Emergency Treatment of Multiply Injured Patients with Unstable Disruption of the Posterior Pelvic Ring by Using the “C–Clamp”

Abstract Purpose: Evaluation of the therapeutic usefulness of the “pelvic C–clamp” (PCC) during emergency treatment of multiply injured patients with unstable disruption of the posterior pelvic ring. Patients and Methods: The data of 28 patients with polytrauma in combination with an unstable fracture of the posterior pelvic ring (average Injury Severity Score [ISS]: 49 points; average Polytrauma Score [PTS]: 41 points) were retrospectively analyzed from the moment they were admitted to the emergency room until 48 h after admittance. The PCC was used immediately for primary stabilization of the pelvis after clinical diagnosis of the unstable pelvic fracture. Main outcome measurements: development of mean blood pressure, development of oxygenation level, period of time until the PCC was placed, number of blood units needed, period of time until circulatory stabilization occurred. Results: The PCC was applied in all cases within an average of 64.7 min after trauma. Seven patients (25%) died within the first 45 min after admission. The surviving patients showed:• an increase in mean blood pressure of 25% 20 min after application of the PCC,• a hemodynamic stabilization 6 h after application of the PCC,• a stabilization of the oxygenation level 6 h after application of the PCC,• a decrease in the number of required blood units 6 h after application of the PCC. Conclusion: The present study shows, that the application of the PCC to critically injured patients with unstable pelvic fractures leads to stabilization of the vital parameters within a short period of time.     

Prof. Dr. Dr. Elmar Esser zum 65. Geburtstag

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Diagnostik und Therapiestrategie bei Weichteilsarkomen

Soft tissue sarcomas (STS) represent a rare entity of all malignant tumors (1%). Thus, an in-depth understanding of multidisciplinary treatment strategies may not be sufficiently present at all operative units. Consecutively, optimal diagnostic and therapeutical pathways may not be applied. Magnetic resonance imaging (MRI) is the procedure of choice in diagnosing STS. Biopsies should be performed in specialized centers. Identification of cytogenetic factors has become more important for the typing and prognosis of STS. Management of STS should employ multimodal treatment concepts (Oncology, Radiotherapy, Surgical Oncology). The decision on whether radiotherapy, chemotherapy or another option is indicated should be taken by an interdisciplinary tumor board, which also determines the sequence of treatment in relation to resection. To obtain sufficient information from histopathologic examination of the resected tumor, a clear and distinct definition of critical margins and topography by the surgeon is essential. Following these concepts, optimal local tumor control associated with resections preserving function and limbs is achieved without impairment of overall prognosis. Tumor resection alone, without previous evaluation and where appropriate adopting multimodal treatment strategies, no longer meets modern standards. After primary treatment is complete, patients have to be enrolled in a standardized follow-up program.     

Optimized and combined T1 and B1 mapping technique for fast and accurate T1 quantification in contrast-enhanced abdominal MRI.

Fast T(1) mapping techniques are a valuable means of quantitatively assessing the distribution and dynamics of intravenously or orally applied paramagnetic contrast agents (CAs) by noninvasive imaging. In this study a fast T(1) mapping technique based on the variable flip angle (VFA) approach was optimized for accurate T(1) quantification in abdominal contrast-enhanced (CE) MRI. Optimization methods were developed to maximize the signal-to-noise ratio (SNR) and ensure effective RF and gradient spoiling, as well as a steady state, for a defined T(1) range of 100-800 ms and a limited acquisition time. We corrected B(1) field inhomogeneities by performing an additional measurement using an optimized fast B(1) mapping technique. High-precision in vitro and abdominal in vivo T(1) maps were successfully generated at a voxel size of 2.8 x 2.8 x 15 mm(3) and a temporal resolution of 2.3 s per T(1) map on 1.5T and 3T MRI systems. The application of the proposed fast T(1) mapping technique in abdominal CE-MRI enables noninvasive quantification of abdominal tissue perfusion and vascular permeability, and offers the possibility of quantitatively assessing dilution, distribution, and mixing processes of labeled solutions or drugs in the gastrointestinal tract.     

Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes.

BACKGROUND: Blue dyes used for lymphatic mapping in sentinel lymph node biopsy cause intraoperative anaphylactic reactions in up to 2.7% of patients. With increasing implementation of this technique, the incidence of anaphylaxis to these dyes can be expected to increase. In the literature, the chemically often unrelated and inconsistently designated dyes have been confused, adding to other inconsistencies in the nomenclature. OBJECTIVE: To demonstrate the nomenclature, chemical and physiologic differences, and allergenicity of the various blue dyes used in a medical context. METHODS: We describe a patient with an intraoperative grade IV anaphylactic reaction to isosulfan blue. Immediate-type hypersensitivity was proved by positive skin test reactions and CD63 expression to isosulfan blue and cross-reactivity to patent blue V. RESULTS: A review of the literature clarified the exact nomenclature of the blue dyes and the possible pitfalls of confusing nomenclature in the context of structurally closely related dyes with different allergenic properties. For the detection of type I hypersensitivity, intracutaneous tests are valuable tools. An IgE-mediated mechanism has been shown recently. In most cases, sensitization exists without known previous exposure in a medical context. This may be due to the widespread use of such dyes in objects of everyday life. Preoperative antiallergic medication use does not prevent anaphylactic reactions but apparently reduces their severity. CONCLUSION: For better comparison and precision, the Chemical Abstracts Service number of the respective dye should always be given.     

Anterior Cruciate Ligament Reconstruction: State of the Art

Abstract The rupture of the Anterior cruciate ligament (ACL) belongs to the most common ligament injuries of the human knee joint. ACL rupture results in an increased anterior translation and internal rotation of the tibia. Untreated knee instability causes a disintegration of the roll and sliding movement and a high incidence of secondary meniscus and chondral damages with consecutive or advanced arthritic changes. For deciding on a conservative or operative therapy, it is necessary to develop a high-risk profile. Elderly, inactive patients without instability symptoms can be treated conservatively; younger, active people and complex ligament injuries should receive an ACL replacement. The goal is to eliminate instability by maintaining the physiological kinematics of the knee. Anterior cruciate ligament may be reconstructed arthroscopically assisted by autologous tendons. Predominantly, hamstring- and bone-patellar-tendon grafts are used. No significant differences in knee laxity, clinically and functionally, were observed between both grafts. Various reconstruction techniques, single- or double-bundle techniques, were described. Successful replacement depends on a correct tunnel placement and reconstruction of the physiological band tension, a sufficient mechanical stability of fixation, an impingement-free range of motion and an adequate rehabilitation. A high degree of patient satisfaction in clinical and functional outcome could be evaluated.     

Increase in the degree of phosphorylation of circulating fibrinogen under thrombolytic therapy with urokinase

Human fibrinogen is phosphorylated in vivo to an equal extent at two positions, one at Ser 3 located on fibrinopeptide A, the other at Ser 345 of the A alpha-chain. As has been shown previously, the degree of phosphorylation of the circulating fibrinogen pool can be determined in vitro from the ratio between the HPLC peaks formed by phosphorylated and non-phosphorylated fibrinopeptide A which has been cleaved from plasma fibrinogen by thrombin or reptilase. Plasma samples were obtained from patients with venous thrombosis undergoing fibrinolytic therapy with urokinase (n = 8). The degree of phosphorylation increased from about 35% before treatment to values between 50% and 70% within 48 hours. It remained at these high levels as long as urokinase was administered and declined slowly thereafter. This behaviour of the degree of phosphorylation of fibrinogen is explained by a model which assumes that fibrinogen is secreted in the phosphorylated form and then dephosphorylated in the circulation by an up to now unidentified phosphatase by first order kinetics. When this system is in steady state, the degree of phosphorylation is about 25% under normal conditions. If the elimination rate of fibrinogen is greatly enhanced by fibrinogenolysis the system will approach a new steady state with a higher degree of phosphorylation, the magnitude of which will depend on the new ratio of dephosphorylation and elimination.     

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