Pulmonary aspergilloma - clinical findings and surgical treatment.

The management of pulmonary aspergilloma is still a topic of discussion. Demonstrating several cases of pulmonary aspergilloma, their clinical course and their follow-up, we try to contribute some arguments for the preference of an early operation. Between 1992 and 1998, 18 patients underwent thoracotomy for treatment of pulmonary aspergilloma. The most common indication for operation were hemoptysis [6] and indeterminate mass [6]. Lobectomy was the most frequent operation [11]. Underlying diseases were bronchiectasis [10], tuberculosis [3], carcinoma [2], blebs [2], and epitheloid granuloma. Two patients had postoperative complications, another three died later in the clinical course because of liver failure, septicemia, and persisting air leakage and sepsis. We recommend early resection of symptomatic, cavitating aspergilloma in the simple form and even with an inflammatory reaction of the surrounding tissue. Especially low-risk patients profit highly from an early operation. High-risk patients should be operated on only in cases of life-threatening complications.

[Pyrost, a spongious, mineral bone substitute. Experimental bases and 13-year clinical experience in over 1000 cases]. / Mineralisches, spongiöses Knochenersatzmaterial Pyrost. Experimentelle Grundlagen und 13 Jahre klinische Erfahrung bei über 1000 Fällen.

In different animal investigations Pyrost demonstrated osteoconductive and osteostimulative effects. In ectopic tissues and especially in conditions of low osteogenetic potency, the combination of Pyrost and autogenic bone marrow effects bone formation. In a clinical prospective study, Pyrost was implanted in 1117 cases in the following indications: Donor site defects after bone transplantation, bone defects after tumor resection, revision of THA, acetabuloplasty, fracture treatment, pseudarthrosis and lengthening osteotomy, spondylodesis. In 87.3% the regeneration of the bone defects was complete, in 8% a partial regeneration was found. Excessive bone formation took place in 2.7%, insufficient regeneration in 2.0% in cases of instability or infection. According to the clinical results Pyrost is a suitable bone substitute in small bone defects and it is a valuable completion to the autogenic bone graft in large defects. In disadvantageous bone bed Pyrost has to be augmented with bone marrow and in large segmental defects the combination with autogenic bone grafts is recommendable. Presupposition for the application of bone substitutes like Pyrost in large defects is a sufficient primary stability of the bone bed. The application in infected tissue is not favorable.

[An ultrasound hip screening program--middle term results of flexion-abduction orthosis therapy]. / Aus einem hüftsonographischen Screeningprogramm--Mittelfristige Ergebnisse nach Spreizhosentherapie.

INTRODUCTION: Today the hip sonography is an established method to detect congenital hip maturation disturbances in the first days of life. Short-term follow-ups have showed that mature hip joints can be performed with an flexion-abduction bandage within a few months. METHODS: This prospective study reviews in a middle-term follow up 57 dysplastic hips at birth of 42 children after an average period of 7.8 years, who took part in an ultrasonic hip screening and were treated successfully with an abduction pant (33 hips type IIg, 16 hips type D, 8 hips type III according to Graf). RESULTS: There were only 3 cases (5%) who had slight limitations of motion clinically according to the classification of Tönnis. The radiographic control showed an average AC-angle of 11 degree, an average CE-angle of 28 degree and an average hip-score according to Tönnis of 8.5. Slight radiological deviations were found in 9% of the cases. Severe pathologic radiographic appearance or avascular necrosis of the femoral head were not observed. CONCLUSIONS: If DDH is detected in first day of life and immediately treated with abduction pants is physiological development of the hip probably.

Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of the literature, and discussion of possible biological pathways involved.

