Andreas K. Dacho

Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist)

Summary:Outcome evaluation of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist). Purpose:Scaphoid nonunion or scapholunate ligament instability results in carpal collapse and subsequent arthrosis. These conditions, termed SLAC-wrist and SNAC-wrist, are the most common patterns of arthrosis in the wrist. The purpose of this retrospective study was the evaluation of functional outcomes following midcarpal arthrodesis and of patients’ satisfaction with these outcomes. Methods:Forty-nine patients were reexamined at a mean follow-up time of 47 months. Active range of motion (AROM) was verified with a goniometer; grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0–100) for stress and under resting conditions. Patients’ upper-extremity functioning was captured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Radiographic evaluation of bony consolidation was verified by conventional x-ray. Results:Postoperative AROM was 56% and grip strength was 76% compared with the contralateral side. The DASH score was 29 points. Pain relief was 34% at rest and 31% after stress. Forty-five patients demonstrated bony consolidation in x-ray control. Six patients (12%) further required a total arthrodesis of the wrist because of pain or absence of bony consolidation. Conclusion:Our data demonstrate that midcarpal arthrodesis is a reliable procedure for treating SLAC- and SNAC-wrists in stages II and III and, furthermore, one which preserves some range of motion. Total wrist fusion should only be used in exceptional circumstances.

Transcardiopulmonary thermal dye versus single thermodilution methods for assessment of intrathoracic blood volume and extravascular lung water in major burn resuscitation

The purpose of this study was to compare the approximated values for intrathoracic blood volume (ITBV) and extravascular lung water (EVLW) obtained from a single indicator dilution to the exact data measured by double-indicator dilution. Eighteen patients with an average TBSA of 46.3% (range, 26 to 67%) and an average abbreviated burn severity index of 8.7 (range, 7 to 11) were included into a intraindividual comparative prospective study over a 20-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain both the exact measurements, as well as the estimated values for ITBV and EVLW. Two hundred ninety intraindividually comparative measurements were performed during the first 4 days after the burn injury. A good correlation between both techniques was shown for ITBVI (0.77; P <.01) for the overall measurements. However, the overall bias demonstrated a standard deviation higher than the mean value (-87.4 +/- 136 ml/m2), and precision for the estimated values for ITBVI was poor (-491 to 783 ml/m2). Additional analyses demonstrated a poor but significant correlation for low states of ITBV (r =.37; P <.01), but no significant correlations were found between the techniques for normal and high ITBV states. Thus, the approximated ITBV obtained from single thermodilution should not be used to guide volume therapy in major burn resuscitation. Furthermore, the EVLW is neither suitable for diagnostic use nor for therapeutic decisions because it is calculated on the basis of the poorly estimated values for ITBV in single thermodilution. Transcardiopulmonary single thermodilution is not suitable to assess intrathoracic blood volume and extravascular lung water in burn shock. However, the method is suitable to assess cardiac output and its derived parameters in burn resuscitation as shown in previous studies. It still must be proven whether the exactly measured ITBV obtained from transcardiopulmonary double-indicator dilution is superior to the commonly used parameters to guide major burn resuscitation.

Current Concepts in the Treatment of Scaphoid Fractures

AbstractFractures of the carpus are frequent injuries and typically result from of a fall onto the outstretched hand. Scaphoid fractures are the second most frequent fracture type of the hand (80%). 95% of the patients with acute scaphoid fractures are male, and the average age is approximately 25 years. Conservative treatment of acute scaphoid fractures with immobilization in a plaster cast was the therapy of choice for a long time. Surgical treatment was reserved to severe dislocated fractures only. A progress could be obtained by the principle of intramedullary fixation, whose forerunner is represented by the Herbert screw, and the introduction of cannulated screws guaranteed a continuous improvement. The decision to treat the fracture by surgery requires a clear definition of the fracture type. Therefore, precise radiologic technique is mandatory to detect the fracture and to analyze the pathomorphological circumstances. In order to get an exact classification for the decision on how to proceed, three standard X-ray projections (posteroanterior [PA], lateral and Stecher projection) and a CT scan have to be performed. The most well-known classification has been defined by Herbert & Fisher which combines fracture anatomy, stability and disease history in order to derive prognostic and therapeutic criteria. Also, delayed healings and nonunions are considered. To decide on the adequate treatment, a prerequisite for conservative therapy of acute scaphoid fractures is the anatomic position of the scaphoid. Conservative therapy should be reserved to fracture types, which are stable and heal reliably in the lower-arm plaster cast within 6 weeks. All displaced and unstable acute scaphoid fractures should be operated, and whenever possible, rigid internal fixation should be achieved because of interfragmentary compression. Therefore, several intramedullary implants are available for surgical treatment of acute scaphoid fractures, e. g., Herbert screw, Mini Herbert screw, AO screw (cannulated), Acutrac screw (cannulated), or Twin-fix screw (cannulated). With improved surgical and radiologic techniques, most scaphoid fractures are amenable to minimally invasive fixation. The dorsal approach guarantees a good overview in treating proximal pole fractures. Yet, not all types of fractures can be treated in this way. Severely displaced fractures require the classic open palmar approach. In order to prevent the development of a scaphoid nonunion or an advanced carpal collapse (SNAC-wrist), an early and sufficient diagnostic algorithm is necessary. We recommend internal fixation with a cannulated Herbert screw in B1 and B2 fractures and a Mini Herbert screw in fractures of the proximal third (B3). A2 fractures can be treated conservatively. Early diagnosis and operative treatment will shorten the time off work, minimize the risk of nonunion, and reduce the costs of health care in the long term.

