Traction radiography for the diagnosis of scapholunate ligament tears.

The diagnosis of scapholunate ligament injury by traction radiography was investigated within a consecutive study. The right wrists of 25 healthy volunteers and 22 wrists with arthroscopically proven complete scapholunate ligament tears were examined. Traction radiography was performed under fluoroscopy with a force of 5 kg applied to the thumb. In the normal wrists, this led to selective widening of the scapholunate joint space whereas the lunotriquetral distance remained unchanged. In 25 healthy right wrists, the median scapholunate distance measured 2.1 (range 1.3-2.6) mm on resting radiographs and 2.2 (range 1.7-3.5) mm on the stress radiographs. For the 22 wrists with complete scapholunate ligament tears, the median scapholunate distance was increased from 2.0 (range 1.0-3.0) mm to 3.8 (range 3.0-5.5) mm by traction (median difference of 1.8 (range 1.0-3.0) mm). In conclusion, a scapholunate distance of 3.0 mm or more in unloaded wrists or widening of the scapholunate interval by 1.0 mm or more under thumb traction should both be considered as pathological findings. We recommend traction radiography as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury.

Detection of differential gene expression in human osteoblastic cells by non-radioactive RNA arbitrarily primed PCR.

The aim of the present study was to detect differentially expressed genes in the human osteoblast-like osteosarcoma cell line SaOS-2 using non-radioactive RNA fingerprinting (RNA arbitrarily primed polymerase chain reaction, RAP-PCR). RNA was isolated at different time points from SaOS-2 cells grown with and without dexamethasone (DEX). By RAP-PCR we detected changes in band patterns of cells treated with DEX compared with untreated cells. PCR fragments further characterized and sequences from three of these gave perfect matches to the coding sequences of the human nucleophosmin gene B23, cDNA clone 4_c6 from P1 H25 and the human TRA1 gene, respectively. differential regulation of these genes in DEX-stimulated SaOS-2 cells could be demonstrated by RT-PCR.

Bioengineered human bone tissue using autogenous osteoblasts cultured on different biomatrices.

Surgical treatment of critical-size posttraumatic bone defects is still a challenging problem, even in modern bone and joint surgery. Progress in cellular and molecular biology during the last decade now permits novel approaches in bone engineering. Recent conceptual and technical advances have enabled the use of mitotically expanded, bone-derived cells as a therapeutic approach for tissue repair. Using three different tissue carrier systems, we successfully cultivated human osteoblasts in a newly developed perfusion chamber. We studied cell proliferation and the expression of osteocalcin, osteopontin, bone morphogenetic protein-2A, alkaline phosphatase, and vascular endothelial growth factor as parameters for osteoblast function and viability. Adherence of highly enriched human osteoblasts had already started after 1 h and resulted in completely overgrown human bone pieces after 10 days. Expression analysis of bone-specific alkaline phosphatase indicated differentiating osteoblasts, whereas the high mRNA expression of osteocalcin and osteopontin revealed terminally differentiated osteoblasts and the process of mineralization. Additionally, gene expression was significantly higher when demineralized bone was used as biomatrix, compared to autoclaved bone and hydroxyapatite ceramics. We conclude that with our newly developed perfusion culture system, vital autogenous bone implants of clinically applicable size can be generated within 17 days in order to manage critical-size bone defects.

Posterior atlanto-occipital dislocation and concomitant discoligamentous C3-C4 instability with survival.

STUDY DESIGN: A case report is presented. OBJECTIVES: To describe the diagnostic procedure, treatment, and outcome of a 56-year-old man with posterior atlanto-occipital dislocation and concomitant discoligamentous C3-C4 instability. CASE REPORT: A 56-year-old male seat-belted driver of a car was involved in an accident. After initial spontaneous breathing and weak movements of all his extremities, artificial respiration became necessary because of increasing respiratory insufficiency. Radiologic diagnostics, including computed tomography scans, showed a posterior atlanto-occipital dislocation and a Grade 2 craniocerebral trauma with occipital subarachnoidal bleeding. Further examination showed a serial rib fracture with concomitant hemopneumothorax. After stabilization of the patient, magnetic resonance imaging of the cervical spine showed a contusion of the upper cervical spinal cord. Additionally, rupture of the interspinal ligaments and the posterior longitudinal ligament could be seen, as well as a rupture of the intervertebral C3-C4 disc. Operative stabilization was performed by posterior fusion of C0-C4 using the CerviFix-System and autogenous bone grafts taken from the iliac crest. At 12 months after the operation, the patient had only slight weakness of the left arm and a 70% limitation in the range of motion of the cervical spine. CONCLUSIONS: With improvements in advanced trauma life support, the number of patients with atlanto-occipital dislocation admitted to hospital alive is increasing, so this particular lesion must be kept in mind. When the patient survives the accident, the long-term prognosis is quite good, with a high rate of recovery after initial neurologic deficits.

