[Complications after hip resurfacing using the ASR prosthesis in patients with osteoarthritis]. / Komplikationen nach ASR-Oberflächenersatz am Hüftgelenk bei Patienten mit Coxarthrose.

PURPOSE: The purpose of this study was to evaluate peri- and postoperative complications and the clinical/radiological results after hip resurfacing with the ASR prosthesis in patients with osteoarthritis. METHOD: A prospective cohort study was performed including all patients who received a hip resurfacing (ASR prosthesis, DePuy, Motech, Warsaw, IN, USA) because of osteoarthritis between 1/2005 and 7/2006. 115 prostheses were performed in 110 patients (58 female, 52 male). In all patients a dorsal approach was used. The mean age was 57.82 years (range: 34 to 72 years) and the mean follow-up was after 12.5 months (range: 6 to 23 months). At the time of follow-up an X-ray (a. p. and axial) of the operated hip was performed in addition to the to standard clinical examination. To measure the functional outcome the Harris hip score was used. RESULTS: We observed postoperative complications in 18 patients. Three non-trauma-related femoral neck fractures were seen after a mean of 58 days (range: 41 to 70 days). One trauma-related femoral neck fracture was found after 7 months. Neural complications were found in two patients. In 8 patients a revision of the acetabular component was necessary. 3 dislocations could be managed without further revision. One revision was necessary because of a persisting seroma without infection. No infections or thromboembolic complications were seen. The mean Harris hip score developed from preoperative 59 points (range: 50 to 65 points) to postoperative 96 points (range: 85 to 100 points). CONCLUSIONS: Excellent early postoperative results can be reached by hip resurfacing. Special attention is necessary performing the correct positioning of the femoral and acetabular components. If notching is seen intraoperatively the operation should be switched and a large head prothesis should be implanted. Long-term results are still lacking.

[Extensive hip joint ganglion as a rare cause of chronic pain in the groin]. / Ein ausgedehntes Hüftgelenkganglion als seltene Ursache für chronische Leistenschmerzen.

A 66-year-old woman had complained for 6 months of worsening pain in the left groin with resultant difficulty in walking though there had not been any previous injury. MRI showed a cystic tumor extending from the left hip joint to the inner surface of the os ileum. CT-controlled puncture yielded a small volume of a gelatinous substance that was the content of the cyst, and bacteriological examination of this was negative. We resected the tumor using an ileofemoral approach. Histological examination showed that the tumor was a ganglion of the hip. These ganglia can grow very large without compressing vessels or nerves. They should be included in the diagnosis when patients present with chronic pain in the groin.

Length and angle measurements of the lower extremity in digital composite overview images.

We here introduce a digital scanning method for determining leg length and angles. The leg length and angle measurements, image quality and radiation dose were evaluated. A composite overview image was reconstructed from a series of individual images. In 45 overview images, the total leg length and the femoro-tibial angle were determined by two radiologists, and the inter- and intra-observer variability was examined in the light of the measured values as well as the subjective assessment of the image quality. A dose comparison was carried out with a series of conventional whole leg images. The mean standard deviation of the multiple measurements of leg length was 0.4 mm for researcher I and 0.5 mm for researcher II. The difference in the mean values of the measured leg lengths between the researchers was 0.3 mm. The mean standard deviation of the multiple measurements of the femoro-tibial angle was 0.1 degrees for both researchers. The difference in the mean values of the measured femoro-tibial angle between the researchers was 0.03 degrees. On average, the marks for the image quality awarded by researcher II with an average score of 2 were very significantly worse than those awarded by researcher I with an average score of 1.5. The mean entrance dose value determined was 0.16 mGy lower in the digital system (0.49 mGy) than that of the comparative conventional series (0.65 mGy). Where there is a large number of possible length and angle measurements, the proposed procedure offers the advantages of good image quality, digital image processing, measurements that are easy to perform, reproducible and accurate, and lower radiation dose, and it is superior to conventional whole leg images.

[Value of magnetic resonance tomography (MRI) in diagnosis of triplane fractures of the distal tibia]. / Die Wertigkeit der Magnetresonanztomografie (MRT) bei der Diagnostik von Ubergangsfrakturen im Bereich der distalen Tibia.