Spontaneous remission of cancer (SR) is defined as a complete or partial, temporary or permanent disappearance of all or at least some relevant parameters of a soundly diagnosed malignant disease without any medical treatment or with treatment that is considered inadequate to produce the resulting regression. We report the case of a 61-year-old man who presented with extensive metatastic disease five months after pneumonectomy for poorly differentiated large cell and polymorphic lung cancer. A vast metastatic tumour mass of the abdominal wall was confirmed histolologically and there was clinical and radiographic evidence of liver and lung metastases. Eight months later, the patient was operated on for a hernia, which had developed in the inguinal biopsy scar and the surgeon confirmed complete clinical SR of the abdominal wall metastases. Again five months later there was no longer any radiologic evidence of liver and lung metastases. Complete remission has persisted more than five years. Histology of the primary and of the abdominal metastases were reviewed by several independent pathologists. SR is an extremly rare event in lung cancer. This is the first documented case of clinically evident visceral metastases of a bronchiogenic adenocarcinoma developing after complete resection of the primary and then showing complete SR. The epidemiology of SR is reviewed and possible mechanisms involved in SR are discussed.

Radiographic course after acetabuloplasty and femoral osteotomy in hip dysplasia.

The radiographic course of 101 hips with residual dysplasia treated with roof plasty combined with intertrochanteric varus derotation osteotomy using the osteotomy wedge as a roof graft after Mittelmeier were reviewed. The average followup period was 8.8 years. The acetabular angle was improved by an average of 16 degrees (postoperative mean, 19 degrees; average at followup, 18 degrees). The center edge angle also was improved by 16 degrees and was stable at 25 degrees average at followup. The neck shaft angle, abnormal in 70% of hips preoperatively, was reduced by the varus osteotomies to a mean of 111 degrees and showed a spontaneous postoperative increase to normal values of an average of 129 degrees. There was no correlation of the postoperative of the neck shaft angle to patient age, preoperative valgus extension, correction angle, or length of followup. In nearly all cases, an almost anatomic joint shape was achieved. With a complication rate of only 1%, especially regarding the rate of necroses of the femoral head, the presented surgical technique can be recommended as highly effective, reliable, and safe for the treatment of congenital hip dislocation.

[Lymph- and haemangiosis carcinomatosa--an important prognostic factor in non-small-cell bronchial carcinoma (NSCLC)]. / Lymph- und Haemangiosis carcinomatosa--ein wichtiger Prognosefaktor beim nicht-kleinzelligen Bronchialkarzinom (NSCLC).

Between 1 Jan 1984-1 Jan 1990, 199 patients underwent curative (R0) surgery for non-small cell lung cancer. The pathohistological findings showed that a carcinomatous lymphangiosis and haemangiosis (L/H pos.) were present in 26 patients. In six patients, no lymph node metastases were detected. The median (22 mo. vs. 74 mo.) and 5-year survival (25% vs. 41%) were significantly (p < 0.001) higher compared to patients with and without lymphangiosis and haemangiosis carcinomatosa (L/H neg.). There were also significant (p < 0.05) differences in the survival time between pNO L/H neg. and pNO L/H pos. patients (median 74 mo. vs. 15 mo.-5 years 43% vs. 0%).

Combined acetabuloplasty and varus derotation osteotomy in congenital dislocation of the hip. Long-term results.

Twenty-two patients (33 hips) with congenital dislocation of the hip were examined at an average of 26 years after combined acetabuloplasty and intertrochanteric varus derotation osteotomy. Seventeen patients had no problems despite physically demanding jobs and sporting activities in some cases. The CE angle was improved to the lower end of the normal range. The shaft-neck angle was corrected by 31 degrees to 120 degrees. Restoration to the normal valgus subsequently occurred and we found no evidence of subcapital coxa valga. Although there was an increase in the neck epiphysis angle 5 years after operation indicating a horizontal shift in the epiphyseal plate, most cases had normal hip joints. The incidence of postoperative avascular necrosis of the femoral head was 6%, and we found no increase in femoral deformities. Our long-term results show that the combination of acetabuloplasty and femoral osteotomy has no disadvantages, and is the best way of achieving optimal centring of the femoral head and stabilisation of the hip.

[The reduction of the extent of vascular lesions during angioplasty by the use of a sheath]. / Reduktion des Ausmasses von Gefässläsionen im Rahmen der Angioplastie bei Gebrauch einer Schleuse.

