Objective: To determine predisposing or prognostic factors and mortality rates of patients with Fournier’s gangrene compared to other necrotizing soft tissue infections (NSTI). Material and Methods: Data of 55 intensive care patients (1981–2010) with NSTI were evaluated. Data were collected prospectively. Results: 43.4% of the patients were in septic condition and 27.3% were hemodynamically unstable. Half of the patients showed predisposing factors (52.7%). The lower extremity (63.2%), abdomen (30.9%), and perineum (14.5%) were most affected. Polymicrobial infections were frequent (65.5%, mean 2.8, range: 1–4). The mortality rate was 16.4% (n = 9). An increase was shown for diabetes mellitus (20%), cardiac insufficiency (22.3%), septic condition at presentation (33.3%), abdominal affection (47.1%), and hemodynamic instability (46.7%). Comparing survivors and nonsurvivors, statistical significance was seen with age (p < 0.001), septic condition at admission (p < 0.001), hemodynamic instability (p < 0.001), low blood pressure (p < 0.001), and abdominal affection (p < 0.001). In laboratory findings, an increase of creatine kinase (p < 0.001) and lactate (p < 0.001) and a decrease of antithrombin III (p < 0.007) and the Quick value (p < 0.01) proved to be significant. Conclusion: Patients with Fournier’s gangrene do not differ in all aspects from those with other NSTI. Successful treatment consists of immediate surgical debridement, broad-spectrum antibiotic treatment, and critical care management. Supportive hyperbaric oxygen therapy should be considered.
The measurement of fracture stiffness allows the detection of patients at risk for nonunions. The healing time increased with increasing fracture gap size and was less in patients with younger age, less complex fractures, and lesser degrees of soft tissue damage.
After injuries to the anterior cruciate ligament (ACL) a functional instability is frequently observed which has been attributed to a disturbed sensorimotor function. In light of the clinical importance of ACL injuries and the resulting functional instability, it is of enormous clinical interest to elucidate the role of sensorimotor pathways that involve the ACL. In animals and humans a direct reflex pathway between the ACL and the hamstrings has been shown. The onset latencies of responses reported after ventral tibia translation were around 40-50 ms (range 17.9-65) and were regarded as medium latency responses (MLR). However, ventral tibia translation should also induce a stretch of the hamstring muscles and evoke a short latency response (SLR). Before any muscle response after ventral tibia translation can be ascribed to anatomical structures, it is crucial to analyze the obtained muscle responses carefully. The aim of the present study was the development of an algorithm to differentiate SLR and MLR responses after ventral tibia translation. In ten healthy subjects reflex responses of the hamstrings after anterior tibia translation and after tendon taps on the biceps femoris tendon were evaluated. To investigate the influence of skin afferents, control experiments were performed after lidocain injection of the dorsal calf. The mean onset latency of the tendon jerk reflex was 21.9 +/- 3.1 ms (range 17.3 - 28.7 ms). Both SLR responses (mean onset latency: 20.3 +/- 3.5 ms; range 15.4 - 25.8) and MLR responses (mean onset latency: 38.9 +/- 4.2 ms; range 32.9 - 46.7) were obtained in all subjects. Skin afferents from the calf do not play a major role. The development of an evaluation algorithm is presented that allows a safe differentiation between these partly superimposed SLR and MLR components. It is demonstrated that by measuring the first part of the SLR from the onset to the first peak the end of the SLR can be predicted and that the onset latency of the MLR component can be assessed reliably. Possible reasons are discussed why previous studies only reported responses at MLR latencies. The fact that both SLR and MLR components can be observed after anterior tibia translation underlines the necessity to differentiate the responses before they can be ascribed to any anatomical structures. As a basis for future work the algorithm presented may become a useful tool to differentiate which afferent pathways play a role in initiating hamstring activity.
The role of magnetic resonance tomography (MRI) for the diagnosis of chondral lesions of the knee joint is still unclear. The sensitivity of the method ranges from 15% to 96%. The scope of our daily experiences showed that there were considerable deviations between the tomographical and arthroscopical results, which vary from the results of experimental studies. Therefore we have conducted a prospective study to investigate the question of how MRI can replace arthroscopy (ASC) in the diagnosis of cartilage damages in the scope of daily routine. All 195 patients included in this study received a magnetic resonance tomography followed by an arthroscopy. A clear diagnosis of supposition had to be determined before the magnetic resonance tomography. The patients were divided into 3 Groups. Group A (n=86) received a standard Military Hospital Ulm (MH) MRI--sagittal STIR TSE and PD TSE, coronal and transversal T2 FFE (TR=660 ms, TE=18 ms, FA=30 degrees, 512 matrix). In addition, one sub-Group, AK (n=21) was examined with a special cartilage sequence of the cartilage fs T1 W FFE. Neither patients in Group AK nor in Group A as a whole received any contrast medium. Group B (n=88) was examined with an alternate MRI protocol (Radiological Joint Practice, Neu-Ulm--sagittal T1 SE, T2 SE and T2 FLASH (TR=608 ms, TE=18 ms, FA=20 degrees, 256 matrix), coronal PD fs), employing gadolinium as a contrast medium. 156 cartilage lesions were found arthroscopically. In Group A the sensitivity was 33%, the specificity 99%, and the positive and negative prediction values 75% and 98% respectively. Group B reached a sensitivity of 53% and a specificity of 98%. The positive prediction value was 48% and the negative was 98%. Group AK showed a sensitivity of 38% and specificity of 98%; the positive and negative prediction values came to 50% and 97% respectively. In conclusion, our results indicate that the MRI examination techniques recommended in the literature at present are not able to replace the ASC for the diagnosis of cartilage damages of the knee joint. In view of the high specificity (97%-99%) and the high negative prediction value (97%-98%), MRI is suitable for the exclusion of cartilage lesions. For a negative MRI associated with a cartilage injury, a cautious attitude towards an operative cartilage treatment is therefore justified. Because the MRI can not replace the ASC for diagnostic of cartilage damage, the ASC still has to be seen as the method of choice for the evaluation of cartilage damage.
Anterior cruciate ligament (ACL) ruptures lead to a proprioceptive deficit and therefore joint position sense. This study examined whether active motion is better suited than passive motion to address this deficit. Sixty patients with ACL rupture were prospectively randomised into two groups [continuous active motion (CAM)/continuous passive motion (CPM)]. All patients had an ACL reconstruction. An angle reproduction test was used to assess the proprioceptive deficit. The relevant examinations were performed before surgery (pre-op evaluation) and after the seventh postoperative day. No preoperative difference was found between the two groups. After postoperative treatment, the deficit was reduced in both groups. Significantly better results were, however, obtained in the CAM group (CPM, 4.2+/-1.6 degrees; CAM, 1.9+/-1.2 degrees; P<0.001). During the first postoperative week, a CAM device produced a significantly greater reduction in the proprioceptive deficit and should be the first choice in immediately postoperative rehabilitation after ACL replacement.
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