Highly selective A1‐adenosine‐agonist (2‐chloro‐N6‐cyclopentyladenosine) and reduction of flap necrosis in adipocutaneous flaps in rats

The 2‐chloro‐N6‐cyclopentyladenosine (CCPA) was proven to be a protective factor in ischemic reperfusion injury in myocardium and to reduce the infarct size in the heart. The purpose of this study was to determine whether flap necrosis could be reduced by intravenous administration of CCPA.

Der epigastrisch adipokutane Lappen am Tiermodell zur Evaluierung der ischämischen Präkonditionierung

INTRODUCTION Flap necrosis in ear, nose, and throat surgery, especially in high-risk groups, is not rare, but not all of the individual pathophysiological processes are known. The objective of this study was to establish an animal model to determine whether acute ischemic preconditioning, which has been reported to be successful in organ transplantation, will result in enhanced flap survival. METHODS AND MATERIALS Forty-two Wistar rats were divided into three experimental groups. An epigastric adipocutaneous flap, based on both superficial epigastric arteries and veins, was raised. The flap was either raised (control), clamped for 2 h (ischemic), or subjected to ischemia of 30 min, followed by 30 min of reperfusion and another 2 h of induced ischemia (IP). The mean flap necrosis area was assessed in all groups on the 5th postoperative day. RESULTS All animals were doing well on the final day. The average necrosis in the ischemic group was significantly greater than in the control group. No significant superiority in the IP group was demonstrated. CONCLUSION The data show that the experimental animal model is practicable and that additional approaches to ischemic preconditioning should be verified.

Ischemic preconditioning in a rat adipocutaneous flap model

INTRODUCTION Flap necrosis in ear, nose, and throat surgery, especially in high-risk groups, is not rare, but not all of the individual pathophysiological processes are known. The objective of this study was to establish an animal model to determine whether acute ischemic preconditioning, which has been reported to be successful in organ transplantation, will result in enhanced flap survival. METHODS AND MATERIALS Forty-two Wistar rats were divided into three experimental groups. An epigastric adipocutaneous flap, based on both superficial epigastric arteries and veins, was raised. The flap was either raised (control), clamped for 2 h (ischemic), or subjected to ischemia of 30 min, followed by 30 min of reperfusion and another 2 h of induced ischemia (IP). The mean flap necrosis area was assessed in all groups on the 5th postoperative day. RESULTS All animals were doing well on the final day. The average necrosis in the ischemic group was significantly greater than in the control group. No significant superiority in the IP group was demonstrated. CONCLUSION The data show that the experimental animal model is practicable and that additional approaches to ischemic preconditioning should be verified.

Histological effect on the adipocutaneous flap in rats after preconditioning with 2-chloro-N6-cyclopentyladenosine

2‐chloro‐N6‐cyclopentyladenosine (CCPA) was proven to be a protective factor in ischemic reperfusion injury. The purpose of this study was to determine how CCPA would affect the single tissue layers of the adipocutaneous flap.

Der epigastrisch adipokutane Lappen am Tiermodell zur Evaluierung der ischämischen Präkonditionierung@@@Ischemic preconditioning in a rat adipocutaneous flap model

INTRODUCTION Flap necrosis in ear, nose, and throat surgery, especially in high-risk groups, is not rare, but not all of the individual pathophysiological processes are known. The objective of this study was to establish an animal model to determine whether acute ischemic preconditioning, which has been reported to be successful in organ transplantation, will result in enhanced flap survival. METHODS AND MATERIALS Forty-two Wistar rats were divided into three experimental groups. An epigastric adipocutaneous flap, based on both superficial epigastric arteries and veins, was raised. The flap was either raised (control), clamped for 2 h (ischemic), or subjected to ischemia of 30 min, followed by 30 min of reperfusion and another 2 h of induced ischemia (IP). The mean flap necrosis area was assessed in all groups on the 5th postoperative day. RESULTS All animals were doing well on the final day. The average necrosis in the ischemic group was significantly greater than in the control group. No significant superiority in the IP group was demonstrated. CONCLUSION The data show that the experimental animal model is practicable and that additional approaches to ischemic preconditioning should be verified.