Straight proximal humeral nailing: Risk of iatrogenic tendon injuries with respect to different entry points in anatomical specimens.

BACKGROUND: The purpose of the study was to evaluate the relationship of implant-related injuries to the adjacent anatomical structures in a newer generation straight proximal humeral nail (PHN) regarding different entry points. The proximity of the proximal lateral locking-screws of the MultiLoc proximal humeral nail (ML PHN) may cause iatrogenic tendon injuries to the lateral edge of the bicipital humeral groove (BG) as reference point for the tendon of the long head of biceps brachii (LBT) as well as the lateral insertion of the infraspinatus tendon (IST). MATERIALS AND METHODS: The study comprised n = 40 upper extremities. Nail application was performed through a deltoid approach and supraspinatus tendon (SSP) split with a ML PHN. All tests were performed in three different entry points. First nail (N1) - standard position in line with the humeral shaft axis; second nail (N2) - a more lateral entry point; third alternative (N3) - medial position, centre of the humeral head. After nail placement, each specimen was screened for potential implant-related injuries or worded differently hit rates (HR) to the BG and the IST. The distances to the anatomical structures were measured and statistically interpreted. RESULTS: The observed iatrogenic IST injury rate was 17.5% (n = 7/40) for N1, 5% (n = 2/40) for N2 and 62.5% (n = 25/40) for N3, which was statistically significantly higher (p < 0.001). Regarding the BG, the evaluated HR was 7.5% (n = 3/40) for both N1 and N2. Only the nail placed in the head centre (N3) showed an iatrogenic injury rate of 20% (n = 8/40) (p < 0.062). No statistically significant association between humeral head size and the HR could be observed (head diameter: IST: p = 0.323, BG: p = 0.621; head circumference: IST: p = 0.167; BG: p = 0.940). For the IST and BG, all distances in nail positions N1 and N2 as well as N2 and N3 differ statistically significant (p < 0.001). CONCLUSIONS: An entry point for nail placement in line or slightly laterally to the humeral shaft axis - but still at the cartilage - should be advocated.

Total wrist arthrodesis for septic wrist arthritis and loss of the bony carpus following percutaneous pinning of the fifth carpometacarpal joint: a case report.

We report on a patient who developed septic wrist arthritis with destruction of the entire carpus due to osteomyelitis following percutaneous pinning of a fifth metacarpal base fracture. Arthrodesis was performed using a 6 cm vascularized iliac bone graft. This case report may sharpen the surgeon's awareness of risks in orthopedic surgeries, even though the procedure seems to be rather simple and the patient is young and seems to be healthy.

Thiol oxidation of hemolymph proteins in oysters Crassostrea brasiliana as markers of oxidative damage induced by urban sewage exposure.

Urban sewage is a concerning issue worldwide, threatening both wildlife and human health. The present study investigated protein oxidation in mangrove oysters (Crassostrea brasiliana) exposed to seawater from Balneário Camboriú, an important tourist destination in Brazil that is affected by urban sewage. Oysters were exposed for 24 h to seawater collected close to the Camboriú River (CAM1) or 1 km away (CAM2). Seawater from an aquaculture laboratory was used as a reference. Local sewage input was marked by higher levels of coliforms, nitrogen, and phosphorus in seawater, as well as polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), linear alkylbenzenes (LABs), and fecal steroid in sediments at CAM1. Exposure of oysters to CAM1 caused marked bioaccumulation of LABs and decreased PAH and PCB concentrations after exposure to both CAM1 and CAM2. Protein thiol oxidation in gills, digestive gland, and hemolymph was evaluated. Lower levels of reduced protein thiols were detected in hemolymph from CAM1, and actin, segon, and dominin were identified as targets of protein thiol oxidation. Dominin susceptibility to oxidation was confirmed in vitro by exposure to peroxides and hypochlorous acid, and 2 cysteine residues were identified as potential sites of oxidation. Overall, these data indicate that urban sewage contamination in local waters has a toxic potential and that protein thiol oxidation in hemolymph could be a useful biomarker of oxidative stress in bivalves exposed to contaminants. Environ Toxicol Chem 2017;36:1833-1845. © 2016 SETAC.

