Escin/diethylammonium salicylate/heparin combination gels for the topical treatment of acute impact injuries: a randomised, double blind, placebo controlled, multicentre study.

OBJECTIVES: To investigate the clinical efficacy and safety of escin-containing gels in the topical treatment of blunt impact injuries. METHODS: Competitors in soccer, handball, or karate competitions were enrolled within two hours of sustaining a strain, sprain, or contusion and treated three times with the trial gel within a period of eight hours. Patients were randomised to three parallel groups consisting of two active treatment gels, containing escin (1% or 2%), 5% diethylammonium salicylate, and 5000 IU heparin, or placebo gel. Tenderness produced by pressure was measured at 0 (baseline), 1, 2, 3, 4, 6, and 24 hours after enrollment (within two hours of the injury). Tenderness was defined as the amount of pressure (measured by a calibrated caliper at the centre of the injury) that first produced a pain reaction as reported by the patient. RESULTS: A total of 158 patients were enrolled; 156 were evaluated in the intention to treat analysis. The primary efficacy variable was the area under the curve for tenderness over a six hour period. The gel preparations containing 1% and 2% escin were significantly more effective (a priori ordered hypotheses testing controlling the multiple alpha = 5% significance level) than placebo (p(1) = 0.0001 and p(2) = 0.0002 respectively). The treatment effects were 5.7 kp h/cm(2) (95% confidence interval (CI) 2.9 to 8.5) and 5.9 kilopond (kp) h/cm(2) (95% CI 2.9 to 8.8) between 1% escin and placebo and between 2% escin and placebo respectively. These results were supported by secondary efficacy variables. The time to reach the baseline contralateral tenderness value (resolution of pain) at the injured site was shorter in the treatment groups than in the placebo group (p<0.0001). Both active gel preparations produced more rapid pain relief than the placebo gel. No relevant differences were detected between the two active gels. The safety and tolerability of the escin-containing gels were excellent. CONCLUSIONS: Escin/diethylammonium salicylate/heparin combination gel preparations are effective and safe for the treatment of blunt impact injuries.

Magma storage beneath Axial volcano on the Juan de Fuca mid-ocean ridge.

Axial volcano, which is located near the intersection of the Juan de Fuca ridge and the Cobb-Eickelberg seamount chain beneath the northeast Pacific Ocean, is a locus of volcanic activity thought to be associated with the Cobb hotspot. The volcano rises 700 metres above the ridge, has substantial rift zones extending about 50 kilometres to the north and south, and has erupted as recently as 1998 (ref. 2). Here we present seismological data that constrain the three-dimensional velocity structure beneath the volcano. We image a large low-velocity zone in the crust, consisting of a shallow magma chamber and a more diffuse reservoir in the lower crust, and estimate the total magma volume in the system to be between 5 and 21 km3. This volume is two orders of magnitude larger than the amount of melt emplaced during the most recent eruption (0.1-0.2 km3). We therefore infer that such volcanic events remove only a small portion of the reservoir that they tap, which must accordingly be long-lived compared to the eruption cycle. On the basis of magma flux estimates, we estimate the crustal residence time of melt in the volcanic system to be a few hundred to a few thousand years.

[Sports as a health risk for the locomotor system]. / Sport als Gesundheitsrisiko für das Bewegungssystem.

The analysis of sport injuries commonly takes into account well known external and internal risk factors. This brief review is dealing with some general risks related to emotional and cognitive aspects. It is emphasized that such risks play a major role in developing prevention strategies.

[Typical sports injuries, sports specific risks and comparison with other sources of accidents]. / Typische Sportverletzungen, sportartspezifische Risiken und Vergleich mit anderen Unfallbereichen.

In the discussion of limiting the growth of medical spending there are intentions to exclude the costs of sport injuries from coverage by the public health insurance system. The aim of this study is to analyse typical sport injuries and to compare them with injuries from other fields of accidents and thus to deliver arguments in the discussion of costs in public health system.

Recurrent dislocation of the patella and the Goldthwait operation.

In this study 17 patients with recurrent dislocation of the patella were followed up 10 years after their Goldthwait operation. The subjective and clinical findings were excellent or good in 70%. X-radiographs indicated osteoarthritis of the femoropatellar joint in 60%. Concerning the aetiopathological factors, we found an increased external torsion of the afflicted extremity (measured by computed tomography).

