[Treatment of fingertip defect injuries with a semiocclusive dressing according to Mennen and Wiese]. / Behandlung von Fingerkuppendefektverletzungen mit dem Semiokklusionsverband nach Mennen und Wiese.

OBJECTIVE: The goal of conservative treatment of fingertip defects is to restore a stable and bulky pulp with recovery of sensitivity and a good skin quality. INDICATIONS: Traumatic defects of the fingertip with or without involvement of the fingernail and/or exposed distal phalanx. CONTRAINDICATIONS: Fractures of the distal phalanx with dislocation or joint involvement, necessitating an osteosynthesis. Allergy to any component of the dressing material. DRESSING TECHNIQUE: Application of a semiocclusive film dressing (polyurethane, bacteria- and waterproof, water vapor permeable). If necessary, debridement of necrotic tissue can precede the first film application. Until complete epithelialization of the defect, the dressing needs to be changed not more than once a week. Thereby, the wound itself must be kept untouched. FURTHER MANAGEMENT: Patients must be encouraged to move all finger joints with the applied dressing. After healing, the new skin is initially protected during heavy loading and shear stress, e.g., by a leather finger glove. RESULTS: Based on the method of Mennen and Wiese [3], 200 fingertip injuries (some having involvement of the fingernail or exposed distal phalanx) healed within 20-30 days. The pulp was bulky remodeled with good skin quality including the "fingerprint", as well as nearly normal sensitivity. Using this method, Quell et al. [5] reported on 42 fingertip injuries healed within 2-6 weeks. All fingers could be used without limitation; these were free of pain, with remodeled "fingerprint" and barely visible scars, regular perspiration and restored sensitivity (two-point discrimination 2-8 mm).

[Treatment of bacterial infection in the interphalangeal joints of the hand]. / Die Behandlung bakterieller Infektionen an den Interphalangealgelenken der Hand.

OBJECTIVE: Radical debridement of joint infection, prevention of further infection-related tissue destruction. INDICATIONS: Septic arthritis of interphalangeal joints in the thumb and fingers. CONTRAINDICATIONS: Extensive soft tissue defects. Severe impairment of blood circulation, finger gangrene. Noncompliance for immobilization or for treatment with external fixator. SURGICAL TECHNIQUE: Arthrotomy and irrigation with isotonic solution. Radical tissue debridement. Joint preservation possible only in the absence of infection-related macroscopic cartilage damage. Otherwise, resection of the articular surfaces and secondary arthrodesis. Insertion of antibiotic-coated devices. Temporary immobilization with external fixator. POSTOPERATIVE MANAGEMENT: Inpatient postoperative treatment with 5-day intravenous administration of a second-generation cephalosporine (e.g., Cefuroxim®) followed by 7-10 days oral application. Adaptation of antibiotics according to antibiogram results. In joint-preserving procedures, radiographs and fixator removal after 4 weeks, active joint mobilization. If joint surfaces were resected, removal of fixator after 6 weeks; arthrodesis under 3-day intravenous broad-band antibiotic prophylaxis. Splint immobilization until consolidation (6-8 weeks). RESULTS: In 10 of 40 patients, the infected joint could be preserved. All infections healed. After an average duration of therapy of 6 (3-11) weeks, 4 individuals were free of complaints, and 6 patients had minor symptoms. Overall range of motion in the affected finger was reduced by 25-50° in 5 patients. All patients could return to work after 6.6 (4-11) weeks. A total of 30 patients were treated with joint resection and external fixator. After 5.6 (4-8) weeks, arthrodesis was performed, leading to consolidation in 29 patients. One patient underwent amputation after 4 months due to delayed gangrene. Treatment duration was 15.7 (7-25) weeks. Eight patients reported no complaints, 14 suffered mild symptoms, 5 had moderate, and 3 had severe symptoms in daily life. In 15 cases, range of motion was diminished by 10-80° in the remaining joints of the affected finger. Patients could return to work after 16.2 (6-28) weeks.

[Intramedullary nail removal in the upper and lower limbs. Should we recommend this operation?]. / Entfernung von Verriegelungsnägeln an der oberen und unteren Extremität. Soll diese Operation generell empfohlen werden?

BACKGROUND: Absolute indications for removing intramedullary locking nails (ILN) are undisputed, but there are also relative indications when implant removal might be discussed. The aim of our study was to evaluate complications of ILN removal in the upper and lower extremities. METHODS: Four hundred sixty (460) patients who underwent interlocking nail removal were reviewed regarding complications after removal of implants in the humerus, femur, or tibia. RESULTS: The most common complications were delayed wound healing and wound infections. For the humerus, the complication rate of implant removals due to absolute indication was 29%, and the rate for removals due to relative indication was 12%. In the forearm, no complications were seen. Patients who underwent ILN removal in the femur or tibia for absolute indication had a 21% complication rate; the complication rate in patients with relative indication was 10%. CONCLUSION: The complication rate of interlocking nail removal is too high to justify such a procedure without clear indication.

