[Radiosurgery and fractionated stereotactic radiotherapy of vestibular schwannoma]. / Radiochirurgie und fraktionierte stereotaktische Radiotherapie des Vestibularisschwannoms.

Management of vestibular schwannoma (VS) should always be interdisciplinary and results better than the natural course. Particularly in small VS, either microsurgical resection or radiosurgery (RS) can be employed. RS is a special method (initially only possible stereotactically) for delivering high-precision radiation from many directions to the target point (the isocenter) in a single high dose. With the development of three different systems-Gamma Knife (Elekta, Stockholm, Sweden), special linear accelerators, and CyberKnife (Accuray, Sunnyvale, CA, USA)-the options were extended to 1-5 fractions for RS and multisession RS (msRS), and to up to 6 weeks of conventional fractionation as stereotactic radiotherapy (SRT). Whereas RS uses high ablative single doses, SRT is based on the well-known radiobiological effects of multiple fractions comprising lower single doses up to a required much higher total dose. Evaluation showed that RS and SRT achieve similarly high rates of tumor control of around 90% and low rates of side effects (1-7%). Therefore, SRT is unnecessary for small but clearly progressing VS, which has made RS a very comfortable, effective treatment option. In addition to SRT, larger VS can be treated comparably effectively with CyberKnife-based msRS. Since modern MRI frequently discovers small VS as "incidental findings", the initial biding strategy (wait and scan) is of particular importance. Only with increasing symptoms and detectable tumor growth is the treatment indication established, at which time the decision for surgery and RS/SRT should be taken interdisciplinary under consideration of the patient's wishes.

[Controlled reperfusion of the extremities for preventing local and systemic damage after prolonged ischemia. An experimental study with the swine model]. / Kontrollierte Extremitäten-Reperfusion zur Verminderung lokaler und systemischer Schäden nach mehrstündiger Ischämie. Eine experimentelle Studie am Schweinemodell.

Our previous studies in isolated rat hindlimbs using crystalloid perfusion solutions have shown that control of the initial reperfusion reduces postischemic complications. However, no experimental study has been undertaken to evaluate the concept of controlled limb reperfusion experimentally in an in-vivo blood-perfused model and to assess the local as well as systemic effects of normal blood reperfusion and controlled limb reperfusion. Of twenty pigs undergoing preparation of the infrarenal aorta and iliac arteries, six were observed for 7.5 hours and served as controls. Fourteen other pigs underwent 6 hours of complete infrarenal occlusion. Thereafter, embolectomy was stimulated in 8 pigs by removing the aortic clamp and establishing normal blood reperfusion at systemic pressure. In 6 other pigs, control of the composition of the reperfusate and control of the conditions of reperfusion was done during the first 30 min, followed by normal blood reperfusion. Six hours of infrarenal aortic occlusion lead to a severe decrease in high energy phosphates and muscle temperature and a slight increase in creating kinase (CK) and potassium in the systemic circulation. Normal blood reperfusion resulted in severe reperfusion injury: massive edema developed (80.6% vs. 76.6%, p < 0.0009), the tissue showed a marked decrease in oxygen consumption (7.3 +/- 1.1 vs. 14.3 +/- 2.5 mL )2/100 g/min, p < 0.02), glucose consumption (0.19 +/- 0.06 vs. 0.51 +/- 0.03 mg/100 g/min, p < 0.06), tissue ATP (18.3 +/- 1.9 vs. 36.1 +/- 0.9 mumol/g protein, p < 0.000001), total adenine nucleotides (26.3 +/- 2.6 vs. 45.8 +/- 1.5 mumol/g protein, p < 0.00001), muscle pH (5.9 +/- 0.1 vs. 7.3 +/- 0.1, p < 0.000006) and total calcium in the femoral vein (2. +/- 0.1 vs. 2.7 +/- 0.1 mmol/L, p < 0.002). Furthermore, a massive increase was seen in CK concentration (12,743 +/- 2,562 vs. 513 +/- 80 U/L, p < 0.0003), potassium (7.9 +/- 0.3 vs. 4.4 +/- 0.2 mmol/L, p < 0.000001) and muscle rigidity (60 +/- 11 vs. 122 +/- 1 degree, p < 0.00008). In sharp contrast, initial treatment of the ischemic skeletal muscle by controlled limb reperfusion resulted in normal water content (77.6 +/- 0.4 vs. 76.8 +/- 0.3%), oxygen consumption (13.2 +/- 1.6 vs. 14.9 +/- 3.2 mL O2/100 g/min), glucose consumption (0.58 +/- 0.18 vs. 0.46 +/- 0.11 mg/100 g/min), flow (5.4 +/- 1.1 vs. 4.6 +/- 4.6 +/- 0.5 mL/100 g/min) and muscle rigidity (106 +/- 4 vs. 122 +/- 1 degree). Furthermore, controlled limb reperfusion resulted in higher total adenine nucleotides content (78% vs. 57% of control), less tissue acidosis (6.6 +/- 0.2 vs. 5.9 +/- 0.1, p < 0.002), severely reduced CK release (2,618 +/- 702 vs. 12,743 +/- 2.562, p < 0.02) and potassium release (5.1 +/- 0.3 vs. 7.9 +/- 0.3 mmol/L, p < 0.0002) as compared to normal blood reperfusion. In conclusion this study shows that 6 hours of acute infrarenal aortic occlusion will result in a severe reperfusion injury (postischemic syndrome) if normal blood at systemic pressure is given in the initial reperfusion phase. In contrast, initial treatment of the ischemic skeletal muscle by controlled limb reperfusion reduces the metabolic, functional and biochemical alterations.

