Bilateraler Funktionsverlust der Quadrizepsmuskulatur nach einseitiger Kreuzbandruptur mit Begleitverletzung durch zentrales Aktivierungsdefizit

Ziel der Studie war es zu untersuchen, in welchem Ausma? ein Defizit der willkürlichen Aktivierbarkeit des M. quadriceps bei schweren Knieverletzungen vorliegt und welchen Einfluss ein Aktivierungsdefizit auf die Muskelfunktion hat. Untersucht wurden 33 m?nnliche Patienten nach Rupturen des vorderen Kreuzbandes (VKB) mit Begleitverletzungen der Kniegelenke im Vergleich zu 22 Patienten mit einer isolierten VKB-Ruptur und einem altersangepassten gesunden Kontrollkollektiv. Mit einer sensitiven Twitch-Interpolationsmethode wurde die isometrische Maximalkraft des M. quadriceps und die F?higkeit der Probanden, die Quadrizepsmuskulatur willentlich zu aktivieren, bestimmt.     

Bilateraler Hydrothorax mit Hydromediastinum nach akzidenteller Katheterdislokation

We report a complication during the insertion time of a central venous catheter in a patient with intracerebral bleeding. This complication was caused by an inadvertent dislocation of a subclavian catheter. Hydromediastinum and bilateral hydrothorax developed. There was a clear diagnosis followed by removal of the central venous catheter after radiological investigations could explain the cause of the complication and the clinical symptoms. In the course of events mediastinitis was diagnosed. The clinical condition improved under antibiotic therapy. The patient could be transferred to another clinical unit for endovascular treatment of an arterio-venous cerebral malformation.     

Ösophagusperforation durch Osteosynthesematerial nach ventraler Spondylodese der HWS

Esophageal perforation after cervical spine surgery is a rare complication. Based on the case of a 77-year-old female patient with a late, asymptomatic esophageal perforation after a ventral spondylodesis of the cervical spine, the symptoms, diagnostics, and therapy of this complication are discussed. The therapy of choice is the operation. Nonoperative therapy should only be chosen – like in our case – for special indications. An esophageal perforation with symptoms should be treated operatively. Our patient was treated conservatively in consideration of her age and missing symptoms.     

Kostensenkung durch Dekontamination zur Prävention der Nahtinsuffizienz nach Gastrektomie

Zusammenfassung. Es war Ziel der Untersuchung, den Einflu? der Dekontamination im Vergleich zu einer Placebomedikation auf die postoperativen Behandlungskosten nach Gastrektomie zu ermitteln. Die Ergebnisse einer prospektiv doppelblind angelegten und placebokontrollierten Multicenterstudie zeigen, da? eine perioperative i. v.-Prophylaxe mit Cefotaxim und eine topische Dekontamination mit Polymyxin B, Tobramycin, Vancomycin und Amphotericin B in der Pr?vention oesophagojejunaler Anastomoseninsuffizienzen h?chst wirksam ist. Beim Kostenvergleich der beiden Gruppen wurden nur dem Studienprotokoll entsprechend dekontaminierte Patienten (n = 90) den mit Placebo behandelten (n = 103) gegenüber gestellt, weil der Einflu? der Dekontamination auf die Behandlungskosten ermittelt werden sollte. Die oesophagojejunale Nahtinsuffizienzrate betrug 10,6 % bei Placebopatienten (n = 103) und konnte unter Dekontamination (n = 90) hochsignifikant auf 1,1 % reduziert werden (p = 0,0061; Fisher-exact-Test, 2-tailed). Es konnte nur eine asymptomatische Anastomoseninsuffizienz im Gastrografinschluck nachgewiesen werden. Auch die Lungeninfektions- (p = 0,0173) und Gesamtkomplikationsrate (p = 0,0238) waren in der Gruppe der Dekontaminierten signifikant reduziert. Im Beobachtungszeitraum verstarben 9 (8,7 %) der Placebopatienten und 3 (3,3 %) der Dekontaminierten. Die Kostenermittlung umfa?te die orale Prophylaxe, Pflegekosten der Normal- und Intensivstation, Nachsorgeklinik, Antibiotica sowie Reoperationen und Interventionen. Sie beschr?nkte sich ausschlie?lich auf die ersten 42 postoperativen Tage. Die Gesamtkosten der Placebogruppe beliefen sich pro Patient auf 20 000,– DM. Die durchschnittlichen Gesamtkosten pro Patient betrugen in der Prophylaxengruppe dagegen nur 16 200,– DM, weil signifikant weniger Patienten für kürzere Zeitr?ume intensivmedizinisch behandelt werden mu?ten (p = 0,0082), signifikant weniger Patienten antibiotisch therapiert (p = 0,0232) wurden und die Anzahl der Patienten mit Reoperationen und Reinterventionen geringer war als in der Placebogruppe (p = 0,0909). Die Durchführung einer Prophylaxe zum Preis von 400,– DM senkte die postoperativen Behandlungskosten um 3800,– DM oder 19 %. Die Prophylaxe kann empfohlen werden, weil sie die Morbidit?t, die Letalit?t und die Kosten der Gastrektomie senkt.      

