaloids.

Ergot alkaloids increase the tone of isolated canine vein strips dose-dependently in concentrations considerably lower than noradrenaline, but the maximal responses are only about one third of those to noradrenaline. This action can be blocked by prior administration of phentolamine. It is therefore concluded that the long-lasting stimulant action of ergot alkaloids on vascular smooth muscle is mediated mainly by alpha-adrenoceptors. Using the autoperfused hind limb of the cat, it has been shown that dihydroergotamine increases dose-dependently the tone of the capacitance vessels in a manner very similar to electrical stimulation of the sympathetic nerve with increasing frequencies. However, in contrast to sympathetic nerve stimulation, dihydroergotamine elicits only a very weak increase in arteriolar resistance.

Anaesthetised normotensive rats for the detection of hypotensive activity of a beta-adrenoceptor antagonist and other antihypertensive agents.

A simple method for the detection of antihypertensive activity in anaesthetised (66 mg/kg i. v. alpha-chloralose and 20 mg/kg i. v. aprobarbital) normotensive rats is described. Dihydralazine (0.5 to 2 mg/kg i. v.) reduced blood pressure dose-dependently but did not provoke the anticipated tachycardia. Clonidine (1 to 8 microgram/kg i.a.), guanethidine (0.5 to 5 mg/kg i.a.) and alpha-methyldopa (2.5 to 10 mg/kg i.a.) reduced blood pressure dose-dependently; the effect of reserpine (0.1 to 1.0 mg/kg i.a) was, however, not dose-dependent. Although all four drugs reduced heart rate, only clonidine and guanethidine did so in a dose-dependent manner. Phentolamine (0.5 to 2 mg/kg i. v.) and propranolol (0.01 to 1 mg/kg i. v.) elicited dose-dependent falls in blood pressure. Whereas phentolamine increased heart-rate slightly, propranolol elicited a bradycardia. It is concluded that the chloralose-aprobarbital anaesthetised rat is a suitable and economical model for the screening of potential antihypertensive agents including beta-adrenoceptor antagonists. However, reflex trachycardia provoked by peripheral vasodilators may not be apparent.

Oxytocic activity of two dihydrogenated ergot peptide alkaloids on the rabbit uterus in situ.

The effect of two recently synthetized dihydrogenated ergot peptide alkaloids has been investigated on the rabbit uterus in situ. The method is described in detail. 6-Nor-6-isopropyl-9,10-dihydro-2'beta-methyl-5'alpha-benzyl-ergopeptine (DZ 26-474) and 6-nor-6-idopropyl-9,10-dihydro2'8-methyl-5'alpha-isopropyl-ergopeptine (28-377) possess 33% and 59%, respectively, of the oxytocic activity of methylergometrine (Methergine). The uterotonic effect of DZ 26-474 and 28-377 can be completely abolished by pretreatment with alpha-adrenoceptor blocking drugs, indicating involvement of alpha-adrenoceptors. Results obtained are discussed in relation to the concept that dihydrogenated ergot peptide alkaloids usually inhibit spontaneous contractions of the uterus and contractions induced by methylergometrine.

Completion of the natural groups of ergot alkaloids: syntheses and pharmacological profiles of beta-ergosine and beta-ergoptine.

The syntheses and pharmacological potencies of beta-ergosine and beta-ergoptine, the missing links in the natural groups of ergot peptide alkaloids are described.