Acromioclavicular reconstruction augmented with polydioxanonsulphate bands. Surgical technique and results.

During a 5.5-year period, we treated 64 patients with acute acromioclavicular separations by surgical reconstruction. According to the classification of Rockwood and Matsen, 54 patients had type III lesions, 1 patient had a type IV lesion, and 9 patients had type V lesions. Both the coracoclavicular ligaments and the ligaments of the acromioclavicular joint were reconstructed. An additional ligamentous augmentation was performed using completely resorbable 5- and 10-mm polydioxanonsulphate bands. Forty-five patients (70%) were re-examined at 2 to 7.5 years after surgery (mean, 32 months). The results were good or excellent in 40 cases (89%). Forty-one patients (92%) achieved a range of motion with an abduction deficit of less than 20 degrees. Calcifications in the area of the coracoclavicular or acromioclavicular ligaments did not affect the final range of motion. Complications consisted of one subcutaneous infection, one deep infection, and one failure of the reconstruction. Augmenting the reconstruction with polydioxanonsulphate bands allowed an early functional postoperative treatment. With this procedure, patients do not require removal of an implant, and complications from breakage or migration of metal implants are avoided.

[A simple device for examination of the ankle joint (author's transl)]. / Eine einfache Vorrichtung für gehaltene Aufnahmen des oberen Sprunggelenks.

Ligamentous injuries of the ankle joint can be demonstrated radiologically by special techniques using lateral and A.P. projections. A device is described for obtaining the requisite views. It enables accurate projections to be achieved and a standardised technique is assured by applying a pull of constant weight. The problem of muscle spasm, resulting as a reflex from pain, is discussed.

Technique of using the AO-femoral distractor for femoral intramedullary nailing.

Immediate closed interlocking intramedullary (IM) nailing of femoral shaft fractures in polytraumatized patients using the fracture table may be difficult due to concomitant adjacent injury. We report on the technique of using the AO-femoral distractor for femoral IM nailing and our experience with 56 consecutive cases of IM nailing of the femur. The AO distractor is an alternative to the traction table. Unlike the latter, it does not rely on intact adjacent structures to distract the main fragments. Schanz screws are placed into the femur condyle and into the lesser trochanter. The fracture is distracted and reduced by manipulating the mobile elements of the device. The femur is aligned and stabilized while reaming and nailing commence. Between April 1988 and June 1992, 56 IM nailings were performed using the AO distractor for reduction: 41 for acute unstable fractures and 15 for corrective procedures. In 11 of 15 polytraumatized patients, the fractured femurs were nailed immediately. Intraoperatively, the distractor greatly facilitated fracture reduction and presented no problems for proximal or distal interlocking. Intraoperative complications included two fracture extensions during nailing and three rotational malalignments over 15 degrees. One nonunion occurred; otherwise, all fractures were considered healed within 16 weeks. No postoperative nerve palsies were recorded, and no infection occurred. Based on our experience, we believe that the AO distractor is a suitable alternative to the traction table as a distraction and reduction device and can be implemented in all nailing cases. We particularly recommend its use in polytrauma cases in which concomitant injury precludes the initial use of the fracture table.

External patellotibial transfixation: indications, operative technique and outcome.