Influence of joint stability on the results of arthroscopic subacromial decompression.

We performed arthroscopic subacromial decompression on 70 patients. Each of them had either type I or type II impingement according to Neer. Sixty-five patients were then observed for a postoperative period of three years. The follow-up checks were performed by ultrasound in order to assess the extent of passive inferior shift of the humeral head, compared with the preoperative stage. A shoulder score of 100 was used as a reference. Whereas the average preoperative score was 58.5 (standard deviation +/- 12.2), postoperative results showed an increased average value of 79.7 (standard deviation +/- 11.4). In twenty cases (31% of all treated patients), the postoperative score was less than 85 points, i.e. treatment had shown no results. Comparing these patients with the other 45 who had a score above 85 points, we noted that the age of patients, the preoperative duration of complaints, the preoperative score and duration of the postoperative stay in hospital were of no relevance to the results. However, among all patients, ultrasound measurements showed significant deviations in the extent of passive inferior shift of the humeral head. Patients in the group with unsuccessful treatment had an average shift value of 5.1 mm. (+/- 2.0 mm), compared with an average value of only 2.4 mm (+/- 0.9 mm) among patients in the successful group. The statistical negative Pearson correlation coefficient of -5.36 between postoperative score and inferior shift of the humeral head is very significant. We conclude that hypermobile glenohumeral joints or unstable joints should not be treated by subacromial decompression in the presence of any subacromial pathology.

[Densitometric studies of the tensile strength of the proximal femur]. / Densitometrische Untersuchungen zur Bruchfestigkeit des proximalen Femur.

The prognostic assessment of the fracture resistance of the proximal femur is of great importance to the age related increasing incidence of femur neck fractures. This is particularly important in sport for the elderly. The statistical relationship between the osteodensitometrically determined bone density and the risk of a femur neck fracture has been shown in epidemiological studies, whereby the determination of bone density at the proximal femur has provided the most precise predictive results. The present investigation determines the direct relationship between bone density and fracture resistance. Twenty isolated femurs were investigated with the DPX-L-system (Lunar) to measure the bone density in three different areas of the metaphysia as well as important morphometric parameters. Subsequently the femora were fractured in a special device which also recorded the forces required for fracture. The statistical analysis showed a high correlation between the fracture forces and the bone density of the femur neck and trochanter regions. This was true to a lesser extent in the Ward triangle. No significant correlation was found to the morphometric parameters. Quite different forces with considerably greater amplitudes can occur in falls. These may also be absorbed by different structures such as muscle tissue, and, therefore not act directly upon the femur neck. Despite these limitations the determination of bone density appears to permit the individual estimation of fracture risk of the femur neck.

[Bone density measurements of the proximal femur in relation to torsion of the femoral neck]. / Die Knochendichtemessung am proximalen Femur in Abhängigkeit von der Torsion des Schenkelhalses.

The DEXA-method allows for bone mineral density measurements of different regions of the skeletal system. It is known that results obtained from the spine with this two-dimensional method may be biased in cases of spondylosis, spondylarthritis, and compression fractures; similarly biased results can be expected at the proximal femur due to morphometric peculiarities. The influence of anteversion and rotation of the femoral neck has been investigated in the present study. The results indicate that errors due to rotation as occurring in incorrect positioning or in arthrogenic variabilities mainly have effects on measurements of Ward's triangle: The average measurement error at 20 degrees external rotation amounts to 33.8% with a maximum of 66.5%. Measurements of the trochanteric region and of femoral neck region show a variation of 6.2% and 9.7%, respectively.

[5-10-year results with the straight-shaft Müller prosthesis]. / 5-10 Jahres-Ergebnisse mit der Müller-Gradschaftprothese.

103 patients with 106 Müller straight stem prostheses could be evaluated clinically and radiologically after an average follow-up period of 6.8 years (range 5 to 10 ys.). Although until now no revision for aseptic loosening has become necessary 3 p.c. of the stems and 11 p.c. of the acetabular components showed radiological loosening. The clinical results were rated as satisfactory. After surgery 67 p.c. of the patients were completely painfree, 28 p.c. still had slight pain, 4 p.c. moderate and 1 p.c. severe pain. The investigation concentrated particularly on radiographic changes of the interface of the femur. Whereas radiolucency typically was non-progressive and located in the proximal part of the femur we found an increasing atrophy of the cortical bone on the calcar. Moreover, we found a continuous and increasing subsidence of the stem during the whole period of observation. At the time of follow up 56 p.c. of the straight stems had subsided about 2 mm and more. Calcar atrophy and radiolucency were significantly less present in femurs with a tapered medullary canal than in those with a cylindrical shape.

