[Dyamic screw fixation for slipped capital femoral epiphysis. Treatment results]. / Dynamische Schraubenfixation bei der Epiphyseolysis capitis femoris juvenilis Therapieergebnisse.

Slipped capital femoral epiphysis always requires surgical treatment. The operative technique depends on the degree of dislocation and the type of the slip. The goal of treatment is to achieve physeal stability until the epiphyseal plate closes without harming the further femoral growth. In situ fixation is generally recommended for slipped capital femoral epiphyses of a mild degree. For this purpose the technique of dynamic screw fixation (DSF) is applicable using a long cannulated screw with a short thread.DSF is easy to handle, provides sufficient long-term fixation of the epiphysis, does not promote premature closure of the epiphysis, and engenders few complications. Therefore, this technique is also applicable for the prophylactic treatment of the contralateral unaffected hip, which we always perform. Moreover, DSF can be used following gentle reduction of acute epiphysiolysis, if the amount of eventual residual dislocation does not exceed 30 degrees. We report our results with dynamic screw fixation of 29 slipped capital femoral epiphyses of a mild degree, and the prophylactic dynamic screw fixation of 34 unaffected hips. The fixation technique achieved a reliable stabilization with no visible growth disturbance of the femoral neck in all cases.

Slipped capital femoral epiphysis: a prospective study of dynamic screw fixation.

Twenty-five consecutive children (29 hips) who had slipped capital femoral epiphysis of a mild degree (slip angle less than 30 degrees) were treated with dynamic screw fixation. The goal of dynamic screw fixation is to achieve physeal stability to prevent additional slippage and to avoid premature physeal closure. Seventeen boys and eight girls were followed up for an average of 7 years (range, 4-13 years). There were 25 chronic slips, three acute slips, and one preslip. The average age at the time of surgery was 11.7 years for the girls (range, 11.1-12.9 years) and 13.9 years for the boys (range, 9.4-16.1 years). The average time to physeal closure was almost the same in both genders (boys, 3.0 years; girls, 3.2 years), ranging from 1.1 years to 6.3 years. No increase in the degree of slippage occurred; there were no perioperative complications, and avascular necrosis and chondrolysis were not apparent. In all 29 hips, no growth disturbance, including greater trochanteric overgrowth, coxa brevis, or coxa vara, was seen. According to the clinical criteria of Heyman and Herndon, 26 hips were rated either excellent or good, and two were rated fair. One was rated poor because of the presence of slight pain after strenuous exercise. The technique of dynamic screw fixation provides sufficient immediate and long-term fixation, does not promote premature physeal closure, and permits normal hip development.

[An important differential diagnosis for persistent back pain]. / Infektiöse Spondylitis als Differenzialdiagnose persistierender Rückenschmerzen. Atiogenese, Diagnostik und Therapie Vertebral osteomyelitis.

PATIENTS: Between 1/1994 and 12/1998 40 patients with a vertebral osteomyelitis were treated at the Orthopedic University Hospital of Witten/Herdecke. All data of 15 female and 25 male patients with an mean age of 61 years (25-87 years) were analyzed in a retrospective study. Diagnosis of vertebral osteomyelitis was made between 1 and 84 weeks after onset of symptoms. Before admissions in our hospital up to 4 hospitalizations without proper diagnosis were reported. TREATMENT: The treatment consisted bed-rest in an individual orthesis and percutaneous discovertebral biopsy before systemic administration of antibiotics. In 11 from a total of 21 biopsies we could prove bacteria as follows: 6 times Staphylococcus aureus, 2 times E. coli and 3 times Mycobacterium tuberculosis. Radiological diagnosis was made by conventional x-ray in 2 dimensions and nuclear magnetic resonance. Together with radiological, histological, microbiological and laboratory investigation we found 11 patients with a specific tuberculosis of the spine, 25 patients with a pyogenic vertebral osteomyelitis and 4 patients with a post-nucleotomy osteomyelitis. 14 patients underwent operative treatment. All patients were mobilized in an individual brace after CRP and ESR indicated remission of inflammation. DURATION OF HOSPITAL TREATMENT: Duration of the hospital treatment lasted between 33 and 137 days. At follow-up 12 months after demission 35 patients were free of symptoms, two patients had still signs of osteomyelitis, two patients, one of them with recurrence of spondylitis, were reoperated because of dislocation of the implants, and one patient died after surgery suffering from severe peritonitis and multi-organ-failure. DISCUSSION: We report pathogenesis and the current diagnostic and therapeutic concept of treatment of the vertebral osteomyelitis. Despite modern diagnostic possibilities, diagnosis of vertebral osteomyelitis is often made very late. Vertebral osteomyelitis is an important differential diagnosis for persistent back pain and needs to be considered more often.