PURPOSE: To document the protection of the vessel using an introducer sheath. MATERIAL AND METHODS: In eleven in situ specimens we compared in the inguinal vessel the macroscopic and histologic trauma to the vascular wall during antegrade percutaneous balloon dilatation either without or with a sheath. RESULTS: Significant differences we observed regarding both the puncture site configuration and the puncture hole border, which were evaluated macroscopically. During the histological assessment we found only small intimal trauma in the puncture track in the group where a sheath had been used. Severe intimal damages and the media showed tears if no sheath had been used (100/36% vs. 0/64%). CONCLUSION: It is evident that using a sheath during angioplasty reduces the risk of intimal damage and, consequently, of complications such as recurrent haematoma, stenosis at the puncture site or formation of aneurysms due to the puncture.

[Primary stability of autologous and heterologous implants for intervertebral body spondylodesis]. / Die primäre Belastbarkeit autologer und heterologer Implantate für die interkorporelle Spondylodese.

In this study, we tested the stability of the xenograft SURGIBONE and of human iliac crest graft depending on the donor's bone density. The mean load bearing capacity of SURGIBONE was 4816 N, the compressive strength 32.8 N/mm2. This even exceeds the values given by the producer. Yet in clinical use the material caused problems by collapses or lysis of the graft. According to our results, those failures can not be explained by missing primary stability. Perhaps there is a immunogenic reaction of the host against the remaining protein as it once was proved for the "kielspan"-graft. The iliac crest grafts of donors with normal bone density had a load bearing capacity of 3397 N. Grafts of donors with reduced bone density of less than 60 mg/ml Ca-Equivalent showed reduced load bearing capacities of 2265 N. DEXA (Dual-Energy X-Ray Absorptiometry) seems to be suitable to scan preoperatively the iliac crest graft stability in order to recognize the danger of reduced stability by osteoporosis.

[Ischemia of the extremity as a rare complication of alloplastic joint replacement]. / Extremitätenischämie als seltene Komplikation nach alloplastischem Gelenkersatz.

Two cases of extremity ischemia after alloplastic knee and hip joint replacement are presented. In both cases early operative intervention led to complete recovery. The mechanisms of iatrogenic vascular injury following arthroplastic operations on the hip and knee joint are demonstrated. In particular, the importance of preexisting vascular occlusive disease is stressed. Diagnostic procedures and implications for treatment are discussed.

[Development assessment of a hip ultrasonographic screening program for the early diagnosis of congenital hip dysplasia at the orthopedic university department Homburg/Saar from 1986 to 1990]. / Verlaufsbeobachtung eines hüftsonographischen Screeningprogrammes zur Früherkennung angeborener Hüftreifungsstörungen an der Orthopädischen Universitätsklinik Homburg/Saar im Zeitraum von 1985 bis 1990.

The results of the hip ultrasound newborn screening at the orthopaedic department of the University Hospital Homburg/Saar underline the necessity of an early diagnosis of Hip dysplasia already during the first days of life. In the course of the following publication the benefit of using abduction-pants in case of physiological unripe and primary pathological hips is described closely. From October 1985 to December 1990 2317 newborns have been examined by ultrasound. The rate of Hip Dysplasia (type IID, IIg, IIIa) was at 104 hips (2.2%). Clinical striking facts were only found in 46.3% of all patients with primary pathological hips. After an precautionary broad swadling (Breitwickeln) or abduction-pants-treatment 331 (90.0%) hips of the 368 regular checked hips with type IIa developed with an average secondary anatomical healing of 2.5 months to Ia- or Ib-hips. After 3 months only just 12 hips corresponded to a diagnosis of type IIb according to Graf. A deterioration to a IIg or IIIa hip was only ascertained in two cases. With all 41 sufficiently controlled primary pathological hips an improvement to type Ia or Ib according to Graf achieved when treated with abduction pants (average duration of treatment: 4.3 months). None of the children had to undergo an operation because of instable hips.

[Medium-term results of cement-free autophor hip endoprosthesis]. / Mittelfristige Ergebnisse der zementfreien Autophor-Hüftendoprothese.

