Shoulder arthrodesis.

Current indications for shoulder arthrodesis include posttraumatic brachial plexus injuries, paralysis of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. The trapezius, levator scapulae, serratus anterior, and rhomboid muscles must be functional to optimize the functional result following shoulder arthrodesis. A consensus has not been reached concerning the ideal position of the shoulder arthrodesis, although excessive abduction or flexion has been associated with chronic postoperative pain. Decortication of both the acromiohumeral and the glenohumeral surfaces to increase the surface area available for arthrodesis is the most common means for obtaining successful fusion. Although there are numerous methods for stabilization of a shoulder arthrodesis, the most popular method today is probably the AO technique with either a single plate or double plates.

Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder.

Between June 1983 and March 1992, we performed a capsular reconstruction procedure through an anterior approach in ten patients (ten shoulders) who had multidirectional laxity of the shoulder and symptomatic atraumatic posterior glenohumeral instability. The procedure included closure of the capsule in the rotator interval and imbrication of the anterior, inferior, and posteroinferior aspects of the capsule by a double-breasting technique that decreases the overall capsular volume. The mean duration of follow-up was sixty months (range, twenty-four to 103 months). According to the system of Rowe and Zarins, the result was graded as excellent for five shoulders, good for four, and poor for one. On the basis of our results, we recommend capsular reconstruction through an anterior approach only in patients who have persistent multidirectional laxity and symptomatic atraumatic posterior instability of the shoulder despite participation in an intensive rehabilitation program.

Repair of soft tissue to bone using a biodegradable suture anchor.

The medial collateral ligaments of 18 New Zealand rabbits were surgically detached from bone. In one knee, the ligament was repaired using a biodegradable suture anchor composed of a co-polymer of lactic and glycolic acid. The contralateral medial collateral ligament was not repaired. Animals were sacrificed at 4, 8, and 12 weeks after the operation, and the knee that had the ligament repair was compared with the contralateral control knee. All knees were tested manually tested for stability to valgus stress and then prepared for histologic examination. Medial collateral ligaments repaired using the biodegradable suture anchor demonstrated stability to valgus stress and anatomic healing at the bone-tendon junction. Resorption of the implant was virtually complete by 12 weeks. All specimens demonstrated less inflammatory reaction to the suture anchor than to the attached Vicryl suture. This contrasts with the control group, which was grossly unstable and demonstrated scarring in this nonanatomic position. These results demonstrate efficacy of this particular material of biodegradable implant and justify further investigative efforts.

Treatment of complications of shoulder arthrodesis.

A reconstructive osteotomy was performed to correct symptomatic malposition after arthrodesis of the shoulder in nine of fourteen patients who had complications related to the arthrodesis. The clinical position of the arm in relation to the trunk was determined with the method described by Rowe. Malposition was primarily the result of fusion in more than 15 degrees of either flexion or abduction, or both, coupled with improper rotation, defined as rotation of less than 40 degrees or more than 60 degrees. Reconstructive osteotomy eliminated pain and improved the ability of the patient to perform six activities of daily living. The complications necessitating operative treatment after the arthrodesis in the remaining five patients included failure of the arthrodesis site to unite (three patients), a wound hematoma at the iliac-crest donor site (one patient), and a superficial wound infection (one patient). Two additional complications - a fracture through a screw-hole in the humerus and a fracture distal to the internal fixation device - occurred after the reconstructive osteotomies for malposition. All of the complications resolved with treatment. Arthrodesis of the shoulder is a technically demanding procedure that can lead to serious complications that necessitate operative intervention. Careful attention to operative technique and to the position of the arthrodesis are essential.

Resection arthroplasty of the sternoclavicular joint.

The results of resection of the medial end of the clavicle to treat a painful sternoclavicular joint in fifteen patients were retrospectively reviewed. The patients fell into two groups: eight patients who had had a primary arthroplasty of the sternoclavicular joint in which the costoclavicular ligament was left intact (group I), and seven patients who had had revision of a failed arthroplasty of the sternoclavicular joint and in whom the costoclavicular ligament had to be reconstructed (group II). The results for these two groups were compared at an average of 7.7 years postoperatively. All eight patients in group I had an excellent result. In sharp contrast, three patients in group II had an excellent result, three had a fair result, and one had a poor result. We conclude that preservation or reconstruction of the costoclavicular ligament is essential at the time of resection of the medial portion of the clavicle in order to obtain a satisfactory result.

Loss of the deltoid after shoulder operations: An operative disaster.