Reperfusion injury in skeletal muscle: controlled limb reperfusion reduces local and systemic complications after prolonged ischaemia.

Previous studies in isolated limbs using crystalloid perfusion solutions have shown that control of the initial reperfusion reduces postischaemic complications. However, no experimental study has been undertaken to evaluate the concept of controlled limb reperfusion experimentally in an in vivo blood-perfused model and to assess the local as well as systemic effects of normal blood reperfusion and controlled limb reperfusion. Of 20 pigs undergoing preparation of the infrarenal aorta and iliac arteries, six were observed for 7.5 h and served as controls; 14 others underwent 6 h of complete infrarenal occlusion. Thereafter, embolectomy was simulated in eight pigs by removing the aortic clamp and establishing normal blood reperfusion at systemic pressure. In six other pigs, the composition of the reperfusate and the conditions of reperfusion were controlled during the first 30 min, followed by normal blood reperfusion. Some 6 h of infrarenal aortic occlusion leads to a severe decrease in high-energy phosphates and muscle temperature, together with a slight increase in creatine kinase and potassium in the systemic circulation. Normal blood reperfusion resulted in severe reperfusion injury: massive oedema developed, the tissue showed a marked decrease in oxygen consumption, glucose consumption, tissue ATP, total adenine nucleotides, muscle pH and total calcium in the femoral vein. Furthermore, a massive increase was seen in plasma creatine kinase concentration and potassium, together with the development of muscle rigidity. In sharp contrast, initial treatment of the ischaemic skeletal muscle by controlled limb reperfusion resulted in normal water content, oxygen consumption, glucose consumption, flow and muscle rigidity. Furthermore, controlled limb reperfusion resulted in higher total adenine nucleotides content, less tissue acidosis, markedly reduced creatine kinase release, and potassium release as compared with that of normal blood reperfusion. This study shows that 6 h of acute infrarenal aortic occlusion will result in severe reperfusion injury (postischaemic syndrome) if normal blood at systemic pressure is given in the initial reperfusion phase. In contrast, initial treatment of the ischaemic skeletal muscle by controlled limb reperfusion reduces the metabolic, functional and biochemical alterations.

Emesis induced in domestic pigs: a new experimental tool for detection of antiemetic drugs and for evaluation of emetogenic potential of new anticancer agents.