Representation of middle-term observations of cementless ceramic THR (type Autophor) in a period of now nearly 18 years with altogether 1974 primary arthroplasties. The design of the conical shaped screwed ceramic socket proved to be very successful, its aseptic loosening rate amounted to 1.8% at last. We could confirm the favourable biocompatibility and wear behaviour of ceramic/ceramic joint pairing. The stem design had to be improved twice during the observation period due to upcoming aseptic loosening problems; the femoral component 900 S with macro- and microprofile, which has been in clinical use since 1984, shows an aseptic failure quote of less than 2% after 8 years. The very low average age of our patients with cementless THR at time of operation (48.9 years) proves, that--when using wear resistant biomaterials and surface enlarged prosthetic components to be implanted without bone cement--Charnley's strict age indication of THR may be abandoned.

[Cushing syndrome in a neuroendocrine pancreatic tumor. Clinicopathologic case report]. / Cushing-Syndrom bei einem neuroendokrinen Pankreastumor. Klinisch-pathologischer Fallbericht.

A 59-year-old female patient with mild clinical features of a Cushing syndrome underwent surgery for a suspected hormonally active tumor of the left adrenal gland. Surprisingly, the adrenal gland was unremarkable, however, a tumor in the pancreatic tail was found. A left pancreatic resection with splenectomy resulted in curative removal of the tumor. The pathohistological examination of the tumor established the diagnosis of an ACTH-producing pancreatic carcinoid. Morphology and pathogenesis of pancreatic carcinoids which are tumors of the APUD-cell-system are discussed in detail.

Sixteen-years' experience with ceramic hip prostheses.

The introduction of alumina ceramic combined with the self-locking principle by surface increase has many followers. There is no manufacturing company in the world that does not produce self-locking hip prostheses with ceramic components. Despite increased interim results with conventional prostheses by improved cement technique, the self-locking principle with wear resistant ceramic components is better, at least in young, active patients.

[Comparative biomechanical studies of conventional and self-tapping cortical bone screws]. / Biomechanische Vergleichsuntersuchungen über herkömmliche und selbstschneidende Kortikalisschrauben.

In normal cortical screws the thread must be cut by a separate thread-cutter. So a high stability of the connection is achieved. On the other hand thread cutting needs time, which may be assumed to several minutes during a plate osteosynthesis. To avoid thread-cutting, self-tapping screws were used 20 years ago. These old self-tapping screws had a reduced stability and a lower torque at the final screw driving so that they tended to destroy the thread. By a modification of the cutting edges at the tip of the screw the tapping quality is increased decisively. The microscopic examination showed a better cutting of the new screws with little difference to a thread-cutter. In biomechanical tests the final torque and the maximum tension force of the self-tapping screws were at the same level as in usual pre-cut screws. In the practical use the new self-tapping screws have a good handling and save time during operation. In osteoporosis, they should be used carefully in order to meet the opposite corticalis' hole and not to destroy the ipsilateral corticalis' thread.

[Hip surgery in early childhood]. / Hüftchirurgie im Kleinkindesalter.

Congenital dysplasia of the hip after conservative treatment does not always lead to satisfactory results. Remanent hip dislocation causes severe problems for the gait and static of the vertebral column. Here surgical treatment in early childhood (open reduction, intertrochanteric osteotomy and roof plasty, may produce an essential improvement, even if for a long term arthritis may be expected. But nowadays we have satisfactory techniques of arthroplasties with wear resistant ceramic selflocking prostheses for these cases. Besides on the CDH valuable surgical methods are available also in other hip diseases in early childhood (myelodysplasia, Perthes, cerebral palsy). Indication and surgery need special experience.

[Cause, prognosis and therapy of tibial pseudarthroses]. / Ursache, Prognose und Therapie von Tibiapseudarthrosen.

A report on surgical treatment of 75 pseudarthroses of the tibia, 64 cases of which could be followed up for assessing the treatment results. The majority of these were pseudarthroses due to infection or associated with atrophy, that is to say, cases that were difficult to treat. Stabilization was usually effected by osteosynthesis with autocompression plates; in the majority of cases autologous bone grafts were performed additionally. In 82.8% of the cases cure of the pseudarthrosis was achieved, in 68.8% already by first surgery. 7.8% of the patients refused further surgical treatment. 9.4% are still under treatment at the time of writing.