A series of 36 patients who had a postoperative loss of the anterior or anterior lateral deltoid muscle after shoulder operations (i.e., acromioplasties, anterior shoulder reconstructions, or arthroplasty procedures) was referred to the senior author. Three patients last the function of their deltoid after an injury to the axillary nerve, and 33 patients lost deltoid function after loss of the origin of the deltoid from the clavicle and acromion. All patients were significantly disabled. All patients were dissatisfied with the result of the previous operation, and eight patients experienced painful anterior or anterior/superior dislocation of the glenohumeral joint. Treatment was nonspecific and supportive. The authors conclude that loss of anterior deltoid function secondary to denervation or detachment results in irrevocable pain and impairment of function. Careful attention to the surgical technique of deltoid reattachment and protection of the axillary nerve are essential to the prevention of dire consequences to shoulder function.

Two-part fractures of the proximal humerus.

Between 1981 and 1991, 137 patients had 141 two-part proximal humerus fractures. One hundred thirteen surgical neck, 24 greater tuberosity, 2 anatomic neck, and 2 lesser tuberosity fractures were studied. Eleven patients had died in the interim; the remaining cases were reviewed. The mean age of patients with surgical neck fractures was 57 years (range 20 to 91 years), and 62.8% (71 cases) were women. In 38% of cases there was another significant medical problem. Eighty (70.8%) cases were treated with a sling and early isometric and pendulum exercises. Bony union was obtained in an average of 3.2 months (range 2 to 8 months), and 87.5% achieved satisfactory function. The mean age of patients with greater tuberosity fractures was 37 years (range 20 to 59 years), and 79.2% (19 cases) were men. Ten (41.7%) cases were treated with open reduction and internal fixation, and the remainder were treated without surgery. All patients improved to a satisfactory level of function. Anatomic neck fractures (two) were treated with surgery. Lesser tuberosity fractures (two) were treated conservatively and had good functional results. It appears that conservative measures when coupled with early isometric and pendulum exercises produce a satisfactory result in surgical neck fractures. Similarly, conservative treatment for nondisplaced greater tuberosity fractures and operative intervention for displaced fractures resulted in satisfactory function. Lesser tuberosity fractures without limitation of motion appear to do well with a sling and early motion.

Treatment of cysts of the acromioclavicular joint with shoulder hemiarthroplasty.

A chronic cyst overlying the acromioclavicular joint was managed in four patients, between July 1988 and September 1991. All patients had had previous unsuccessful aspiration and excision of the cyst with recurrence. Each cyst was associated with a chronic, massive defect of the rotator cuff; superior migration of the humeral head; and degenerative osteoarthrosis of the glenohumeral joint. All patients had complained of pain and limitation of motion (mean forward elevation, 95 degrees; mean external rotation, 20 degrees; and mean internal rotation, to the spinous process of the second lumbar vertebra). All procedures consisted of a large-humeral-head hemiarthroplasty, with no operative treatment directed at the cyst or the acromioclavicular joint. At an average of twenty-seven months (range, fifteen to thirty-six months) after the operation, the patients were all pain-free and had not had a recurrence of the cyst. The average postoperative range of motion was 130 degrees of forward elevation, 30 degrees of external rotation, and internal rotation to the spinous process of the first lumbar vertebra.

Fractures of the femur treated by intramedullary nailing using the fluted rod. A report of 193 consecutive cases.

One hundred ninety-three of 196 acute nonpathologic femoral shaft fractures were treated consecutively with intramedullary nailing using the fluted rod. Closed intramedullary nailing was used in 126 fractures, and an open technique was used in 67. This series includes 58 open fractures and 104 comminuted fractures. All fractures treated with the fluted rod united. Complications included three superficial infections (1.5%). Malrotation greater than 20 degrees was noted in six patients (3.1%). Significant shortening (5 cm), which required treatment, occurred in one patient. After initial resuscitation and evaluation, routine treatment included preoperative traction and a first-generation cephalosporin followed by accurate reduction and nailing of the fracture. The results of this series suggest that the fluted rod may be ideal for the treatment of most femoral shaft fractures.

Characterization of acetylcholine- and endothelin-induced calcium entry in cultured human ciliary muscle cells.

We characterized the effects of acetylcholine and endothelin on cultured human ciliary muscle cells, using the calcium-sensitive dye fura-2 to measure intracellular calcium and intracellular microelectrodes to measure the membrane potential. Both agonists, endothelin and acetylcholine, had a typical biphasic effect on the intracellular calcium concentration. Calcium peaked initially, because of its release from intracellular stores, and then reached a plateau, owing to entry of extracellular calcium. Endothelin-induced calcium entry was almost completely blocked by addition of extracellular La3+ (50 mumol/l) and Ni2+ (1 mmol/l). Acetylcholine-induced calcium entry was likewise almost completely abolished by La3+ and Ni2+. Both endothelin and acetylcholine led to an initial transient hyperpolarization with a subsequent depolarization. The hyperpolarization of the membrane potential had a time course similar to the initial calcium peak, while the depolarization occurred parallel to the calcium plateau. The depolarization induced by both agonists was reduced in the presence of La3+ and Ni2+. Verapamil (10 mumol/l) had no effect on either the calcium entry or the depolarization. Acetylcholine did not induce a [Ca2+]i peak when it was applied during the endothelin-induced [Ca2+]i plateau and vice versa. The [Ca2+]i plateau was not higher with concomitant than with single application of acetylcholine or endothelin. Thus, calcium entry and membrane depolarization induced by acetylcholine and endothelin seem to be mediated by a common La(3+)- and Ni(2+)-sensitive but verapamil-insensitive mechanism.

