[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.

[Isolated rupture of the short head of the biceps muscle after a traffic accident]. / Isolierte Ruptur des Caput brevis des Musculus biceps brachii als Folge eines Verkehrsunfalls.

Isolated rupture of the short head of the biceps muscle is a rare injury and only very few cases have been published. This case study describes an isolated, complete, traumatic rupture through the short head of the biceps muscle in a 39-year-old healthy male who was involved in a car accident. We report on the diagnostic and therapeutic measures and compare the procedure with data from the literature.

[Arthroscopic reconstruction of the rotor cuff]. / Die arthroskopische Rotatorenmanschettenrekonstruktion.

Over the last years treatment of rotator cuff tears is evolving gradually from open to complete arthroscopic repair. There had been fast developments in arthroscopic techniques and instruments and there is a better understanding of biomechanical backgrounds. For a good clinical outcome it is not necessary to obtain a watertight closure in all cases but to balance the force couples in the coronal and transverse plane. There is recent discussion regarding the optimum techniques and stitches for cuff reconstruction and resulting developments in this field. To determine the individual reconstruction technique it is crucial to recognize the different tear categories. Based on these findings we are now able to treat nearly every cuff tear arthroscopically, even a retracted massive lesion.

[Treatment of the avulsion of the distal biceps tendon by anatomic reinsertion with suture anchors by using a limited anterior approach--follow-up of 24 patients]. / Die operative Behandlung der frischen distalen Bizepssehnenruptur durch anatomische Reinsertion mittels Fadenankern über einen weichteilschonenden anterioren Zugang - eine prospektive Untersuchung.

Avulsion of the distal biceps tendon is a clear indication of operative therapy. Different techniques have been described. From 10/97 till 4/02 we have treated 25 patients with avulsion of the distal biceps tendon by anatomic reinsertion at the radial tuberosity with suture anchors by using a limited anterior approach. 24 patients underwent a clinical follow-up of at least 3 months, the average follow-up was 15.8 months. All patients were men with a mean age of 46 years (32-64 years). Surgery was performed within 9 days (1-28 days) after trauma. No wound healing complication was observed. 2-3 suture anchors have been used in each patient. After 3 months, most patients reached a free range of motion and full strength with unlimited recreational and professional activity. In three cases (12.5 %) a heterotopic ossification occurred, two of them (8.3 %) underwent surgical revision. In one case (4.2 %) we observed a rerupture after 6 weeks. 6 patients (12.5 %) described an intermittent disturbance of sensitivity in their radial forearm, in two cases (8.3 %) the lack of sensitivity persisted. Each patient would choose the same procedure in case of injury.

Dermatome setting for autografts to cover INTEGRA.

Using the INTEGRA Dermal Regeneration Template requires the outer silastic layer to be replaced with an autograft. We followed the manufacturer's directions for epidermal autografting and frequently obtained shredded, useless grafts, therefore, it seemed important to determine the proper dermatome setting. We evaluated dermatome settings from 0.002 to 0.012 inches. First, with feeler gauges, we verified the dermatome settings. Second, we harvested skin at various dermatome settings and measured the thickness histologically. We found that 1) the dermatome settings are reasonably accurate; 2) harvesting useful sheets at 0.002 and 0.004 inches is virtually impossible; 3) the variability of histologic graft thickness is enormous; and 4) a dermatome setting of 0.006 inches yields useful grafts. We no longer use the term epidermal autografting but rather ultrathin split-thickness grafting. To harvest these grafts, we now merely set the dermatome to 0.006 inches and make whatever midcourse corrections are necessary to obtain translucent grafts.

Adherence regulates macrophage signal transduction and primes tumor necrosis factor production.