The rare transitional fractures occur in adolescents at a time of incomplete dosis of the epiphysis. The anatomy of this fracture type is complex with the fracture line running in multiple planes. Conventional plain film radiographs often underestimate the extent and geometry of the fracture due to its transverse components. This study was performed to asses the benefit of MR-imaging compared to plain film radiographs in diagnosis and analysis regarding fracture-type, anatomy and dislocation of fracture. During a time period of 18 months we treated 15 patients with a fracture of the distal tibial epiphysis. In addition to plain film radiographs they got MRI of the distal tibia. Plain film radiographs and MRI were anonymized and diagnosed by 2 surgeons and 2 radiologists. 12 transitional fractures were diagnosed in plain radiographs as well as MRI, but regarding our criteria as above, we found two wrong classifications of fracture-type, an underestimation of fracture dislocation of an average of 0.5 mm in plain film radiographs and two rotational dislocations were missed. The MRI was found to provide anatomical detail and information superior to plain film radiographs.

[Computer-assisted, robot-assisted hip prosthesis--standard procedure or specialty indication?]. / Computerassistierte, roboterunterstützte Hüftendoprothetik--Standardverfahren oder Spezialindikation?

Approximately 150,000 total hip replacements annually are performed in Germany, with an increasing incidence of implants carried out on young subjects. Due to aseptic loosening, this group will undergo some revision arthroplasty after 15 years. Therefore, a permanent fixation appears mandatory. In case of posttraumatic or postoperative anatomical changes, exact preoperative planning by x-rays is extremely difficult. This might result in a higher rate of complications (e.g., displacement of the implanted prosthesis, fractures of the proximal femur), as documented by the available literature. The preoperative planning with CT images obtained at the 3D workstation shows the exact cortical situation, while the robot-assisted surgery allows the precise execution of the preoperative plan during surgery. By this point of time, long-term results of computer-guided, robot-assisted implantation of endoprosthesic devices are still lacking. However, the preliminary data indicate good results by means of anatomical position of the endoprosthesis and perioperative complications.

[Knee joint endoprosthesis]. / Kniegelenkendoprothetik.

Total knee replacement is increasing in number due to increased life expectancy and improved implants. [figure: see text] Degenerative changes (arthritis) and joint destruction based on polyarthritis and posttraumatic deformities are the common indications. There are basically four modes for knee replacement: Unicompartimental prosthesis, non-constrained, semi-constrained (posterior stabilized) and constrained total knee arthroplasty. Of major importance in knee alloarthoplasty are restitution of the correct limb axis, sufficient lateral ligaments and the restoration of the patellofemoral joint. Therefore particularly in cases with deformities an extensive soft tissue release is mandatory. A meticulous operative technique and versatile implants lead to good clinical outcome. Possible complications are still septic and aseptic implant loosening as well as wound infections.

[The infected endoprosthesis with the example of the hip joint endoprosthesis. An increasing danger to patient and society]. / Die infizierte Endoprothese am Beispiel der Hüftendoprothese. Eine zunehmende Gefahr für Patient und Gesellschaft.

Because of demographic factors there is an increase in the numbers of total joint replacement operations each year. Deep infection after joint replacement remains one of the major complications in orthopedic surgery. The economic consequences for society are enormous. The treatment of such infections usually means a long and difficult course for the patient. In most cases multiple operations, including removal or exchange of the prosthesis are required. Concepts of treatment are very different and vary from debridement and keeping the prosthesis, resection arthroplasty to one- and second-stage exchange procedures. It is essential to know the special advantages and disadvantages of each concept to be able to choose the right strategy of treatment. Even getting the right diagnosis may be difficult since only about 2/3 of all cases go along with a positive microbiology. By the example of the infected hip prosthesis, the aim of the article is to give recommendations on the bases of current literature and our own experience. The strategy of treatment of infections used in our hospital is reported.

The stabilizing effects of different orthoses in the intact and unstable upper cervical spine: a cadaver study.

BACKGROUND: Although cervical orthoses are frequently used in prehospital stabilization and in the definitive treatment for lesions of the cervical spine, there is little information about the control of extension-flexion, lateral bending, and rotation given to individual segments by different designs. METHODS: In an experimental in vitro study with four fresh frozen cadavers, the halo vest was compared with the soft collar, prefabricated Minerva brace, and Miami J collar. The controlling effects for the segments C1-2 and C2-3 were tested for all four devices in the intact and the unstable spine with an Anderson type II fracture of the odontoid. RESULTS: All four orthoses reduced the range of motion at both C1-2 and C2-3 of the intact spine significantly, although none of the three semirigid devices provided a halo-like immobilization in the intact spine. The osteotomy of the odontoid increased the range of motion in the segment C1-2. The soft collar did not give any clinically relevant stability to the unstable spine. Miami J and Minerva brace provided a similar moderate control in the sagittal plane but a much better control of "torque" in the upper cervical spine. The halo vest did not allow any measurable motion in any plane with our experimental external loading. CONCLUSION: The halo vest seems to be the first choice for conservative treatment of unstable injuries of the upper cervical spine, although pin track problems, accurate fitting of the vest, and a lack of patient compliance lead to clinical failures.