[The "empty" cruciate ligament notch. Aplasia or trauma aftereffect?]. / Die "leere" Kreuzbandhöhle. Aplasie oder Traumafolge?

Discoligamentary injuries of the knee frequently lead to an arthroscopic inspection of the joint. We present a case in which after two traumatic events a mensal tear and an empty notch were found on arthroscopic examination. The differential diagnosis of congenital aplasia of the anterior cruciate ligament (CAACL) versus neglected rupture of the ACL is discussed.

[Diagnosis of anterior knee instability. Comparison between the Lachman test, the KT-1,000 arthrometer and the ultrasound Lachman test]. / Diagnostik der vorderen Knieinstabilität. Vergleich zwischen dem Lachman-Test, KT-1000-Arthrometer und sonographischem Lachman-Test.

We reviewed 45 patients on average 14.7 years after surgery for rupture of the anterior cruciate ligament. The aim of the study was to compare the reliability of the Lachman test to evaluation of knee laxity with the KT 1000 arthrometer and the ultrasound-assisted Lachman test. Forty-five knees were examined with the Lachman test: 12 knees showed no sign of instability; 20 had a + positive Lachman test with a hard end point; 6 with a + positive test had no end point and were rated as unstable; a +2 Lachman test was found in 7 knees. With the KT 1000 Arthrometer 44 knees were examined: 30 knees were graded as stable according to the criteria of Daniel; 14 knees were unstable. We used the ultrasound-guided Lachman test in 44 knees. Taking only the side-to-side difference into account, 37 knees were stable and 7 unstable. According to Gruber, a single translation greater than 4 mm is also a sign of instability. Therefore, 12 knees were unstable, although 6 of these knees were rated as stable, taking the side-to-side difference into account. Comparing the two instrument measurements, all knees with ultrasound-rated instability on the basis of side-to-side measurements were also rated as unstable with the KT 1000 arthrometer. Only half of the knees rated as unstable because of a single translation greater than 4 mm with the ultrasound technique were rated as unstable with the KT 1000 arthrometer. Our results show that the accuracy of the Lachman test is as good as the instrument evaluation if the end point is taken into consideration. A positive Lachman test indicating anterior knee laxity is one where the soft end point is as described by Torg et al. Both instrument measurements are accurate in indicating anterior knee laxity, but only if they are used by an experienced examiner. Using the side-to-side measurements, the sensitivity of the KT 1000 arthrometer is higher. If only single translations greater than 4 mm without a significant side-to-side difference with the ultrasound technique are interpreted as anterior knee instability, then some knees will be rated as unstable, although both the clinical and KT 1000 arthrometer examinations prove them to be stable. We believe that only a side-to-side difference with the instrument techniques should be interpreted as knee laxity. Borderline positive measurements should only be used together with the clinical findings. Both instrument measurements can help to improve the quality of the clinical examination if the examiners are inexperienced. If instrument measurements are required, we believe that the ultrasound technique is easy and cheap to perform. Nevertheless, we believe that instrument measurements of anterior knee laxity are not necessary if a thorough clinical examination is performed, taking the end point of the Lachman test into consideration.

Subtrochanteric stress fracture of the femur following total knee arthroplasty.

This study reports the first case of a subtrochanteric stress fracture of the femur after total knee arthroplasty. A 61-year-old obese woman was treated by right total knee arthroplasty for osteoarthrosis. Four months after the surgery and 1 month after full weight bearing, she complained of tenderness in the right groin and proximal thigh. There was no history of trauma. Radiographs of the right hip and of the right proximal femur were interpreted as unremarkable, and nonsteroid anti-inflammatory drugs were administered. Three months later, she had a sudden onset of increased pain with instability and giving way of the right leg. Radiographs revealed a subtrochanteric transverse fracture of the right femur. Histologic workup of the bone and tissue specimen taken at open reduction, as well as the laboratory data were consistent with the radiologic and clinical diagnosis of a stress fracture. It is most likely that a decrease in the tension band effect of the iliotibial tract in combination with coxa vara and changes in static and dynamic forces of the femur and an increased level of activity after a period of relative inactivity secondary to the knee arthroplasty are responsible for this very uncommon fracture type.

Parosteal osteosarcoma of the tarsus.

Parosteal osteosarcoma is a very rare bone tumor with a predilection for the posterior aspect of the distal femoral metaphysis. A case of parosteal osteosarcoma of the tarsus of a 23-year-old woman is reported. This is the second case of parosteal osteosarcoma of the tarsus reported in the English literature.

Prophylactic dynamic screw fixation of the asymptomatic hip in slipped capital femoral epiphysis.