While monocyte/macrophage (Mphi) adherence to a matrix is necessary for differentiation and prolonged survival, the effect of adherence on the signaling mechanisms responsible for Mphi activation is unknown. Lipopolysaccharide (LPS) activates Mphi by signaling through members of the mitogen activated protein kinase (MAPK) family thereby inducing transcription of proinflammatory cytokines, such as TNF-alpha. Since adherence has been shown to affect different activities of various myeloid phagocytes, we investigated whether adherence affects intracellular signaling and modulates activation of the Mphi proinflammatory phenotype. We assessed the effect of adherence on activation of rabbit alveolar Mphi by measuring LPS-induced TNF-alpha mRNA and TNF-alpha secreted product in adherent versus nonadherent cells, in vitro. The effect of adherence on LPS-induced activation of MAPK was assessed by western analysis using a dual phosphospecific antibody against p38MAPK, p42,44ERK, and p54SAPK. LPS is known to induce activation of NF-kappaB and AP-1. Modulation of these two transcription factors by LPS under adherent versus nonadherent conditions was evaluated by gel-shift analyses. The results were that adherent cells treated with LPS, 10 ng/mL or 1 microg/ml, elicited a 26- and 132-fold increase, respectively, in TNF-alpha production. Nonadherent cells did not elicit significant TNF-alpha in response to LPS. Adherence alone induced significant ERK and AP-1 activation, but did not stimulate a significant TNF-alpha response and no further activation of ERK and AP-1 was observed with LPS stimulation. Adherence alone did not activate p38MAPK or NF-kappaB, but primed Mphi for an augmented response to LPS in activation of p38, NF-kappaB and in production of TNF-alpha. We conclude that adherence primes Mphi for activation and regulates MAPK signal transduction pathways.

Alcohol (ethanol) inhibits IL-8 and TNF: role of the p38 pathway.

Acute ethanol (EtOH) intoxication has been identified as a risk factor for infectious complications in trauma and burn victims. However, the mechanism of this immune dysfunction has yet to be elucidated. The monocyte/macrophage production of cytokines, in particular IL-8 and TNF-alpha, is critical in the regulation of the acute inflammatory response to infectious challenge. IL-8 is a potent chemoattractant and activator of neutrophils. TNF-alpha, a proinflammatory cytokine, initiates expression of endothelial cell surface adhesion molecules and neutrophil migration. p38, a member of the mitogen-activated protein kinases, plays an important role in mediating intracellular signal transduction in endotoxin-induced inflammatory responses. We examined the effects of LPS and ethanol on p38 activation and the corresponding IL-8 and TNF-alpha production in human mononuclear cells. LPS-induced IL-8 and TNF-alpha production was inhibited in a similar pattern by pretreatment with either EtOH or SB202190 (1 microM), a specific inhibitor of p38 kinase. Western blot analysis, using a dual phospho-specific p38 mitogen-activated protein kinase Ab, demonstrated that EtOH pretreatment inhibited LPS-induced p38 activation. These results demonstrate that alcohol suppresses the normal host immune inflammatory response to LPS. This dysregulation appears to be mediated in part via inhibition of p38 activation. Inhibition of IL-8 and TNF-alpha production by acute EtOH intoxication may inhibit inflammatory focused neutrophil migration and activation and may be a mechanism explaining the increased risk of trauma- and burn-related infections.

[Injury classification and surgical approach in hip dislocations and fractures]. / Verletzungsklassifikationen und operative Zugänge bei Hüftgelenkluxationen und -frakturen.

During the last few decades, traumatic injuries of the hip joint have significantly increased in number, and traffic accidents have also increased. Depending on the speed, direction of the forces and the position of the femur at the moment of impact, different patterns of injury occur. Basically, they are classified as hip dislocations, dislocation fractures and acetabular fractures. These injuries have in common a high rate of concomitant lesions. Several classification systems have been developed for these injuries. Commonly, Stewart and Milford's or Levin's classification is used for dislocations and dislocation fractures. For acetabular fractures, Judet and Letournel's classification and its newer version developed by Helfet (AO classification) are generally accepted. Fractures of the femoral head, though included in these classifications, are typically described by separate classifications like the one presented in 1957 by Pipkin. The multitude of injuries occurring in the hip joint requires vast knowledge of various operative approaches. No single approach exists that would permit the treatment of all injuries in an ideal fashion. Approaches are either considered limited (Kocher-Langenbeck, ilioinguinal iliofemoral) when they permit access only to a restricted segment of the joint, or extended (extended iliofemoral, Maryland, Ruedi) when they allow all-round visualization of the hip joint. The choice of the best approach for an individual patient depends on the type of injury and also on patient variables like age, preexisting disease, and concomitant injuries. The decision is further influenced by the timing of surgery, the kind of fracture stabilization intended and by complications typically seen with certain approaches. The indication for extended procedures is only seen in patients with complex injury patterns involving both the anterior and the posterior column or in delayed cases undergoing surgery more than 3 weeks after trauma. Extended approaches permit excellent visualization of the fracture, but the extent of the soft tissue trauma is reflected in a high rate of postoperative complications. After a phase in which extended procedures were favored, recently a trend towards more limited approaches can be recognized because of their lower complication rate. This is facilitated by modern fracture-reduction methods using indirect techniques.