[Early death of the severly injured patient--A retrospective analysis]. / Die Frühletalität des Schwerstverletzten - Eine retrospektive Ursachen-Analyse -

With 44.9 % trauma is the main cause of death in men under 40 years. From September 3(rd) 1997 to June 30(th) 1998 174 patients with severe injuries or polytrauma were treated in our hospital. The mean ISS was 29 (18-75). 15 (8.75 %) patients died within the first 24 hours. The mean age was 34.5 (2-85) years. The mean ISS of these patients was 48 (25-75). In a retrospective study we analyzed the pattern of injury as well as the preclinical and clinical management. The fact that orthopedic surgery still has got a poor position within the patient's satisfaction-scale and that 15 of 174 analyzed patients had to die within the first 24 hours points out the importance of internal and external quality improvement measurements.

[Techniques of extramedullary osteosynthesis in proximal femoral fractures]. / Extramedulläre Osteosynthesetechnik bei proximaler Femurfraktur.

Plate osteosynthesis at the proximal femur is possible for intertrochanteric and subtrochanteric femoral fractures. Common implants are the dynamic hip screw (DHS), the dynamic condylar screw (DCS) and the condylar blade plate. The dynamic hip screw is mainly used in introchanteric femoral fractures, whereas the other two devices are suitable for stabilizing subtrochanteric fractures. Those extramedullary implants compete with several intramedullary nailing systems. Because of less soft tissue compromise the nailing systems have been favored by many surgeons during the last decade. This is particularly true for the subtrochanteric area where intramedullary devices offer higher primary stability, allowing initial full weight bearing. A good indication for the extramedullary technique with a two-hole dynamic hip screw is the stable intertrochanteric fracture with an intact lesser trochanter. The other fracture types of the proximal femur in the intertrochanteric and subtrochanteric area are better treated with intramedullary devices. The remaining indications for the dynamic condylar screw and the condylar blade plate are correction osteotomies and some salvage procedures.

[Not Available]. / Extramedulläre Osteosynthesetechnik bei proximaler Femurfraktur.

Plate osteosynthesis at the proximal femur is possible for intertrochanteric and subtrochanteric femoral fractures. Common implants are the dynamic hip screw (DHS), the dynamic condylar screw (DCS) and the condylar blade plate. The dynamic hip screw is mainly used in introchanteric femoral fractures, whereas the other two devices are suitable for stabilizing subtrochanteric fractures.Those extramedullary implants compete with several intramedullary nailing systems. Because of less soft tissue compromise the nailing systems have been favored by many surgeons during the last decade. This is particularly true for the subtrochanteric area where intramedullary devices offer higher primary stability, allowing initial full weight bearing. A good indication for the extramedullary technique with a two-hole dynamic hip screw is the stable intertrochanteric fracture with an intact lesser trochanter.The other fracture types of the proximal femur in the intertrochanteric and subtrochanteric area are better treated with intramedullary devices. The remaining indications for the dynamic condylar screw and the condylar blade plate are correction osteotomies and some salvage procedures.

[Benign tenosynovial giant cell tumor in the region of the upper ankle joint. A rare differential diagnosis of a soft tissue tumor of the foot]. / Der benigne tenosynoviale Riesenzelltumor im Bereich des oberen Sprunggelenks. Seltene Differentialdiagnose eines Weichteiltumors am Fuss.

The giant cell synovioma is a benign neoplasia classically located in the fingers. It mostly rises from tendon sheaths, sometimes from the synovia. Other locations than the fingers are rare. Making a differential diagnosis to lipomas, gangliomas or even malignant soft tissue tumors can be very difficult especially in rare locations. We report the case of a 21 years old man suffering from a giant cell synovioma in the area of the right ankle joint. The clinical, radiological and patho-morphological findings are documented. The tumor was excised totally, other foci were not found. The problems of making the right diagnosis are described.

[Rotational dislocation of the cervical spine]. / Die Rotationssubluxation der Halswirbelsäule.

Unilateral cervical dislocations are less common and have fewer accompanying neurological complications than bilateral. A case of unilateral rotational dislocated facet has been described. Postoperatively, all deficts were improved. According to the literature, the diagnosis of this entity is often missed and the treatment is controversial.

Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases.