Patellotibial transfixation with the MPT fixator is a new method of external stabilisation for lesions of the extensor mechanism of the knee joint. The biomechanical principle is the external transmission of tensile forces in the quadriceps muscle from the patella to the lower thigh and the translation of these forces into extension of the knee joint. The construction is an external patellotibial frame. In fitting method A, a Steinmann pin with central thread is inserted transversely through the patella and proximal tibia. Connection is made via laterally positioned rods with rotatable fixator jaws. In fitting method B, a Schanz screw is inserted sagittally into the proximal tibia and connected to the tibiocentral fixator jaw. In the frame construction a threaded pin is tightened into the fixator jaw. The MPT fixator is mostly used to secure suture repairs and transosseous refixations of the patellar ligament, or to reconstruct neglected patellar tendinous or osseous lesions of the distal extensor apparatus when functionally stable results cannot be obtained by osteosynthesis. The advantages of patellotibial transfixation are that: (1) a minimum of internal allogenic material is required to reconstruct the extensor apparatus and the repair is protected against excessive strain; (2) immediate functional post-operative therapy with an unlimited range of motion and early full weight-bearing is possible. Between 1990 and 1997 the MPT fixator was here used on 74 patients, 51 of whom had an acute lesion of the extensor mechanism, 19 lesions had either been neglected or subjected to an earlier operation. Among 20 of the acutely injured knee joints there were other serious associated injuries. Fitting method A was used in 48 patients and fitting method B in 26 patients. In four patients the operation was followed by severe infection, owing to the fixator in two cases. The remaining 70 patients wore the system for an average of 7.3 weeks. Eight patients with caudal comminuted fractures who had had segmental patellectomy and transosseous refixation of the patellar tendon and 15 patients who had had transosseous suture refixation of the patellar ligament after rupture at the lower pole or suture repair after intraligamentous rupture, were followed up isokinetically and radiologically with IKDC scoring for an average of 49.3 months after the operation. The outcome was classified as normal or close to normal in 19 patients and as abnormal in four. Isokinetically only five of the 23 had a 10-20% deficiency in the strength of the extensor muscles of the operated leg in comparison to the opposite side. External patellotibial transfixation with the MPT fixator produced good operative results in re-establishing the continuity of the distal extensor apparatus of the knee joint and is an effective alternative to patellotibial cerclage with wire or synthetic ligament.

MRI versus arthroscopy in the diagnosis of scapholunate ligament injury.

In a prospective study 103 patients with clinically or radiologically suspected tears of the scapholunate interosseous ligament were investigated with magnetic resonance imaging (MRI) and wrist arthroscopy. MRI was performed with the conventional technique in 72 cases and after intravenous injection of contrast medium in the remaining 31 patients. The correct diagnosis was made by MRI in 75% of cases and its overall sensitivity and specificity were 63% and 86% respectively. There was no statistical difference in the accuracy of MRI for acute or chronic tears and the use of intravenous contrast medium did not improve its accuracy. In conclusion, MRI is not recommended for the diagnosis of scapholunate ligament injury.

[Rupture of the anterior cruciate ligament in the athlete]. / Die Ruptur des vorderen Kreuzbandes beim Sportler.

Athletic trauma is the main cause for rupture of the anterior cruciate ligament (ACL). In order to regain joint stability and return to unrestricted sports activities operative management is indicated. The patella tendon autograft with bone plugs on each end is presently the most commonly used graft to reconstruct the ACL. The concept of synthetic augmentation was developed for protection of the biological tissue during revascularization and remodeling. We use as augmentation device the TETRA-L3, which is a 3-mm-wide and 1-mm-thick Trevira braid. The function of the composite graft, which is sufficiently strong to allow early stress, is based on the principle of load-sharing. Isometric placement of the graft without impingement is achieved by using the miniarthrotomy technique and specially designed drill guides. Graft fixation is performed with ligament staples. An accelerated rehabilitation program emphasizing full extension and weight bearing follows. The total rehabilitation program we recommend--preoperative rehabilitation, a reliable surgical procedure, postoperative rehabilitation, and the patient's return to activity--is a team effort. A detailed follow-up evaluation of 41 athletes with ACL reconstruction using a central patellar BTB graft and synthetic augmentation with the TETRA-L3 showed that restoration of stability (KT 1000 testing, maximum manual excursion, < 3 mm difference) and full ROM, muscle strength and power (> 85% of the uninvolved knee) and functional capacity (Hop index > 90%) are the main prerequisites for sports activities at the desired level.

[Progress in external fixation]. / Fortschritte in der externen Stabilisierung.

The monofixateur opens up avenues in external skeleton fixation. Proceeding from Lambotte's groundwork and from the given anatomical conditions and biomechanical requirements, a system has been developed that ensures maximum effectiveness with a minimum of mechanical means and operative procedure. Of particular importance is the dual-application feature of the monofixateur system: it is equally indicated for static as well as dynamic fixation, and is quickly and easily adapted from one function to the other at any time as called for by the treatment process. This system provides for dynamic function when applied without fixation clamping jaws on one of the major bone fragments. It allows for functional axial compression to be exerted through muscle contraction and pressure, while simultaneously excluding the possibility of bending and rotation, thus effectively promoting the healing process. The monofixateur is indicated for treatment of closed, open and infected fractures, pseudarthrosis, osteotomy adaption, arthrodesis and joint transfixations. In brief, the advantages of external fixation by the monofixateur may be summarized as follows: Simple mechanical design affording precise function. High stability with small number of fixation components. Unilateral assembly of device in position biomechanically favorable. Static or dynamic fixation. Little patient impairment.