[Results of histological studies of the flexor tendon sheath in 35 flexor tenosynovectomies in carpal tunnel syndrome]. / Histologische Untersuchungsergebnisse des Beugesehnengleitgewebes von 35 Beugesehnensynovektomien beim Karpaltunnelsyndrom.

This paper presents the results of histologic studies conducted in the context of tenosynovectomy of the flexor tendons to treat carpal tunnel syndrome. The most common findings were inflammatory changes of the synovial sheath, vascular pathology and fibrous changes of the connective tissue.

[Total i.v. anesthesia with S-(+)-ketamine in orthopedic geriatric surgery. Endocrine stress reaction, hemodynamics and recovery]. / TIVA mit S-(+)-Ketamin in der orthopädischen Alterschirurgie. Endokrine Stressreaktion, Kreislauf- und Aufwachverhalten.

UNLABELLED: Clinically-used ketamine is a racemic mixture of two isomers, S-(+)- and R-(-)-ketamine. Previous investigations showed the anaesthetic potency of S(+)-ketamine to be three times higher than that of R-(-)-ketamine. It was the aim of this study to compare the effects of S-(+)-ketamine and racemic ketamine on endocrine and cardiovascular parameters, recovery, and side effects in geriatric patients during total intravenous anaesthesia (TIVA) for orthopaedic surgery. METHODS: Forty patients over 60 years of age scheduled for elective hip or knee replacement were investigated in a double-blind, randomised design. For induction of TIVA, patients received 0.1 mg midazolam, 0.5 mg atropine, 1 mg/kg S(+)-ketamine or 2 mg/kg racemic ketamine, respectively, 2 mg vecuronium, and 1.5 mg/kg suxamethonium. After intubation and relaxation with a total dose of 0.1 mg/kg vecuronium, a continuous infusion of 2 mg/kg per hour S-(+)- or 4 mg/kg per hour racemic ketamine was administered throughout surgery. Blood samples were taken through a central venous catheter at seven time-points, before induction as well during and after surgery, until the 1st postoperative morning for analysis of adrenaline, noradrenaline (by high-pressure liquid chromatography with electrochemical detection), anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), cortisol (by radioimmunoassay), glucose, and lactate. In addition, systolic arterial pressure (SAP), heart rate (HR), and arterial oxygen saturation were measured, and the time intervals between the end of ketamine infusion and the return of consciousness and orientation were protocolled. The incidence and assessment of dreams and other side effects were reported by the patients. RESULTS: Biometric data of the groups were comparable, the mean age of both groups being 68 years. Plasma adrenaline, noradrenaline, ADH, ACTH, cortisol, and glucose as well as SAP and HR increased significantly (P < 0.05) during the course of anaesthesia. The influence on lactate levels was not significant. There were no differences between S(+)- and racemic ketamine with respect to these parameters. Three patients in the ketamine-racemate group showed severe arterial hypertension and were withdrawn from the study. Recovery clearly improved after administration of S(+)-ketamine compared to the racemate. Simple orders were followed after 2.0 +/- 3.4 versus 4.9 +/- 6.8 min (P = 0.07), orientation with respect to person returned after 5.7 +/- 4.0 versus 14.6 +/- 10.0 min (P < 0.001) and spatial orientation after 8.2 +/- 5.4 versus 17.4 +/- 9.7 min (P < 0.001). After racemic ketamine, 1 patient remembered a negative dream and 1 patient a positive dream. In the S(+)-group, 1 positive dream was reported. No intraoperative awareness was reported, and all patients would accept the same anaesthesia again. CONCLUSIONS: Increases in cardiovascular parameters and insufficient reduction of the stress response with respect to ADH, ACTH, and cortisol seem to require a more potent hypnotic element during TIVA with ketamine. With regard to endocrine and cardiovascular parameters, the pharmacodynamic effects of racemic and S-(+)-ketamine were comparable. Because of the significant improvement in recovery and the reduced quantitative drug load, S-(+)-ketamine offers a clinical advantage compared with currently used racemic ketamine.