Do we still need autopsy in times of modern multislice computed tomography?-Missed diagnoses in the emergency room.

INTRODUCTION: In spite of increasing quality of emergency room (ER) assessment in trauma patients and improved accuracy of modern multislice computed tomography (MSCT), the number of potentially missed diagnoses is still controversial. The aim of this study was to compare the initial findings of ER assessment and MSCT to the findings during autopsy in trauma patients not surviving the first 48 h after admission. We hypothesized that autopsy was more accurate than MSCT in diagnosing potentially fatal diagnoses. PATIENTS AND METHODS: Between January 2004 and September 2007, all trauma patients undergoing ER treatment in our institution who deceased within 48 h after admission were analyzed regarding diagnoses from initial ER assessment, including MSCT, and diagnoses from autopsy. Data were prospectively collected and retrospectively analyzed. Autopsy reports were compared to diagnoses of ER assessment and MSCT. Missed diagnoses (MD) and missed potentially fatal diagnoses (MPFD) were analyzed. RESULTS: Seventy-three patients with a mean age of 53.2 years were included into the study. Sixty-three percent were male. Autopsy revealed at least one missed diagnosis in 25% of the patients, with the thoracic area accounting for 67% of these. At least one MPFD was found in 4.1% of the patients, all of them being located in the thorax. Total numbers of MD and MPFD were significantly lower for the newer CT generation (64 MSCT, N = 11), compared to older one (4 MSCT, N = 26). CONCLUSIONS: As determined by autopsy, modern multislice computed tomography is an accurate method to diagnose injuries. However, 25% of all diagnoses, and 4.1% of potentially fatal diagnoses are still missed in trauma patients, who deceased within the first 48 h after admission. Therefore, autopsy seems to be necessary to determine potentially missed diagnoses for both academic and medicolegal reasons as well as for quality control.

Summary of Meta-Analyses Dealing with Single-Row versus Double-Row Repair Techniques for Rotator Cuff Tears.

BACKGROUND: Several meta-analyses of randomized clinical trials have been performed to analyze whether double-row (DR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing compared to single-row (SR) repair. The purpose of this study was to sum up the results of meta-analysis comparing SR and DR repair with respect on clinical outcomes and re-tear rates. METHODS: A literature search was undertaken to identify all meta-analyses dealing with randomized controlled trials comparing clinical und structural outcomes after SR versus DR RCR. RESULTS: Eight meta-analyses met the eligibility criteria: two including Level I studies only, five including both Level I and Level II studies, and one including additional Level III studies. Four meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas four favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas six found DR repair to be superior for tears greater than 3 cm tears. CONCLUSION: No clinical differences are seen between single-row and double-row repair for small and medium rotator cuff tears after a short-term follow-up period with a higher re-tear rate following single-row repairs. There seems to be a trend to superior results with double-row repair in large to massive tear sizes.

Allograft augmentation in proximal humerus fractures.

OBJECTIVE: Achieve stable fixation to initially start full range of motion (ROM) and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone. INDICATIONS: (Secondarily) displaced proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency, weak/osteoporotic bone, pre-existing psychiatric illnesses or patient incompliance to obey instructions. CONTRAINDICATIONS: Open/contaminated fractures, systemic immunodeficiency, prior graft-versus-host reaction. SURGICAL TECHNIQUE: Deltopectoral approach. Identification of the rotator cuff. Disimpaction and reduction of the fracture, preparation of the situs. Graft preparation. Allografting. Fracture closure. Plate attachment. Definitive plate fixation. Radiological documentation. Postoperative shoulder fixation (sling). POSTOPERATIVE MANAGEMENT: Cryotherapy, anti-inflammatory medication on demand. Shoulder sling for comfort. Full active physical therapy as tolerated without pain. Postoperative radiographs (anteroposterior, outlet, and axial [as tolerated] views) and clinical follow-up after 6 weeks and 3, 6, and 12 months. RESULTS: Bony union and allograft incorporation in 9 of 10 noncompliant, high-risk patients (median age 63 years) after a mean follow-up of 28.5 months. The median Constant-Murley Score was 72.0 (range 45-86). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Mean correction of the initial varus displacement was 38° (51° preoperatively to 13° postoperatively).