Weichteilrekonstruktion nach Skalpierungsverletzung durch Hundebiss

The reconstruction of soft-tissue damage on the part of the head which is covered with hair is aimed not only at repairing the damage in such a way that it will withstand mechanical strain but also at the restoring the hair on the scalp. In a 5-year-old boy with a scalping injury involving second- and third-degree soft-tissue damage over an area of 20 x 12 cm after a dog bite, surgery was initially performed to transform the damage into purely second-degree damage, which was then repaired with a split skin graft. One year later, the scalp containing the hair was stretched with the aid of two skin expanders over a period of 3 months, so that the split skin graft area could be removed and the hair on the scalp restored.     

Analgesie durch intraartikuläres Morphin nach Kniegelenksarthroskopien? Eine doppelblinde,randomisierte Studie mit patientenkontrollierter Analgesie*

Previous studies investigating the peripheral action of locally instilled morphine after arthroscopic knee surgery found evidence for an analgesic effect. Follow-up studies have lead to conflicting results.We used patient-controlled analgesia (PCA) to test the analgesic potency of intraarticular morphine. Methods. Patients undergoing arthroscopic knee surgery under general anaesthesia received, after written informed consent and in double-blind and randomised manner, 1?mg morphine diluted in 10?ml saline either intraarticularly or intravenously at the end of the surgical procedure. A control injection of 10?ml saline was given at the other site. The pain intensity on a visual analogue scale (VAS) and the cumulative morphine consumption were recorded at 1, 2, 3, 4, 6, 8 and 24?h after the end of general anaesthesia. Statistics: Wilcoxon rank sum test with P<0.05. Results. A total of 59?patients were included in the study; 29 received morphine intraarticularly (verum group), 30 intravenously (control group). There was no difference in gender, age, duration of arthroscopy or anaesthesia. There were more than 60% diagnostic arthroscopies in both groups; other types of surgery were comparable, with the exception of cruciate band repair procedures only in the control group. We found no difference in morphine consumption or pain intensity between the two groups throughout the study period. Median overall consumption of morphine after 24?h was 14?mg in the verum group and 15?mg in the control group, with wide interindividual variation. Pain intensities were remarkably low. The peak pain intensity of both groups was found at 1?h postoperatively, with median 16/100 on the VAS in both groups. Blinding was robust. Conclusion. We found no reduction in postoperative morphine supplementation after 1?mg morphine intraarticularly compared to 1?mg intravenously given at the end of knee arthroscopies. There were also no differences in pain intensities on a VAS. We conclude that titration of postoperative pain with a morphine-filled PCA pump was unable to show a difference in analgesic potency between intraarticular and intravenous morphine.     

Intraabdominale Blutung nach Myokardinfarkt mit kardiopulmonaler Reanimation und Thrombolysetherapie

Adverse effects of resuscitation due to closed-chest cardiac massage are common, and the incidence is increased when an incorrect technique is used. Nevertheless, thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation (CPR). In these patients, the risk of thrombolytic therapy-induced bleeding is immanent. Case reports. Within 9 months, two male patients aged 44 and 52 years were admitted to the intensive care unit after out-of-hospital CPR for myocardial infarction with cardiac arrest. In both cases, thrombolytic therapy was undertaken due to the cardiovascular situation or echocardiographic results. Thrombolytic therapy was successful with regard to the ECG changes, but a few hours later both patients demonstrated increasing cardiovascular instability. After abdominal sonography, intra-abdominal bleeding was suspected. Emergency laparotomy became unavoidable, although the coagulation profile was severely impaired in both patients (Tables 1 and 2). Anaesthetic management was characterised by introduction of central venous and intra-arterial catheters, replacement of volume and oxygen carriers using large-bore IV lines, restoration of coagulation factors with fresh frozen plasma, and the choice of “modified neuroleptanaesthesia” with blood pressure-adjusted, small doses of fentanyl, midazolam, and pancuronium. Intraoperatively, a liver injury due to closed-chest cardiac massage was found in both cases. The postoperative courses were complicated by respiratory problems, which led to prolonged mechanical ventilation, but both patients survived without remarkable neurological deficits. Conclusion. In patients with thrombolytic therapy after CPR and persisting cardio-vascular instability, a resuscitation injury with consequent haemorrhagic shock should be suspected. For diagnosis, chest X-ray films and abdominal and thoracic sonography are useful and practicable, even at the bedside. Anaesthetic management should focus on adequate monitoring, replacement of volume and oxygen carriers, fast restoration of plasma coagulation, and careful, blood pressure-adjusted maintenance of anaesthesia.     