[Results of studies of surgically treated carpal tunnel syndrome with obligate tenosynovectomy of the flexor tendons]. / Untersuchungsergebnisse beim operativ behandelten Karpaltunnelsyndrom mit obligater Tenosynovialektomie der Beugesehnen.

The authors present a follow-up of thirty five patients with carpal tunnel syndrome, who had undergone surgical treatment including synovialectomy of the flexor tendons. Beyond the clinical findings, pre- and postoperative comparison of the electromyograms, conduction velocities and an exact analysis of the lipid disorders were studied. These findings and the results of the histological analysis of the tenosynovial membrane are evaluated with special regard to the etiology of the carpal tunnel syndrome.

Range of motion after total condylar knee arthroplasty.

In this study the function of the knee measured at a medium-follow-up of 5-6 years was correlated with influencing factors concerning the implant of total condylar knee prosthesis in 90 patients. The only variable affecting postoperative extension was the preoperative range of extension whereas postoperative flexion was influenced by the preoperative flexion, valgus deviation of the preoperative AP tibial-femoral angle, position of the patella, and thickness of the resection of the distal femur cut.

[Habitual patella dislocation and Goldthwait's surgery]. / Habituelle Patellaluxation und Operation nach Goldthwait.

In this study 17 patients with recurrent dislocation of the patella were followed up 10 years after Goldthwait-operation. The subjective and clinical findings were excellent rsp. good in 70%, whereas the x-ray findings showed osteoarthritis of the femoropatellar joint in 60%. Concerning the aetiopathological factors we found an increased external torsion of the afflicted extremity measured by computed tomography.

[Transverse skeletal axes of the lower extremity in coxarthrosis]. / Transversale Skelettachsen der unteren Extremität bei Coxarthrose.

Femoral anteversion, anteversion of the acetabulum and tibial torsion of 47 patients with idiopathic osteoarthritis of the hip were determined by computerized tomography. From all these parameters only the anteversion of the acetabulum showed differing values in hips with and without osteoarthritis. There was a considerable range at the individual measured values in all parameters and differences between the male and female groups could be found in femoral anteversion and anteversion of the acetabulum.

[Calcareous tendinitis--special forms of the upper extremities. Clinical aspects and differential diagnosis]. / Tendinosis calcarea--Sonderformen an der oberen Extremität. Klinik und Differentialdiagnose.

Calcifying tendinitis of the shoulder joint is a relatively common condition. Its pathogenesis is well documented in anatomical-pathological terms. The clinical observation of four unusual locations in the upper limb makes us to suspect the same pathological process as in the supraspinatus location. The clinical course of calcifying tendinitis in a typical location is discussed in detail.

[Postoperative dislocation as an early complication of total hip endoprosthesis]. / Die postoperative Luxation als Frühkomplikation der Hüft-TEP.

Basing on 13 dislocations of 215 total hip arthroplasties are presented the characteristics of this complication. All things considered the dislocation following total hip arthroplasty seems to be no serious complication, if there is no severe operation failure and if the necessary treatment consisting in plastic cast immobilisation is performed.

[Results of follow-up of untreated anterior cruciate ligament rupture]. / Nachuntersuchungsergebnisse bei unbehandelter vorderer Kreuzbandruptur.

A series of 90 patients, 85 males and 5 females, all with ACL-ruptures had a follow up between 5 and 12 years. All of them had a primary arthrotomy with or without meniscectomy but in no case an operative repair of the ACL-rupture was done. The most concomitant injury was a torn medial meniscus in 76.3%, a damaged lateral meniscus was found in 17.1%, chondromalacia was seen in 53%, either of tibia, femur or patella. Nearly 60% of the patients could resume their former sports activities in some cases on a lower level, whereas 33% had to change their sport or even had to give up any sport. 75%-80% of the patients with partial or total meniscectomy and 90% of those without meniscectomy estimated the outcome as good or fair. In contrast to this 61% rsp. 86% of the patients with partial or total meniscectomy had an osteoarthritis of grade III and IV, patients without meniscectomy in only 23%.