Prophylactic dynamic screw fixation (DSF) of clinically and radiographically unaffected hips of 34 patients with a contralateral slipped capital femoral epiphysis and no evidence of an endocrinopathy or systemic disorder was performed using a single cannulated screw. Follow-up ranged from 2 to 12 years (average, 5.4 years). There was no case of perioperative complication and no avascular necrosis or chondrolysis occurred. No preslip or slip became apparent. In all 34 hips, no tendency toward premature closure of the epiphysis could be observed, no growth disturbance including greater trochanteric overgrowth, coxa brevis, or coxa vara was noted. This study supports the prophylactic treatment of the asymptomatic hip, using a simple and safe fixation method.

Is instillation drainage for the treatment of infected joints, bones and soft tissues still up to date?

For the treatment of infected joints, bones and soft tissues, either an instillation drainage therapy or the use of gentamicin-polymethyl-methacrylate (PMMA) chains (Septopal) in addition to surgical revision and systemically given antibiotics is currently in clinical use. We investigated 102 patients treated in our clinic by means of instillation drainage and compared the results with those obtained with gentamicin-PMMA chains by other authors. The overall long-term success with non-recurrence of the infection is nearly comparable (80% instillation drainage, 84% gentamicin-PMMA chains); however, with instillation drainage the duration of hospitalisation is significantly longer (mean 42.26 days vs 15.3 - 33 days). Additionally, there was a high rate of germ shifts with instillation drainage (33.3%) and a disappointing result in 20 infected endoprostheses (9 recurrences with 11 revisions). Regarding the intensive nursing care required and the necessary isolation from other patients, instillation drainage can only be recommended for the therapy of infected joints, bones and soft tissues if the results are better in comparison with gentamicin-PMMA chains. An improvement may be achieved with the closed instillation drainage system.

Classification of bone healing after intertrochanteric osteotomies. Consequences for the surgical procedure and postoperative rehabilitation.

Intertrochanteric osteotomies produce a rate of 1 to 7% delayed union and pseudarthrosis, mainly as a result of the quality of the surgical procedure employed. In this retrospective and prospective study we have divided the models of bone healing after intertrochanteric osteotomy into 4 groups based on the postoperative x rays, and have taken into account only the factors of sclerosis, radiolucency and fragment contact in the osteotomy plane. This grouping enables us to evaluate the quality of the surgical procedure and to predict the postoperative course at an early stage, thus facilitating timely modification of the postoperative rehabilitation.

[Computer-assisted experimental implantation technique for comparative quality assessment of various cementation techniques in cemented hip prosthesis implantation]. / Computergestützte experimentelle Implantationstechnik zur vergleichenden Qualitätsbestimmung unterschiedlicher Zementierungstechniken bei der zementierten Hüftprothesenimplantation.

For the anchorage of femoral prosthesis stems in total hip arthroplasty, various cement application techniques are used. Experimental comparison of these techniques requires a set-up in which only the cementing technique itself is tested. We used a computer-controlled implantation device based on a milling machine and standardized artificial femur models. The stems are reproducibly positioned by the machine and any influence of manual positioning during the implantation is excluded. The results can be evaluated macroscopically and radiologically with no interference by disturbing bone--with sufficient sensitivity to objectify differences in cement quality. The increase in pressure in the peripheral medullary cavity, which is responsible for the embolisation, can be determined experimentally for the individual cementing technique. The experimental implantation device described enables a standardized comparison of various cementing techniques.

[Importance of newly defined epiphyseal version in diagnosis and therapy of epiphysiolysis capitis femoris (additional data to epiphyseal dislocation and epiphyseal torsion)]. / Bedeutung einer neu definierten Epiphysenversion für die Diagnostik und Therapie der Epiphyseolysis capitis femoris (Ergänzung zur Epiphysendislokation und Epiphysentorsion).

The displacement of the femoral epiphysis in epiphyseolysis capitis femoris is usually determined by measuring both the epiphysis-diaphysis angle (ED angle) in the plane of the dislocation and the epiphysis-torsion angle (ET angle) in the torsional plane. In this paper we define an epiphyseal version angle (EV angle) in the sagittal plane of the femur, calculate it trigonometrically and show it in diagrams and tables. The clinical application of the EV angle indicates that in cases of displacement with an ED angle of less than 135 degrees, absolute displacement is better shown than with the ET angle. Additionally, the EV angle improves our comprehension of the 3-D displacement due to the fact that, in the "Lauenstein" x-ray, the femur is increasingly projected more in a sagittal plane with increasing abduction. The essential correction using the Imhäuser-osteotomy is also done in the sagittal plane. The ability of the orthopaedic surgeon to visualize the situation in three dimensions is also improved by this additional standard plane.