Experimental evaluation of seven different spinal fracture internal fixation devices using nonfailure stability testing. The load-sharing and unstable-mechanism concepts.

Fracture site immobilization capabilities of seven internal spine fixation systems were experimentally evaluated: Harrington double distraction (plain, supplemented with Edwards sleeves, supplemented with sublaminar wires), Luque rectangle, Kaneda device, transfixed Kaneda device, and Steffee plates. Stability evaluation involved comparing the three-dimensional motion that occurred across an experimentally created L1 slice fracture, and the load resistance of the implants when subjected to axial, flexion, extension, lateral bending, and torsional loads. Each implant was tested on 15 different vertebral segments from 200-250-lb calves. All implants load-shared with the fractured vertebral column to varying degrees. All except the Steffee plate system showed an obvious biomechanical weakness in one or more load modes. The unstable 4R-4bar mechanism configuration of bilevel spinal implants was identified. Mechanism configurations allow free movement with little or no resistance to the applied load until load sharing by the spinal column stops the collapse and resists the applied load.

Results of total knee arthroplasty using the posterior stabilized condylar prosthesis. A report of 137 consecutive cases.

One hundred thirty-seven consecutive posterior stabilized total knee arthroplasties (TKAs) were reviewed. Average age of the patient was 61.1 years and length of postoperative follow-up period was 29.2 months. Patients were evaluated using the Hospital for Special Surgery (HSS) knee rating scores. Average preoperative scores improved from 52 to 92, postoperatively. Ninety-eight percent of patients had no pain or mild occasional pain postoperatively compared with 99% of patients experiencing severe to disabling pain preoperatively. Complications included one myocardial infarction, two deep venous thrombosis, one urinary tract infection, one patellar dislocation, and four wound problems. There were two incidences of seroma, one hematoma, and one deep infection requiring revision after joint debridement and systemic antibiotics. Also noted was one incidence of ligamentous laxity and one patella fracture.

A comparison of transfusion requirements after total knee arthroplasty using the Solcotrans autotransfusion system.

Twenty-five consecutive total knee arthroplasties were performed with the Solcotrans unit for scavenging postoperative drainage (study group) and were compared with the previous 25 arthroplasties performed without the Solcotrans unit (control group). Mean preoperative hematocrits, estimated blood loss, and fluid replacement for both control and study groups were nearly identical. When the autotransfusion system was not used, 10 patients in the control group required transfusion of a total of 20 units of packed red blood cells, while only two patients utilizing the Solcotrans unit required transfusion of five units of packed red blood cells (P less than .01). The total amount autotransfused in the study group averaged 607.9 mm, and the hematocrit of the scavenged drainage was 29.3%. Samples from all autotransfusions were sent to the microbiology lab for routine culture and were finalized as no growth after 14 days. Serial postoperative hematocrits, platelet counts, prothrombin, partial thromboplastin, blood urea nitrogen, and creatinine values were compared between the two groups. No significant differences were found, and no evidence of coagulopathy, thrombocytopenia or renal dysfunction was found in the study group.

Early clinical experience with Orthofix external fixation of complex distal radius fractures.

Twelve patients with complex fractures of the distal radius were treated with the Orthofix external fixation system (EBI Medical Systems, Fairfield, NJ). On follow up physical examination, the average wrist dorsiflexion was 46 degrees, and the average volar flexion was 55 degrees. The average grip strength in the involved hand was 38 lb force. The average final radial angle was 18 degrees, and the average residual radial height was 12 mm. Average volar tilt was 3 degrees. The complication rate was 42%. Very rigid axial stability is afforded by the fixator, but the large 3.5 mm tapered bone screw diameter precludes redrilling for screw adjustment. The apparatus needs frequent monitoring to reconfirm the security of the locking nuts and cam mechanisms, and the Orthofix system can be reused only four times.

[Blood glucose self-monitoring with the Glucosignal test strip in routine practice--experiences of a district diabetes center]. / Blutglucoseselbstkontrolle mit dem Teststreifen Glucosignal unter Arbeitsbedingungen--Erfahrungen einer Diabetikerkreisstelle.