The domestic pig was used to develop a new model for evaluating the emetogenic potential of anticancer drugs and determining the antiemetic activity of drugs. Emesis was characterized by expulsion of solid or liquid material. In each animal, the number of vomits after infusion of the emetogenic drug (infusion in ketamine and xylazine anesthesia) was recorded in 1-hr periods during the first 4 hr and then in a 4- and a 16-hr period. Intravenous infusion of cisplatin caused a concentration-dependent emetic response. Anti-cancer drugs other than cisplatin such as carboplatin, dactinomycin, cyclophosphamide, and ifosfamide, also induced emesis, indicating that the domestic pig is suitable to detect the emetogenic potential of chemotherapeutic agents. A cisplatin dose of 2 mg/kg i.v. proved to be most suitable for studying the effect of potential antiemetic drugs (applied as i.v. injection), because this cisplatin dose caused consistent emetic responses without other toxic signs in the 24 hr following its infusion. Emesis induced by cisplatin was reduced by high doses of metoclopramide (25 mg/pig; approximately 0.8 mg/kg). The more selective dopamine D2 receptor antagonists, alizapride and domperidone, even at high doses (25-50 mg/pig; approximately 0.8-1.6 mg/kg), did not inhibit cisplatin-induced emesis, nor did haloperidol up to 20 mg/pig (approximately 0.6 mg/kg). Sulpride (50 mg/pig; approximately 1.6 mg/kg) halved the occurrence of vomits in the first 4 hr after cisplatin, but this effect was followed by an increase in the frequency of vomits; thus, no change in the total number of vomits was observed in the 24-hr observation period.(ABSTRACT TRUNCATED AT 250 WORDS)

[Static and dynamic infrared thermometry and thermography in malignant melanoma of the uvea and conjunctiva]. / Statische und dynamische Infrarotthermometrie und -thermographie beim malignen Melanom der Uvea und Konjunktiva.

BACKGROUND: Thermometry and -graphy prove asymmetries of the circulation. Contact-free thermometry of the cornea is applied to find out whether this method can contribute to differential diagnosis of ocular melanomas. MATERIALS AND METHODS: Under standardized conditions the temperature of the cornea was measured in 30 patients with malignant melanoma of the choroid and the conjunctiva and 35 healthy subjects. The instruments were a handpyrometer (HPM, Messgerätewerk, Magdeburg) and the thermovision camera of AGA Infrared System, Sweden, with dynamic recording in colour. RESULTS: In healthy subjects there are no significant asymmetries in temperature under standardized conditions. The temperature of the cornea is elevated in both malignant melanomas of the choroid and the conjunctiva. CONCLUSIONS: Thermometry and -graphy of the cornea can contribute to the differentiation of malignant ocular melanomas from other ophthalmological diseases. They are also suited in long term observation of the course of the melanomas.

Protective property of azelastine against histamine challenge of rhinal mucosa in domestic pigs.

In anaesthetized domestic pigs a filter paper sampling technique was applied to estimate basal and histamine induced nasal secretion. Histamine (0.2 mg/nostril) increased secretion more than twofold, a dose of 2 mg/nostril more than 10 fold. Intranasally instilled azelastine (A-5610, CAS 58581-89-8) prevented this histamine induced rhinorrhea without reduction of basal secretion. The protective effect remained for more than 2 h even when histamine challenge was repeated.

Influence of various adrenergic compounds on plasma potassium levels in conscious dogs and anaesthetized domestic pigs.

The influence of various compounds with affinity to beta-adrenoceptors on plasma potassium levels was investigated in conscious dogs and anaesthetized pigs. There was a marked fall, amounting to about 1 mmol/l following salbutamol and pirbuterol but nearly no effect following dobutamine and xamoterol. In dogs the hypokalaemic effect of salbutamol was augmented when prazosin was additionally applied. It is concluded, that the plasma potassium level is reduced mainly by beta 2-adrenoceptor stimulation. Blocking of alpha-adrenoceptors enhanced this effect and should therefore be avoided when beta 2-agonists are used therapeutically.

Pediatric update #9. Revision surgery in congenital dislocation of the hip.