[Current concepts for treatment of massive rotator cuff tears]. / Aktuelle Behandlungskonzepte für Massenrupturen der Rotatorenmanschette.

The ideal treatment for massive rotator cuff tears is influenced by the morphology and chronicity of the tear, tissue quality, the degree of concomitant osteoarthritis, and patient-specific factors. Traditionally, massive rotator cuff tears have wrongly been equated with irreparable tears. A variety of improvements in surgical technique and materials now permit successful arthroscopic management of many massive rotator cuff tears when non-operative management has failed. This study provides an overview of the current treatment options for large and massive rotator cuff tears, including their expected outcomes. Finally, a possible treatment algorithm is suggested.

[A Systematic Review of Personality Disorders and Addiction: Epidemiology, Course and Treatment]. / Persönlichkeitsstörungen und Sucht: Systematische Literaturübersicht zu Epidemiologie, Verlauf und Behandlung.

AIM: This paper provides a systematic overview of the comorbidity of personality and addictive disorders including behavioural addictions. METHOD: Systematic review. RESULTS: Personality disorders and substance-related addictions show high comorbidity rates. This is equally true of behavioural addictions. Most empirical research is on comorbidity with borderline personality disorder. For treatment of individuals with dual diagnoses, three psychotherapies have been demonstrated to be effective. Pharmacotherapeutic approaches have hardly been investigated. CONCLUSION: METHODologically integrative treatment represents therapy of choice for patients with dual diagnoses. Comorbidity of personality disorders and behavioural addictions needs further investigation.

[Psychosocial Treatment of Addictive Disorders--An Overview of Psychotherapeutic Options and their Efficacy]. / Psychosoziale Behandlungen bei Suchterkrankungen--Suchtspezifische Psychotherapieformen und ihre Wirksamkeit.

Addictive disorders are chronic relapsing conditions marked by compulsive and often uncontrolled use of psychotropic substances or stimuli. In this review, we present and discuss the current specific psychosocial interventions for addictive disorders and their effectiveness. In particular cognitive behavioral therapy, motivational interviewing, relapse prevention, the community reinforcement approach, and contingency management were found to be effective. For these psychotherapeutic treatments, mostly moderate effect sizes have been found. Their effectiveness seems to be highest in cannabis dependence. Empirical evidence for dependence on "hard" drugs is largest for contingency management, while for alcohol dependence motivational interviewing and the community reinforcement approach show the largest effect sizes. Presumably, combinations of different approaches as well as online interventions will bring further progress in the psychosocial treatment of addictive disorders in the future.

[Bony Bankart lesions]. / Die ossäre Bankart-Läsion.

Fractures of the anteroinferior glenoid rim, termed bony Bankart lesions, have been reported to occur in up to 22% of first time anterior shoulder dislocations. The primary goal of treatment is to create a stable glenohumeral joint and a good shoulder function. Options for therapeutic intervention are largely dependent on the chronicity of the lesion, the activity level of the patient and postreduction fracture characteristics, such as the size, location and number of fracture fragments. Non-operative treatment can be successful for small, acute fractures, which are anatomically reduced after shoulder reduction. However, in patients with a high risk profile for recurrent instability initial Bankart repair is recommended. Additionally, bony fixation is recommended for acute fractures that involve more than 15-20% of the inferior glenoid diameter. On the other hand chronic fractures are generally managed on a case-by-case basis depending on the amount of fragment resorption and bony erosion of the anterior glenoid with high recurrence rates under conservative therapy. When significant bone loss of the anterior glenoid is present, anatomical (e.g. iliac crest bone graft and osteoarticular allograft) or non-anatomical (e.g. Latarjet and Bristow) reconstruction of the anterior glenoid is often indicated.

Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.

Technical complications during removal of locking screws from locking compression plates: a prospective multicenter study.

PURPOSE: To assess the risk for technical complications in patients undergoing removal of locking compression plates (LCP) with head locking screws. METHODS: A total of 205 patients who were scheduled for implant removal surgery after a healed fracture of the femur, tibia, humerus, distal radius, or clavicle in nine Austrian clinics were prospectively included in the study, all of whom had previously undergone fracture fixation by plates, with titanium implants used in 98 % of the patients. Intraoperative technical complications and the methods used to solve them were documented by the surgeon. RESULTS: During the course of this study, a total of 1,462 locking screws were removed from 204 LCPs. While 95 % of these screws could be removed without difficulties, technical complications were reported for 41 patients with 78 screws which could not be removed with standard screwdrivers and required the use of additional instruments. The estimated risk for the occurrence of at least one technical complication during implant removal surgery was 20.1 %. The most frequently observed complications were screws that could not be loosened because they were jammed in the LCP, screws with a damaged recess in which the screwdriver turned freely, as well as a combination of both events. The majority of these screws could be removed with the use of a conical extraction screw or by drilling off the screw head. In one patient, an intraoperative refracture of the humerus occurred during plate removal. Even though there is a rate of 20 % for technical complications when removing the implants, only a few patients experience a clinical impact. CONCLUSIONS: Titanium LCPs are prone to technical complications during implant removal, but the majority of the issues can be solved using special techniques.

Regression and persistence: remodelling in a tissue engineered axial vascular assembly.

In later stages of vasculoangiogenesis a vascular network is going through a metamorphosis for optimal perfusion and economy of energy. In this study we make a quantitative approach to phenomena of remodelling in a bioartificial neovascular network and suggest variance of calibre as a parameter of neovascular maturation. For this study, 18 male Lewis rats were subjected to the AV loop operation in combination with a hard porous biogenic matrix and an isolation chamber. The animals were allocated into three groups for different explantation intervals set to 2, 4 and 8 weeks, respectively. Collective attributes like vascular density, percent fractional area and variance of calibre were evaluated for a predefined region of interest (ROI). Late morphogenesis was evaluated by means of scanning electron microscopy. After the fourth week the absolute number of vessels within the ROI decreased (P < 0.03) whereas, on the contrary, the fractional area of all segments increased (P < 0.02). The variance in calibre was significantly increased in the 8-week group (P < 0.05). Lymphatic growth after week 4, early pericyte migration as well as intussusceptive angiogenesis were identified immunohistologically. Phenomena of remodelling were evaluated quantitatively in a neovascular network and variance could be proposed as a parameter of net vascular maturation.

The venous graft as an effector of early angiogenesis in a fibrin matrix.

The arteriovenous loop (AV loop) model is gaining importance as a means of initiating and sustaining perfusion in tissue engineering constructs in vivo. This study represents an attempt to dissect the morphology of early arterialization and angiogenesis in the AV loop in a fibrin matrix with special focus on the interpositional venous graft (IVG) segment. An AV loop was constructed in 30 rats using the femoral vessels and an IVG. The AV loop was encased in an isolation chamber filled with a fibrin matrix. Evaluation methods included scanning electron microscopy (SEM) of corrosion casts, immune histology and micro magnetic resonance angiography (MRA). Direct luminal neovascular sprouting was evident between day 10 and day 14 from the vein and the IVG but not from the arterial segment. Arterialization of the IVG manifested itself on the corrosion casts as a gradual reduction in luminal caliber with onset after day 7. Microdissection of the microvascular replicas could demonstrate for the first time the presence of direct luminal sprouts from the IVG. MRA was used to display the shunt pattern of perfusion in the patent AV loop. From the three segments of the vascular axis in the AV loop the IVG is the most versatile for applications in the clinical as well as the experimental setting. Kinetics of angiogenesis warrant further investigation in the IVG.

