No abstract

Our experiences with organ saving procedures of the spleen in childhood are presented. In 9 out of 12 children (75%) with traumatic rupture we preserved the organ partially or completely. In 4 patients a partial splenectomy was performed, in three cases of splenorrhaphy was done, and once the organ was repaired with fibrin adhesive. One child was treated conservatively. Another patient underwent splenectomy followed by autotransplantation. Two out of twelve died intra- or postoperatively from severe concomitant injuries. Out of 11 patients with Hodgkin's disease we performed partial splenectomy in five. Only in macroscopically involved cases the organ was removed. In one patient a huge epidermoid cyst of the spleen was enucleated. In another child with a big twisted wandering spleen a splenopexy after partial resection was carried out. In children the spleen should be preserved if ever possible.

The application of crushed ice or hydrogenated silicate, a micro-crystalline substitute has been used as a method to treat posttraumatic and postoperative irritations of the locomotor system for a long time. Closed systems using pumps can be viewed as further development as they enable continuous, water-free cooling of operating areas. The analgetic effect of postoperative cold therapy was evaluated in a prospective clinical trial, including 312 patients after total knee or hip arthroplasty. Conventional cold packs, consisting of microcrystalline silicate were compared to a continuous applicable closed system. Continuous cryotherapy resulted in a depression of skin temperature to 12 degrees C, whereas intermittent cooling only caused a mean temperature decrease of 1 degree C. Clinically continuous cold application leads to a more than 50% decrease of analgetic demands in both, systemic and regional application (p < 0.001). This observation was found in a significant correlation with patient's pain sensation as well as primary range of motion. Intermittent cryotherapy was found to be ineffective in postoperative pain relieve in hip- and adequate in knee arthroplasty patients. We could not report an influence on postoperative blood loss, as discussed in previous reports.

No abstract

We examined the extent and effect of an assumed neuromuscular transmission disorder by performing a prospective clinical study on 75 patients with therapy-resistant radiohumeral epicondylopathy. Before operating, we diagnosed with electromyography an increased rate of polyphasic potentials of the long wrist extensors as well as a prolonged motor latency of the respective muscles. Disordered neuromuscular recruitment combined with a reduced maximum strength and elasticity corresponding to the suspected damage to the distal part of the motor neuron could be proven. Both effects were significantly reversible (P < 0.001) through operative intervention. We found a significant correlation (> 0.90) between the normalization of the motor latency and increased strength. Subgroups were formed according to different preoperative diagnostic efforts and differing radicality regarding the type of soft-tissue operation performed; thus, the clinical validity of the findings diagnosed in the anatomical/ electrophysiological part of the study was additionally examined. The failure rate varied between 10% and 30%, depending on the radicality of the tenotomy, which could be interpreted as a general indication for a complete extensor carpi radialis brevis tendon release. In this connection it is remarkable that the clinical result of electromyographically localized damage in the area between the epicondyle and arcade of Frohse could not be improved through open neurolysis. Dealing with strictures located on the proximal side of the epicondyle on the other hand, this technique seems to play an important role in the recurrence prophylaxis.

A 16−year−old girl presented to us with a perforated esophagus after accidental in− gestion of a toothbrush. The referring physician had already tried to retrieve the brush endoscopically without suc− cess. Esophagogastroduodenoscopy (EGD) re− vealed the head of the brush impacted in the rear wall of the esophagus right under the upper esophageal sphincter. Oral re− trieval of the brush was not possible so it was moved to the stomach first and then retrieved using a loop around the neck of the brush and an overtube. Inspection of the esophagus showed a near total per− foration of the rear wall under the upper esophageal sphincter measuring approxi− mately 1.5 2 cm (l " Fig. 1). The patient was treated conservatively with antibiotics and nil by mouth. Two days after the primary intervention a sec− ond EGD was performed to inspect the perforation site. An area measuring 1 2 cm covered with fibrin was found. This area was treated with factor XIII in all four quadrants of the lesion up to a to− tal of 125 IU (2 ml) (l " Fig. 2). Coagulation factor XIII was first described by Laki and Lórµnd in 1948 as "fibrin−sta− bilizing factor" [1]. Factor XIII is the last enzyme (plasma protransglutaminase) in physiological coagulation and is also im− portant for proliferation and immigration of fibroblasts in wound healing. Factor XIII also inhibits the migration of macro− phages [2]. Factor XIII has been used in the therapy of ulceration due to pressure, large burns, sepsis, and acute liver disor− ders [3]. On the 9th day after primary intervention only a very small lesion barely covered with fibrin without any suspicious signs was seen (l " Fig. 3). The diet was in− creased without complications and the patient was discharged. Eight weeks after the incident EGD showed a completely healed wound at the site of the rupture (l " Fig. 4).

We examined extent and affection of an assumed neuromuscular transmission disorder by performing a prospective clinical study on 75 patients with therapy-resistant radiohumeral epicondylopathy. Before operation, we electromyographically diagnosed an increased rate of polyphasic potentials of the long wrist extensors as well as a prolonged motor latency of the respective muscles. Corresponding to a hereby implied damage to the distal part of the motor neuron, disordered neuromuscular recruitment combined with a reduced maximum strength and -elasticity could be proven. Both effects were significantly reversible (p < 0.001) through operative intervention. We found a significant correlation (corr < 0.90) between the normalization of the motor latency and increased strength. Subgroups were formed depending on different pre-operative diagnostic efforts and differing redicality regarding the performed soft-tissue operation, thus the clinical validity of the findings diagnosed in the anatomic and neurophysiologic part of the study was additionally examined. It was proven that the failure rate varies between 10% and 30%, depending on the radicality of tenotomy, which could be interpreted as a general indication for complete extensor carpi radialis brevis tendon release. In this connection it is remarkable that the clinical result of an electromyographically localized damage in the area between epicondyle and arcade of Frohse could not be improved through open neurolysis. Dealing with strictures located on the proximal side of the epicondyle on the other hand, this technique seems to play an important role for recurrence prophylaxis.

Several authors believe that a compression syndrome of the radial nerve or its muscle branches is responsible for the clinical picture of radiohumeral epicondylopathy. Various structural and functional stenoses have been discussed as possible causes. We performed systematic electromyographies (EMGs) on the extensors subdividing from the radial epicondyle and found significant changes (P < 0.05) in 27/51 patients regarding latency, velocity of nerve conduction and rate of polyphasic potentials. Especially affected were the extensor carpi radialis brevis and the extensor digitorum muscle. In order to clarify causal anatomic correlations, we performed a longitudinal and cross-sectional study on a total of 40 arms from cadavers. We found constant variations from the topographic anatomy published in the standard literature which corresponded to the EMG results in the area between the epicondyle and place of entry into the supinator muscle. In addition, we observed a regularly occurring ulnar deviation from the distal part of the extensor carpi radials brevis origin which protrudes over the plane of insertion of the joint extensor tendon aponeurosis and forms in most cases the arcade of Frohse. Because the deep radial branch and its parallel muscular branches cross this part at an obtuse angle, we think that dynamic pressure on a nerve without structural influences is the pathoanatomic result of this heterogeneously interpreted clinical picture.