Of 759 dislocated hips operated on in our department, 667 received their primary treatment in our hands, while 92 were revised by us after failure of primary surgery. In 71 hips, reconstructive operations were possible, whereas in 21, the joint was destroyed beyond any possibility of repair and a total hip replacement was performed. The reconstructive operations included 16 reopen reductions, five Colonna arthroplasties, six varization derotations, four open reductions and derotations, two valgization osteotomies, and 38 combined procedures. The latter included a shortening varization derotation osteotomy with an open reduction and a Chiari osteotomy of the pelvis. All the revised cases were improved in comparison with their functional status prior to revision. Of the 71 reconstructed joints, the result was good in 59. In the remaining 12, function was improved as compared with the preoperative status, but a total hip replacement will most probably be required in the future. Revision surgery after failure of previous operations for congenital dislocation of the hip can always improve function, but can rarely result in a normal joint. Primary operations should be performed with maximum caution, and it is certainly better to leave limping pain-free children alone than to transform them into limping children in pain.

Congenital dislocation of the hip treated by total hip arthroplasty.

Thirty-two total hip arthroplasties (THAs) were performed on 26 severely incapacitated patients with congenital dislocation of the hip. The arthroplasty technique varied with the problems encountered, but the cup was always placed in the true acetabulum. In 19 cases, femoral head autografts were transplanted. The overall results were satisfactory. Roentgenologic evaluation of the bone grafts showed no nonunion or secondary displacement. Nineteen previously invalid patients now lead normal lives. Five patients are minimally incapacitated and only two were unimproved by the operation. THA with autogeneic grafts to deepen the acetabulum is recommended whenever a congenital dislocation of the hip in an adult is associated with severe pain.

Spondylothoracic dysplasia. A report of ten cases with follow-up.

Details of ten new cases of spondylothoracic dysplasia (the Jarcho-Levin syndrome) are presented. During follow-up, lasting between 8 and 21 years, two children in this group died. Our observations did not confirm Heilbronner's theory concerning the existence of two distinctive types of this syndrome: Type 1 or fatal, and Type 2, with a normal longevity. From the two illustrative cases presented in some detail, and the pertinent literature review, familiarity with spondylothoracic dysplasia is necessary in order to avoid an unjustifiably pessimistic prognosis and to permit correct parent counseling.

Popliteal pterygium syndrome.

Popliteal pterygium syndrome is rare, with 50 cases described in the literature. Three additional cases are reported. The syndrome includes a popliteal web extending from the ischium to the heel associated with toenail dysplasia, eventual deformities of the foot and toes, and oral cavity abnormalities, such as cleft palate or lip pits. The main orthopedic problem is a severe flexion contracture of the knee and an equinus foot. Surgical treatment consists of resection of the web. A technical problem emerges on liberating or reconstructing the sciatic nerve or its branches, which are sometimes included within the contracted cord.

Radical wedge resection for ingrown toenail: long-term results.

This paper describes an operation for ingrown toenail that is simple, has a low recurrence rate, leaves patients with an intact, pain-free, cosmetically acceptable nail-bearing toe, and permits the wearing of normal shoes within a short period of time. Among the numerous techniques devised for the treatment of ingrown toenail, no other operation fulfills all of these criteria. It is usual to sacrifice appearance in the hope of cure. During the last 20 years we have adopted a radical wedge resection that has the advantage of resulting in permanent healing and a good-looking toe. After a first series of 67 cases thus treated without a single recurrence, the technique was used in a further series of 339 cases reported here.

External fixation for fractures and pedicle flap immobilization: a convenient and inexpensive substitute.

A simple, inexpensive, broadly applicable, and quickly applied substitute for the Hoffman apparatus is demonstrated. The procedure uses materials commonly available in hospital operating rooms and provides an excellent immobilization of transosseous pins in pedicled flap surgery and various open and closed fractures of long bones.

Salvage operations for failure of previous surgery in congenital dislocation of the hip.

Salvage operations for failure of previous surgery were performed on 27 children with 35 congenitally dislocated hips. In two children with rigid joints, surgery was limited to the correction of flexion contracture and of fixed pelvic obliquity. In all cases where the affected hip was mobile, concentric reduction and good coverage were obtained. In difficult cases, a combined operation including femoral shortening, open reduction, varization derotation, and a Chiari osteotomy gave satisfactory results.