[Prevascularisation strategies in tissue engineering]. / Prävaskularisationsstrategien im Tissue Engineering.

INTRODUCTION: Experiments on animals have underlined the importance of vascularisation for biointegration and functionality of any given tissue engineering device. The aim of this investigation was to dissect the angiogenetic process in the frame of axial neovascularisation of a xenogenic solid matrix. The ultimate goal of this series of studies is the application of cells onto a prevascularised matrix, with the ambition to enhance cell survival after transplantation in vivo. MATERIALS AND METHODS: We performed a study in the rat with different vascular configurations in an isolation chamber. A disc-formed biogenic hard matrix (9 x 5 mm) was encased into an isolation chamber made of Teflon. In group 1, an arteriovenous fistula (AV loop) between the femoral vessels was microsurgically constructed and was placed around the matrix (n = 15). In group 2, the vascular carrier had the form of an arteriovenous ligated pedicle (n = 15). Evaluation intervals were two, four and eight weeks after implantation. The modes of evaluation included histology, scanning electron microscopy of corrosion casts as well as intravital micro-magnetic resonance imaging (MRI). RESULTS: The arteriovenous loop as vascular carrier revealed a higher capacity for angiogenesis over the bundle configuration. The neo-fibrovascular tissue displayed minimal inflammatory elements but dense vascularisation. Scanning electron microscopy demonstrated a vivid angiogenesis with rapid evolution of the vascular bead into mature, hierarchically organised network. Micro-MRI could be used for serial investigation in terms of flow measurements and detection of thrombosis. DISCUSSION: The presence of a vascular bed prior to cell transplantation might protect against hypoxia-induced cellular death, especially at central portions of the matrix, and therefore ensure physiological function of the device. The generation of vascularised bioartificial tissue substitutes might offer new modalities of surgical reconstruction for use in reparative medicine.

Human peripheral null lymphocytes. II. Producers of type-1 interferon upon stimulation with tumor cells, Herpes simplex virus and Corynebacterium parvum.

Human blood lymphocytes, exposed for 6 to 24 h in vitro to tumor cells (K 562, IGR3, L1210), Herpes simplex virus type 1 (HSV) or Corynebacterium parvum (CP), produced high levels of anti-viral activity which was identified as type-1 interferon (IF). In mixed lymphocyte tumor cell cultures (MLTC), the generated type-1 IF was definitely shown to originate from the lymphocytes and not from the tumor cells. Supplementation of leukocyte cultures with 10% fetal calf serum instead 10% human AB serum had little influence on tumor cell-induced IF production, but strongly reduced CP-induced IF production. Lymphocyte fractionation procedures involving iron/plastic treatment, nylon wool columns, Ig-anti-Ig columns and rosette (E, EA) separation led to the identification of null cells as highly efficient producers of type-1 IF. T cells obtained by different ways (E-rosette sedimentation, passage through 1 nylon and 2 Ig-anti-Ig columns, or thoracic duct lymphocytes) were poor IF producers in response to tumor cells, HSV and CP, but secreted anti-viral activity when stimulated with phytohemagglutinin. In MLTC, the level of generated type-1 IF roughly stimulated with phytohemagglutinin. In MLTC, the level of generated type-1 IF roughly paralleled nautral killer (NK) cell activity. Evidence is presented that type-1 IF can be produced by an Fc receptor-negative null cell subset, whereas NK activity requires Fc receptor-positive cells. It is suggested that production of type-1 IF represents one of the earliest functions in the differentiation process of mononuclear phagocytes and is likely to develop before the appearance of Fc receptors, diffuse esterase staining and latex phagocytosis.