The inflamed biceps tendon as a pain generator in the shoulder: A histological and biomolecular analysis.

INTRODUCTION: The long head of the biceps (LHB) is often resected in shoulder surgery. However, its contribution to inflammatory processes in the shoulder remains unclear. In the present study, inflamed and noninflamed human LHBs were comparatively characterized for features of inflammation. MATERIALS AND METHODS: Twenty-two resected LHB tendons were classified into inflamed ( n = 11) and noninflamed ( n = 11) samples. For histological examination, samples were stained with hematoxylin eosin, Azan, van Gieson, and Masson Goldner trichrome. Neuronal tissue was immunohistochemically visualized. In addition, specific inflammatory marker gene expression of primary LHB-derived cell cultures were analyzed. RESULTS: Features of tendinopathy, such as collagen disorganization, infiltration by inflammatory cells, neovascularization, and extensive neuronal innervation were found in the tendinitis group. Compared to noninflamed samples, inflamed LHBs showed a significantly increased inflammatory marker gene expression. CONCLUSION: Structural and biomolecular differences of both groups suggest that the LHB tendon acts as an important pain generator in the shoulder joint. These findings can, on the one hand, contribute to the understanding of the biomolecular genesis of LHB tendinitis and, on the other hand, provide possibilities for new therapeutic approaches.

[Periprosthetic humeral fractures: Strategies and techniques of revision arthroplasty]. / Periprothetische Humerusfraktur: Strategien und Techniken der Revisionsendoprothetik.

The primary aims when performing revision arthroplasty of periprosthetic humeral fractures (PHF) are preservation of bone stock, achieving fracture healing and preserving a stable prosthesis with the focus on regaining the preoperative shoulder-arm function. The indications for revision arthroplasty are given in PHF in combination with loosening of the stem. In addition, further factors must be independently clarified in the case of an anatomical arthroplasty. In this context secondary glenoid erosion as well as rotator cuff insufficiency are potential factors for an extended revision procedure. For the performance of revision surgery modular revision sets including long stems, revision glenoid and metaglene components as well as plate and cerclage systems are obligatory besides the explantation instrumentation. Despite a loosened prosthesis, a transhumeral removal of the stem along with a subpectoral fenestration are often required. Length as well as bracing of revision stems need to bridge the fracture by at least twice the humeral diameter. Moreover, in many cases a combined procedure using an additional distal open reduction and internal fixation (ORIF) plus cable cerclages as well as biological augmentation might be needed. Assuming an adequate preparation, the experienced surgeon is able to achieve a high fracture union rate along with an acceptable or even good shoulder function and to avoid further complications.

[Periprosthetic humeral fractures: Strategies and techniques for osteosynthesis]. / Periprothetische Humerusfraktur: Strategien und Techniken der Osteosynthese.

The prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6-2.4%. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6% and 0.9% and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.

[Cuff tear arthropathy ­ long-term results of reverse total shoulder arthroplasty]. / Defektarthropathie ­ langzeitergebnisse der inversen Schultertotalendoprothesenimplantation

The results after reverse total shoulder arthroplasty for cuff tear arthropathy are superior and the complications fewer than for other etiologies, such as rheumatoid arthritis, fracture, fracture sequelae or even revision. The improvements in function and pain are excellent whereas rotation may be unaffected. Revisions and complications can be encountered in the first 3 years and the survival curve of the prosthesis is still good after 10 years with 90%. Progressive functional and radiological deterioration is observed after 9 years in approximately 30% of the patients without apparent problems with the prosthesis. Notching is progressive with incidence and size over time, without a proven correlation to the functional results but remains a major concern. Modification of the implants, the operative techniques and experience could significantly improve the results and reduce the rate of complications. Lateralization of the center of rotation and smaller inclination angles have a positive effect on the rate of notching and the range of motion, especially for the rotation. New prosthetic designs and operative techniques attempt to implement a combination of the biomechanical improvements. Reverse shoulder arthroplasty remains a challenging operation with a high rate of complications. The results depend on the etiology and the function of the remaining muscles and therefore on the experience and the skill of the surgeon to implement the appropriate biomechanical factors. Because of the concerns regarding the longevity, reverse shoulder arthroplasty should be reserved for the elderly over 70 years of age.