OBJECTIVE: To analyze the results of 45 patients after ankle arthrodesis in the presence of joint infection. METHODS: Arthrodesis was performed with two compression screws and an anterior plate in 29 patients and with two compression screws only in 16 patients. In all patients, additional stabilization with external fixation was used. In 29 patients, isolated fusion of the ankle joint was performed; in 13 patients, the ankle and subtalar joints were fused, and in 3 patients, isolated arthrodesis of the subtalar joint was performed. RESULTS: In 39 of 45 patients (86.6%), solid fusion was obtained. Nonunions occurred in 6 patients (13.4%). A below-knee amputation was necessary for one patient. Full weight-bearing was achieved after 21.6 weeks on average. Thirty-two patients returned to work after 35.5 weeks on average. Five of the six patients with failed ankle fusion needed special shoes; in one patient, a below-knee amputation was performed. A total of 33.3% of failed ankle fusions were associated with systemic disorders such as diabetes mellitus, and other concomitant diseases compromising local arterial blood supply and proprioception. CONCLUSION: Our results prove that limb salvage is possible even in complex ankle and subtalar pathology by thorough fusion by using a number of different techniques.

[Pediatric forearm fractures: indications, technique, and limits of conservative management]. / Unterarmfrakturen im Kindesalter. Indikationen, Technik und Grenzen der konservativen Behandlung.

Although several "minimal invasive" techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4-112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 degrees (15 degrees -50 degrees ). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.

[Minimally invasive therapeutic concepts in fracture surgery]. / Minimal-invasive Therapiekonzepte in der Unfallchirurgie.

Recent publications show a clear tendency towards minimally invasive procedures for fracture care in trauma patients. Intramedullary stabilization has become the first choice in reconstructing axis and length of the diaphyseal fractures of the long bones. Indications for intramedullary nailing have become wider with the development of unreamed or retrograde nailing. Essential modifications of plate osteosynthesis from limited contact implants to percutaneous plating and the development of an internal fixator have made this procedure minimally-invasive as well. Techniques of closed reduction and percutaneous osteosynthesis or arthroscopically-assisted procedures have become more important in the stabilization of metaphyseal fractures. Although long term results of some of the mentioned procedures are unknown by now, minimally-invasive techniques appear to have positive influence on functional outcome in most patients. However problems of intraoperative control of axis and rotation in long-bone fractures as well as the surgeon's high exposure to radiation remain unsolved problems in minimally-invasive traumatology.

Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children.

The standard treatment in forearm fractures in children is usually conservative. Unstable fractures of the proximal parts of the forearm often show poor results after nonoperative management so that these fractures usually require surgical intervention. We report 30 children (ages, 4-14 years) who were treated by elastic intramedullary nailing. Sixteen patients were treated by intramedullary splinting immediately after their accident; 14 children required intramedullary nailing after failure of conservative treatment and fracture redisplacement. At the time of follow-up 6 months later, functional results were excellent in 24 children, good in five children, and fair in one child. There were no serious complications other than one delayed union. According to these results intramedullary nailing can be recommended for the treatment of unstable fractures of the proximal and middle thirds of the forearm in children.

[Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate?]. / Der sprunggelenksnahe Unterschenkelbruch. Ist die Osteosynthese mit ungebohrtem Marknagel ausreichend?

In a prospective study, 53 fractures of the distal fifth of the tibia were stabilized by unreamed nailing. Additional involvement of the ankle joint occurred in 18 patients. 50 patients returned for follow-up. In 30 patients tibia and fibula were fractured at the same (distal) level; in 20 patients the fracture of the fibula was located more proximally. In 12 patients the fractures extended into the tibial pilon. Severe soft tissue damage was seen in 24 fractures (18 open, 6 closed). Ninety percent of all fractures healed uneventfully without further surgical intervention after unreamed nailing. In two patients the unreamed nail had to be exchanged for a reamed tibial nail. Bone grafting and secondary dynamization of the nail by removal of a proximal interlocking bolt were performed in one case each. Thirty-one fractures healed in anatomical position. Valgus or varsus angulation of less than 5 degrees occurred in 18 patients. One fracture healed with rotatory angulation of 15 degrees. The highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.

[Traumatic axial dislocation injury of the carpus and metacarpus with triquetrum fracture. Rare entity or typical injury]. / Traumatische axiale Luxationsverletzung von Karpus und Metakarpus mit Triquetrumfraktur. Rarität oder typische Verletzung?

Although there are only 39 reports of compression injuries with axial dislocation of the carpus and metacarpus, there are similar patterns of injury. In all cases the dislocation is located either between the first and second or the third and fourth metacarpals and the corresponding carpal bones so that weak points of the carpal arch can be assumed in these regions. Clinical and radiological findings in a 22-year-old patient with dislocation of the third and fourth metacarpals and a fracture of the os triquetrum of the right hand after compression injury of both forearms with severe soft tissue injuries are described. Wound débridement and subsequent skin grafting were performed. The osseous lesions were reduced and held by two Kirschner wires and an external fixator. Results at follow-up were satisfactory.