Die Naht der frischen Achillessehnenruptur Vergleich der offenen mit einer perkutanen Nahttechnik

Introduction. The open repair of the acute Achilles' tendon rupture reduces the incidence of rerupture compared with nonsurgical treatment; however, it yields more surgical complications. Early mobilization of the patients improves the postoperative outcome. Percutaneous suture techniques have a low incidence of rerupture and improve the conditions for early mobilization. Methods. This study includes all patients (n=97) with acute subcutaneous rupture of the Achilles' tendon with surgical treatment at the University of Heidelberg from 1992 to 1999. Open surgical repair and postoperative immobilization has been compared with a percutaneous suture technique and postoperative early mobilization. Altogether, 77 patients (80%) have been interviewed and 62 patients (65%) have undergone a clinical examination. Results. There were local complications in 18% of the patients after open repair (n=49) compared with 6% of the patients after percutaneous suture. In both groups there were two patients (4%) who sustained a rerupture. In the control group there were two patients with deep vein thrombosis (4%) and 1 lung embolism (2%). The clinical examination revealed no difference between open and percutaneous repair except for some disturbances in sensitivity of the sural nerve after percutaneous repair. The lower expenditure of therapy in percutaneous versus open sutures show the comparison of the hospitalization rates (29% versus 88%) and the rates of endotracheal anesthesia (53% versus 90%). Conclusion. Percutaneous suture technique for the repair of the Achilles' tendon is a simple and safe surgical procedure which allows early mobilization with a low rerupture rate. Thus this method should be performed as standard procedure for acute subcutaneous rupture of the Achilles' tendon.     

Erfahrungen mit der Kollagenunterspritzung bei der männlichen Streßinkontinenz

Zusammenfassung Neunzehn konsekutive M?nner (Durchschnittsalter 69,5 Jahre; mittlerer Verlaufsbeobachtungszeitraum 12,7 Monate) mit einer Stre?inkontinenz Grad II oder III nach urologischen Eingriffen erhielten im Zeitraum von 4/92–7/95 transurethrale, tiefmuk?se Kollagenunterspritzungen im Bereich des M. sphincter urethrae externus. Bei 58 % der Patienten wurden mindestens 2 Unterspritzungen vorgenommen, wobei die injizierte Kollagenmenge im Mittel 16 ml betrug. Unmittelbar postoperativ waren alle Patienten kontinent; im Nachbeobachtungszeitraum von 3 Monaten kehrten jedoch alle Patienten zur Ausgangsinkontinenz vor Therapie zurück. Es traten keine perioperative Komplikationen auf. Obwohl die Kollagenunterspritzung eine einfache, sichere und komplikationsarme Methode ist, kann dessen Einsatz bei der Behandlung der schweren m?nnlichen Stre?inkontinenz nach den vorliegenden Ergebnissen nicht empfohlen werden.      

Chondroblastom der Patella mit pathologischer Fraktur

Chondroblastoma is a rare benign bone tumor of cartilaginous origin. The typical localization of a chondroblastoma is the epiphysis of long tubular bones--the patella is a very unusual site with an estimated occurrence of 2%. We report a case of a 16-year-old patient with a chondroblastoma of the patella associated with a pathologic fracture. Partial resection of the patella was performed. This is the sixth case in the literature that associates patellar chondroblastoma with fracture.     

Beeinflussung der Pharmakodynamik von Rocuronium durch Cimetidin

Cimetidine is a commonly used H₂-receptor antagonist that has been recommended for the prevention of acid aspiration syndrome and has been shown to potentiate vecuronium-induced neuromuscular block. The present study was designed to investigate the influence of a single IV dose of cimetidine on the neuromuscular effects of rocuronium, an analogue of vecuronium with a short onset time. Methods. Twenty adults aged 18–65 years were included in the study with their informed consent and approval of the Ethics Committee. Following oxazepam premedication, 10 patients were randomly allocated to receive cimetidine 400 mg IV 30 min before anaesthesia. After fentanyl and thiopentone induction, single-twitch stimulation of the ulnar nerve was performed every 10 s. Following stabilisation of control responses, patients received rocuronium 0.6 mg/kg for intubation. Anaesthesia was maintained with enflurane ≤0.8 vol.% (end-tidal) and 65% nitrous oxide. Onset time and recovery times to 25% and 75% of the twitch control values were recorded. Results. Onset and recovery times did not differ between groups. Conclusions. The results of the present study demonstrate that cimetidine does not increase the duration of rocuronium neuromuscular blockade. Inhibition of the cytochrome P450 system or a direct effect at the neuromuscular junction have been suggested as the mechanisms of drug interaction associated with cimetidine. Impairment of hepatic microsomal drug metabolism results in a prolonged duration of action of vecuronium, which appears to be eliminated primarily via the liver. Data on the elimination pathway of rocuronium in humans are not available. The fact that cimetidine does not alter the recovery from rocuronium-induced neuromuscular block confirms a previous suggestion that rocuronium may not be eliminated principally by the liver. A direct effect of cimetidine on the neuromuscular junction could not be confirmed by this study. Therefore, cimetidine can be given as premedication without a risk of prolonged rocuronium block.