[Arthropathy of instability. Causes, treatment options and results]. / Instabilitätsarthropathie. Ursachen, Behandlungsoptionen und Ergebnisse.

Glenohumeral arthritis may develop after primary or recurrent shoulder dislocation or after surgery for stabilization. Postoperatively, the incidence is reported to be from 12% to 62%, depending on different risk factors. There is no certain correlation between the surgical technique and the rate of arthrosis. Capsulorraphy arthropathy is biomechanically and clinically a well defined entity. The risk of developing severe arthrosis of the shoulder following dislocation of the shoulder is between 10 and 20 times greater in comparison to the normal population. Risk factors are the age during the first episode of instability, the age at instability surgery, bony lesions on the humeral head or the glenoid and rotator cuff tears.For mild stages of glenohumeral arthritis, arthroscopic revision with removal of intraarticular metallic parts, arthroscopic debridement or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For more severe stages mobilization of the internal rotation contracture and glenohumeral arthroplasty are indicated. With sufficient integrity of the head and glenoid, a surface replacement is adequate. With intact rotator cuff and without bone graft the results for shoulder arthroplasty are comparable to those following primary omarthrosis. With a bone graft at the glenoidal side the risk for implant loosening is 10 times greater. For the functional outcome the quality of the rotator cuff, i.e. the fatty degeneration, is more predictive than the type of previous surgery or the preoperative external rotation contracture.

[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 %).

[First traumatic anterior shoulder dislocation: postoperative results 6 months and 2 years after arthroscopic stabilization in young patients]. / Die traumatische Schultererstluxation : Ergebnisse 6 Monate und 2 Jahre postoperativ nach arthroskopischer Stabilisierung beim jungen Patienten.

BACKGROUND: The purpose of this prospective clinical trial was to report about results of primary or early secondary arthroscopic stabilization after first traumatic anterior dislocation of the shoulder. PATIENTS AND METHODS: Within 2 weeks or in the 7th to 12th week post trauma, 51 subjects between 16 and 30 years received arthroscopic stabilization and rehabilitation. The patients were followed-up 6 months and 2 years post operation and assessed with the Rowe and the Constant scores. RESULTS: At a mean follow-up of 27.9+/-4.3 months all patients returned to work in their profession. Of the patients, 79.2% were satisfied with the result of the operation; 91.7% returned to their sports. During the follow-up period five patients (10.4%) suffered redislocation. There was no difference in the result comparing the time of operation. The Rowe and Constant scores showed excellent results. CONCLUSIONS: Arthroscopic stabilization after first traumatic anterior shoulder dislocation of the young patient is an appropriate approach and regardless of whether it is performed as a primary or early secondary operation it significantly lowers the redislocation rate. The method leads to quick reintegration into professional life and sports activities.

[Shoulder arthroplasty for treatment of the sequelae of proximal humerus fractures]. / Schulterendoprothetik bei posttraumatischen Deformitäten durch Frakturfolgen.

The sequelae of fractures of the proximal humerus can be of considerable clinical significance. Careful classification of the sequelae allows precise determination of whether correction osteotomy, reconstruction, or implantation of one of the various prostheses available is indicated. The integrity of the greater tuberosity, its position and continuous osseous integration to the metaphysis of the proximal humerus is the most important predictive factor for a good outcome following implantation of an anatomical shoulder prosthesis. When there is some incongruence of the glenohumeral joint while the greater tuberosity remains intact, shoulder arthroplasty can give a better clinical outcome than is seen after arthroplasty for a primary fracture. In the case of nonunion of subcapital fractures the results achieved by reconstruction, i.e. bone grafting and internal fixation using plates with fixed-angle blades, are superior to those possible with an anatomical prosthesis. Reverse shoulder arthroplasty gives better results than anatomical prostheses in the treatment of severe tuberosity malunion. The results of reverse shoulder arthroplasty for the sequelae of fractures are also influenced by the integrity of or damage to the soft tissues, the muscles of the rotator cuff (teres minor muscle), and bone. Secondary interventions for the sequelae of fractures of the proximal humerus are complex and involve high rates of complications and revisions.