[Technical defects of tourniquet manometers]. / Manometerdefekte bei Operationen in Blutsperre oder Blutleere.

The use of a tourniquet causes in 0.013% to 1.15% complications (e.g. delayed wound healing, increased rate of infections, thrombosis, pulmonary embolisms,rhabdomyolysis, and compartment syndromes). The rate of these complications depends on the applied pressure, the duration and the cuff design. Also a technical defect of the pressure gauge can lead to complications. A patient with a peroneal palsy after the use of a tourniquet was referred to the Department for Trauma Surgery of the Medical School of the University of Vienna for medical evidence. As there were no reports in the literature about the occurrence rate of technical defects of tourniquet manometers, we checked all tourniquet pressure gauges used at our clinic. Six from eleven gauges were defect and had to be replaced. To minimize the risk for our patients we recommend to check the calibration of the pressure gauges periodically. With regard to the used pressure rate and duration only different recommendations can be found in literature.

Different intracellular compartmentations of cardiac troponins and myosin heavy chains: a causal connection to their different early release after myocardial damage.

We investigated the net myocardial release of creatine kinase isoenzyme MB (CKMB), myoglobin, cardiac troponin T (cTnT), cardiac troponin I (cTnI), and cardiac beta-type myosin heavy chain (beta-MHC) into the coronary circulation after cardioplegic cardiac arrest in humans. Cardiac markers were measured in paired arterial, central venous, and coronary sinus blood in 19 patients undergoing elective coronary artery bypass grafting (CABG) before aortic cross-clamping and 1, 5, 10, and 20 min after aortic declamping. cTnT and cTnI were released into the coronary sinus in parallel to each other and almost simultaneously to myoglobin and CKMB within 20 min of reperfusion. In contrast, no beta-MHC was released in the same patients during the study period. The average soluble cTnT and cTnI pools in right atrial appendages of 11 patients with right atrial and right ventricular pressures within reference values were comparable and were approximately 8% of total myocardial troponin content. The soluble beta-MHC pool was <0.1% in all patients. Our results demonstrate the impact of the different intracellular compartmention of regulatory and contractile proteins on their early release from damaged myocardium.

Intramural right atrial myocardial hemangioma treated by emergency surgery.

An unusual case of myocardial cavernous hemangioma causing dissection of the right atrial wall is described. A subsequent intramural hematoma presented as an extensive pseudotumor of the heart and was complicated by hematopericardium and tamponade. Tumor resection could be performed successfully. Diagnostic approach, surgical treatment and histopathological findings are presented.

Clinical significance of urinary cyclic guanosine monophosphate in diagnosis of heart failure.

We measured concentrations of guanosine 3',5'-monophosphate (cGMP) in plasma and urine of healthy subjects and patients with congestive heart failure, renal impairment, neoplastic disease, and hepatic cirrhosis. There was no correlation between cGMP concentrations in urine and in plasma. In all patients except those with renal impairment, urinary cGMP concentrations were significantly higher than in healthy persons. Only patients with heart failure or renal impairment showed significantly increased plasma cGMP concentrations. In contrast, cGMP in urine does not relate to the clinically assessed severity of heart failure (New York Heart Association functional classes). Determination of cGMP in plasma results in higher sensitivity and specificity for diagnosing heart failure than measurement of cGMP in urine.

Release of cyclic guanosine monophosphate evaluated as a diagnostic tool in cardiac diseases.

Concentrations of atrial natriuretic peptide (ANP) are increased in plasma of patients with impaired cardiac and renal function. The second messenger of ANP, cyclic guanosine monophosphate (cGMP), is released into the plasma specifically upon stimulation of cells with ANP. Although nitrates can also activate intracellular cGMP synthesis, we detected no increase in plasma cGMP concentrations after infusions of glycerol trinitrate. Because immunoreactive ANP is highly susceptible to degradation and nonspecific influences in blood samples, determinations of ANP require immediate centrifugation and storage of plasma at -20 degrees C. In contrast, we found that cGMP is stable for five days in vitro in blood samples containing EDTA. In 147 healthy blood donors, the upper cutoff value for plasma cGMP was 6.60 nmol/L, not significantly different (P greater than 0.05) from that for 222 patients with disorders other than cardiovascular and renal. In 69 patients with manifest congestive heart failure (NYHA stages II-IV), 65 had increased cGMP values. Using the above cutoff value for cGMP gave diagnostic sensitivity of 94.2% and specificity of 93.7%. Plasma cGMP may thus provide an alternative for routine clinical measurements of ANP in cardiac diseases in the absence of renal disorders.