["Elastic osteosynthesis" with autocompression plates of carbon fiber reinforced thermoplastic material]. / "Elastische Osteosynthese" mit Autokompressionsplatten (ACP) aus kohlefaserverstärktem thermoplastischen Kunststoff.

The problem of atrophic bone that occurs in osteosynthesis employing rigid plates is first depicted. Attempts at fabricating "simirigid" plates, which, however, have so far failed to gain any practical importance are then discussed. The reason for this seems to be that made of duroplastics cannot be molded during the operation and the thermoplastics do not have sufficient strength. The production of semirigid plates made of thermoplastic Polyethersulfon (PES), reinforced with 20% short carbon fibres, results in plates which are made moldable by heating in a small oven, white retaining sufficient static strength, although only limited fatigue strength. Biomechanical examinations revealed that with appropriate dimensioning of the plates, "elastic osteosynthesis" results in less loss of mechanical function of the stabilized bones, so that less atrophy of the bone may be expected. During more pronounced exercise loading, a reversible "springiness" of the fracture results, which might stimulate callus formation and improved stability.

[Spongiosa formation in plate osteosynthesis--a comparative animal experiment study of current and auto-compression plates using the Zespol principle]. / Die Spongiosierung bei der Plattenosteosynthese--vergleichende tierexperimentelle Untersuchung zwischen herkömmlichen und nach dem Zespol-Prinzip funktionierenden Autokompressionsplatten.

Osteosynthesis with modern self-contracting plates has a few fundamental drawbacks apart from its undisputably good points. Among these drawbacks we have the pressure strain on the bone surface; the traction strain exercised by the screw thread in the bone; and, chiefly, spongiotisation and bone atrophy due to so-called stress protection. A new modification of this process, called Zespol, in which the plate is no longer fastened direct to the bone but is fastened floating over the bone surface to so-called platform screws, tries to solve these problems. In a comparative animal experiment tibial transverse osteotomies in the rabbit were treated by osteosynthesis using small fragmentary ACP and Zespol plates. In respect of healing of the fracture none of the two methods showed any advantage. Histological evaluation of the plated bone sections were characterised in both plate systems by increasing spongiotisation and bone atrophy that increased with the length of application. Degradation processes were about equal with both systems. A special feature with the Zespol animals was that the cleft originally existing between the plate and the bone was filled up with newly formed spongy and later cortical bone. Due to this process the original cortex layer lost its function and atrophied severely. After 12 to 18 weeks the bone surface had reached the lower side of the Zespol plate and there was contact by touch. This restored similar biomechanical conditions as those existing in conventional plates after this period.

[Initial clinical experiences with low molecular weight heparin in the prevention of thrombosis in orthopedic surgery]. / Erste klinische Erfahrungen mit niedermolekularem Heparin bei der Thromboseprophylaxe in der orthopädischen Chirurgie.

This is a report on almost 10 years of experience with heparin prophylaxis in orthopaedic surgery, especially on the changeover from the high molecular heparin dihydergot used previously, to the low molecular heparin dihydergot (Embolex) while changing over at the same time from the previously well-tried and successful postoperative initiation of treatment to preoperative start of prophylaxis. Compared with the period before prophylaxis (1965-1977) with 24 fatal pulmonary embolisms, no fatal pulmonary embolisms have occurred in our hospital since prophylaxis was introduced (1978). Changeover to low molecular heparin with only one instead of three injections daily was fundamentally welcomed although preoperative onset of prophylaxis involved a considerable rise in afterbleeding complications. Hence we recently adopted the procedure of conducting prophylaxis with low molecular heparin (as was done previously with success using high molecular heparin) postoperatively; this resulted in a dramatic reduction of bleeding complications while protection against thrombosis is obviously clinically satisfactory. Postoperative initiation of prophylaxis is therefore recommended in case of major orthopaedic surgery.