Role of the wet-to-dry phase of cleansing in preparing the chronic wound bed for dressing application.

The wet-to-dry phase is a method of cleansing that acts as an alternative to rinsing prior to the application of a modern wound dressing. Debris, exudate and pathogens are removed from the wound, reducing itching and inflammation.

Implantation of stimulation electrodes in the subretinal space to demonstrate cortical responses in Yucatan minipig in the course of visual prosthesis development.

PURPOSE: During the course of the development of visual prostheses, subretinal stimulation films were implanted in micropigs in order to prove the feasibility of subretinal electrical stimulation with subsequent cortical response. One aim was to demonstrate that epidural recording of visual evoked potentials is possible in the micropig. METHODS: Film-bound stimulation electrode arrays were placed in the subretinal space of micropigs. This enabled the retina to be stimulated subretinally. Since conventional visual evoked potential (VEP) measuring is virtually impossible in the pig from the neurosurgical point of view, epidural recording electrode arrays were positioned over the visual cortex as permanent electrodes. RESULTS: The feasibility of temporary implantation of film-bound stimulation electrode arrays was successfully demonstrated in the micropig model. On stimulation with monopolar voltage pulses (1000 to 3000 mV), reproducible epidural VEP measurements (5 to 10 micronV) were detected. CONCLUSIONS: The feasibility of subretinal stimulation of the retina was demonstrated in a retinal model that is similar to the human retina. This animal model therefore offers a suitable means of studying the tolerability of stimulation situations in the course of visual prosthesis development.

Implantation of stimulation electrodes in the subretinal space to demonstrate cortical responses in Yucatan minipig in the course of visual prosthesis development.

PURPOSE: During the course of the development of visual prostheses, subretinal stimulation films were implanted in micropigs in order to prove the feasibility of subretinal electrical stimulation with subsequent cortical response. One aim was to demonstrate that epidural recording of visual evoked potentials is possible in the micropig. METHODS: Film-bound stimulation electrode arrays were placed in the subretinal space of micropigs. This enabled the retina to be stimulated subretinally. Since conventional visual evoked potential (VEP) measuring is virtually impossible in the pig from the neurosurgical point of view, epidural recording electrode arrays were positioned over the visual cortex as permanent electrodes. RESULTS: The feasibility of temporary implantation of film-bound stimulation electrode arrays was successfully demonstrated in the micropig model. On stimulation with monopolar voltage pulses (1000 to 3000 mV), reproducible epidural VEP measurements (5 to 10 micronV) were detected. CONCLUSIONS: The feasibility of subretinal stimulation of the retina was demonstrated in a retinal model that is similar to the human retina. This animal model therefore offers a suitable means of studying the tolerability of stimulation situations in the course of visual prosthesis development.

Juxtaacetabular ganglion as a differential diagnosis in pulsating groin masses.

Ganglion cysts of the hip joint are uncommon synovial-lined fluid-filled juxtaarticular groin lesions. Whereas in the past the correct diagnosis was often made only at surgery there are now valuable imaging methods used for the diagnostic work-up. In experienced hands ultrasonography (US) combined with colour duplex Doppler ultrasonography (CDDS) as a real-time imaging technique easily performed at the patient's bedside is a valid alternative to more expensive or invasive investigations. We report on a patient who presented with a ganglion cyst and in whom first supported by conventional US an aneurysm of the femoral artery was suspected. The diagnosis of a juxtaarticular ganglion was subsequently correctly made at our institution by CDDS and magnetic resonance imaging, respectively, and the cyst was exstirpated successfully. The differential diagnosis of a pulsating groin mass as well as the most useful and specific imaging methods in the diagnostic work-up in this clinical setting are discussed.