Injury classifications and operative approaches in hip dislocation and fractures.

During the last few decades, traumatic injuries of the hip joint have significantly increased in number, and traffic accidents have also increased. Depending on the speed, direction of the forces and the position of the femur at the moment of impact, different patterns of injury occur. Basically, they are classified as hip dislocations, dislocation fractures and acetabular fractures. These injuries have in common a high rate of concomitant lesions. Several classification systems have been developed for these injuries. Commonly, Stewart and Milford's or Levin's classification is used for dislocations and dislocation fractures. For acetabular fractures, Judet and Letournel's classification and its newer version developed by Helfet (AO classification) are generally accepted. Fractures of the femoral head, though included in these classifications, are typically described by separate classifications like the one presented in 1957 by Pipkin. The multitude of injuries occuring in the hip joint requires vast knowledge of various operative approaches. No single approach exists that would permit the treatment of all injuries in an ideal fashion. Approaches are either considered limited (Kocher-Langenbeck, ilioinguinal iliofemoral) when they permit access only to a restricted segment of the joint, or extended (extended iliofemoral, Maryland, Ruedi) when they allow all-around visualization of the hip joint. The choice of the best approach for an individual patient depends on the type of injury and also on patient variables like age, preexisting disease, and concomitant injuries. The decision is further influenced by the timing of surgery, the kind of fracture stabilization intended and by complications typically seen with certain approaches. The indication for extended procedures is only seen in patients with complex injury patterns involving both the anterior and the posterior column or in delayed cases undergoing surgery more than 3 weeks after trauma. Extended approaches permit excellent visualization of the fracture, but the extent of the soft tissue trauma is reflected in a high rate of postoperative complications. After a phase in which extended procedures were favored, recently a trend towards more limited approaches can be recognized because of their lower complication rate. This is facilitated by modern fracture-reduction methods using indirect techniques.

Images of evolution: origin of spontaneous RNA replication waves.

Self-replicating molecules set up traveling concentration waves that propagate in an aqueous enzyme solution. The velocity of each wave provides an accurate (+/- 0.1%) noninvasive measure of fitness for the RNA species currently growing in its front. Evolution may be followed from changes in the front velocity, and these differ from wave to wave. Thousands of controlled evolution reactions in traveling waves have been monitored in parallel to obtain quantitative images of the stochastic process of natural selection. An RNA polymerase (RNA-dependent RNA nucleotidyltransferase, EC 2.7.7.6), extracted from bacteria infected by the Q beta RNA virus, catalyzes the replication. The traveling waves that arise spontaneously without added RNA provide a model system for major evolutionary change.

RNA sequencing using fluorescent-labeled dideoxynucleotides and automated fluorescence detection.

Although dideoxy terminated sequencing of RNA, using reverse transcriptase and oligodeoxynucleotide primers, is now a well established method, the accuracy is limited by sequence ambiguities due to unspecific chain termination events. A protocol is described which circumvents these ambiguities by using fluorescence labels tagged to dideoxynucleotides. Only chain terminations caused by dideoxynucleotides were detected while premature terminated cDNA's remain undetectable. In addition, the remaining multiple signals at nucleotide positions can be assigned to sequence heterogeneities within the RNA sequence to be determined.

Traveling waves of in vitro evolving RNA.

Populations of short self-replicating RNA variants have been confined to one side of a reaction-diffusion traveling wave front propagating along thin capillary tubes containing the Q beta viral enzyme. The propagation speed is accurately measurable with a magnitude of about 1 micron/sec, and the wave persists for hundreds of generations (of duration less than 1 min). Evolution of RNA occurs in the wavefront, as established by front velocity changes and gel electrophoresis of samples drawn from along the capillary. The high population numbers (approximately equal to 10(11], their well-characterized biochemistry, their short generation time, and the constant conditions make the system ideal for evolution experiments. Growth is monitored continuously by excitation of an added RNA-sensitive fluorescent dye, ethidium bromide. An analytic expression for the front velocity is derived for the multicomponent kinetic scheme that reduces, for a high RNA-enzyme binding constant, to the Fisher form v = 2 square root of kappa D, where D is the diffusion constant of the complex and kappa is the low-concentration overall replication rate coefficient. The latter is confirmed as the selective value-determining parameter by numerical solution of a two-species system.