32 patients (19 females, 13 males; 28 type I diabetics and 4 type II diabetics) with a diabetes mellitus we taught the blood glucose self-control under working conditions by means of the test strip Glucosignal. 9 diabetics were excluded from the investigation. The main reasons for this were: inability to acquire the withdrawal technique, abuse of alcohol, unreliability and attitude of opposition to the own disease. During the duration of observation of on an average 13.8 months (11 to 25 months) in the remaining 23 patients an improvement of metabolism could be obtained with the same need of insulin. In three quarters of the cases correction of the metabolism were made by the patients by insulin variation and only for the smallest part by physical conditioning. Intensive theoretical and practical training and good motivation of the patients decide on success or failure of the optimization of metabolism. The various possibilities of an influence on ambulatory day-night-profiles under working conditions are discussed.

[Intensive basic therapy decreases the need for drug treatment and improves glucose control: an important result of the diabetes intervention study]. / Intensivierte Basistherapie verringert die Notwendigkeit medikamentöser Behandlung und verbessert die Glukosekontrolle: ein wichtiges Ergebnis der Diabetesinterventionsstudie (DIS).

In a period of five years in the diabetes intervention study (DIS), 1,139 diabetics aged 30-55 years, who in a 6-week screening phase had been classified as dietetically manageable, were treated in a controlled randomized study with intensified non-medicamentous basic therapy and--in a double blind trial--with 1,6 g clofibric acid. The essential components of the basic therapy were a fat-modified diet (so-called prudent diet) and recommendations for endurance training. Thus in comparison to the control group we succeeded in performing a ca. 40% decrease of the application of oral antidiabetic drugs. The fasting blood values were, nevertheless, with 155 mg% significantly lower than in the control group (169 mg%). Clofibric acid had no influence neither on the necessity to use insulin or oral antidiabetic drugs nor to the control of glycaemia.

Membrane disordering effects of anesthetics are enhanced by gangliosides.

The effects of anesthetic drugs on lipid order were evaluated by the fluorescence polarization of the probe molecule, 1,6-diphenyl-1,3,5-hexatriene (DPH) incorporated into vesicles of dimyristoylphosphatidylcholine (DMPC) and DMPC with 10 mol% ganglioside (GD1a). Anesthetics (enflurane, chloroform, diethylether, pentobarbital, ethanol, butanol, hexanol) decreased the fluorescence polarization of DPH in vesicles of DMPC, but relatively large concentrations were required. Addition of gangliosides to DMPC enhanced the lipid disordering effects of anesthetics by several fold. The potencies of these anesthetics in decreasing fluorescence polarization of DPH in DMPC-ganglioside was well correlated with their potencies as anesthetics, and significant decreases in fluorescence polarization occurred at pharmacologically relevant concentrations. These results indicate that gangliosides can enhance the sensitivity of membrane lipids to the disordering effects of anesthetics and suggest that the large ganglioside content of the outer leaflet of the lipid bilayer of neuronal membranes may render this membrane region unusually sensitive to anesthetic agents.

Gangliosides enhance the membrane actions of ethanol and pentobarbital.

The physical properties of vesicles containing phosphatidylcholine (PC) and gangliosides were evaluated by the fluorescent probes 1,6-diphenyl-1,3,5-hexatriene, trans- parinarate (probes of the lower acyl regions), and 1-(4- trimethylammoniumphenyl )-6-phenyl-1,3,5-hexatriene (a probe of the glycerol backbone and upper acyl regions). Exposure of PC vesicles to ethanol produced a decrease in polarization of fluorescence of these probes, but large concentrations (200-600 mM) were required. Incorporation of 10 mole% rat brain synaptic gangliosides into the PC vesicles enhanced the effect of ethanol by several-fold. Synaptic gangliosides also enhanced the effect of ethanol on vesicles containing cholesterol in addition to PC. Comparison of mono-, di-, tri-, and asialogangliosides , sphingosine, and sphingomyelin indicated the importance of the oligosaccharide moiety, but not the sialic acid residues, in the enhancement of ethanol action by gangliosides. Variation of assay temperature and the acyl composition of the PC demonstrated that gangliosides increased the effects of ethanol only if the lipids were near the phase transition temperature. Gangliosides also produced a marked enhancement of the effect of pentobarbital on fluorescence polarization of probes in PC vesicles. The membrane partioning of pentobarbital was increased by gangliosides, but it was not clear that this increase in drug concentration in the membrane was sufficient to account for the large change in fluorescence polarization. These results suggest that ganglioside content may be an important determinant of the effects of alcohols and barbiturates on biomembranes. In particular, the high drug sensitivity of neuronal membranes may be related to the enrichment of gangliosides in these membranes.