Experiences with hydrofibres in the moist treatment of chronic wounds, in particular of diabetic foot.

BACKGROUND: Chronic wounds are an everyday problem in general medicine. Likewise, their persistence, painfulness and frequency of relapse are everyday problems which strain the stamina of patients and doctors to the point of desperation. Over recent years, the moist therapy concept has proven to be a major advance in wound treatment. The introduction of innovative wound dressings in the 1990's made it possible to substantially accelerate wound healing and couple it with a simultaneous alleviation of pain. PATIENTS: In the scope of our team's experience one such product is the hydrofibre. This paper offers information on the possibilities for using this material on the basis of 135 wound situations, 44% of which are within the context of diabetes mellitus. RESULTS: There was a positive influence on wound healing in 92% of the cases. This treatment result is analysed in terms of causal, topographic and iconographic aspects. CONCLUSION: Given the main focal points of our group of patients, it may be stated that hydrofibres are suitable for diabetic wounds.

Topical treatment of venous ulcer with fibrin stabilizing factor: experimental investigation of effects on vascular permeability.

BACKGROUND: The clinical observation of distinct reduction of wound secretion tendency during treatment of venous leg ulcer with topically applied factor XIII let us speculate that this enzyme may be involved in modulation of vascular permeability. METHODS: For experimental study porcine aortic endothelial cells were cultured on filter membrane to confluent monolayer. Endothelial covered filters then were used in a two-compartment modell creating an artificial luminal and abluminal compartment. To investigate the influence of factor XIII on endothelial barrier function, we measured the flux of trypan blue-labeled albumin through endothelial monolayers by spectrophotometer. RESULTS: Monolayers that were exposed to factor XIII showed a distinct (n = 10, p < 0.05) decrease of albumin flux in contrast to control. This effect was not dependent on serum substrates. Partially, the permeability reducing effect was due to a certain amount of albumin that is a stabilizing component of Fibrogammin HS. CONCLUSION: Although the mechanism is unclear at the moment, we conclude that reduction of endothelial permeability can be achieved by factor XIII which may play an important role in wound healing of venous leg ulcer.

[The diabetic foot from the viewpoint of infection surgery]. / Der diabetische Fuss aus infektchirurgischer Sicht.

Pressure ulceration and bacterial superinfection are main risk factors for the diabetic foot. Surgical interventions for prophylaxis and treatment of infection are demanded. The aim of emergency surgery to treat infection is conservation of as much foot as possible. Therapeutic strategies and an algorithm are established for definite treatment of the infected diabetic foot: primary treatment of infection--arterial revascularization--amputation--orthopedic shoesupply.

Quality assurance of physical parameters in radiation oncology at the University Hospital of Basel--a retrospect.

BACKGROUND AND PURPOSE: The necessity for and the benefit of a quality assurance program in radiation oncology are not questioned. Nevertheless, a retrospective analysis of the accumulated results of several years of quality assurance offers the possibility for further optimization. MATERIALS AND METHODS: The results of the physical quality control in radiation treatment planning and on radiation treatment units in the Institute for Radiation Oncology at the University Hospital of Basel for the years 1985, 1991 and 1994 are analyzed and compared mutually. The frequencies of the deviations from the nominal values for the different tests are stated. RESULTS: The relevance of the deviations for the different parameters is rated and the manifested influence of the type and age of the equipment on the results of the quality assurance is discussed. CONCLUSIONS: A condition for the maximum benefit gained from the quality assurance is the oncologist's understanding of the necessity for regular checks and the urgency for eliminating the established deficiencies. In that way the accuracy for the treatment planning, simulation and set-up process and for the realization of the radiation treatment can be increased and the methods can be improved.