[The bone bank--a standardized procedure? Results of a federal survey of German surgical clinics]. / Die Knochenbank--ein standarisiertes Verfahren? Ergebnisse einer bundesweiten Umfrage an deutschen chirurgischen Kliniken.

An inquiry at German surgical departments about their bone bank techniques showed that 45% of clinical hospitals use allogeneic bone implants among other implants. In 1989, the year of the official survey, allogeneic bone was transplanted about 6000 times in these clinical hospitals. Despite of this high transplantation frequency important differences turn out regarding selection and testing of recipients, transplantation storage and treatment. A lot of clinical hospitals do not perform important donor examinations inspite of proven transmission risks of bacterial and viral diseases by deep frozen bone. A trend analysis shows that despite of the risk of an HIV-transmission and the resulting difficulties in the logistic of the bone bank, the transplantation frequency allogeneic bone stays constant. The official surveys prove the large range of bone bank techniques and should give rise to make efforts to take note of the recommendations for bone banking techniques.

[Medullary reaming in chronic osteomyelitis of the stable femur and tibia shaft]. / Die Markraumaufbohrung bei chronischer Osteomyelitis des stabilen Femur- und Tibiaschaftes.

Ten patients with chronic osteomyelitis of the femur or tibia shaft without bone instability were operated by intramedullary reaming. All patients but one had previous surgery, up to 12 operations with the average duration of the disease 10.5 years. After intramedullary reaming all patients received systemic antibiotics for 8 days and in 6 cases the intramedullary cannal was filled with gentamicin-PMMA chains which were removed in local anaesthesia 10 days after surgery. Eight patients who had severe pain at rest were promptly relieved by the operation. In 3 cases of chronic fistulation only one exacerbation was seen. This was because of insufficient reaming, the patient was subsequently reoperated with reaming from a distal approach. During the observation periode from the month 12 to 32 in no case was there a recurrence of pain or infection.

[Thromboembolism complication in multiple trauma patients: an underestimated problem? Results of a clinical observational study of 50 patients]. / Thromboembolische Komplikationen bei mehrfachverletzten Patienten: ein unterschätztes Problem? Ergebnisse einer klinischen Beobachtungsstudie mit 50 Patienten.

INTRODUCTION: The incidence of thromboembolic complications in patients with severe polytrauma in the ICU is not well known. Only a few publications deal with this problem. Systematic investigations in this high-risk patient group are not routinely used. METHOD: From January 1996 to January 1998, 50 polytrauma patients with a mean ISS > 15 were included in a clinical study to evaluate the incidence of thromboembolism in this patient group. Further inclusion criteria were a minimum stay of 72 h in the ICU and mechanical ventilation for a minimum time of 72 h. All patients were examined with color-coded duplex sonography according to a standardized protocol. The duplex sonography was performed before the patients were first mobilized in the ICU (15 +/- 12.8 days). RESULTS: If not otherwise indicated all values are given as mean +/- SD. The age of the patients was 38 years (range 17-77 years), the severity of trauma was characterized by an ISS of 40 (range 16-70). Eight of the included patients died during their stay in the ICU after developing a multiple organ failure. According to autopsy data none of them had a deep venous thrombosis or pulmonary embolus. Eight patients (19%) developed deep venous thrombosis, and 4 patients with thrombosis developed pulmonary embolism. CONCLUSION: The incidence of deep venous thrombosis in polytrauma patients seems to be much higher than expected reviewing the results of other publications. The low detection rate of other authors results from using only clinical signs. The routine use of color-coded duplex sonography is effective in detecting unsuspected deep vein thrombosis.

[Impalement injury of the colon, iliac vein and sacrum--a rare combination in penetrating abdominal trauma. A case report]. / Pfählungsverletzung von Colon, Vena iliaca und Kreuzbein--Eine seltene Kombination bei penetrierendem Abdominaltrauma. Eine Fallbeschreibung.

We report on the treatment of a patient who sustained a penetrating abdominal wound with injury of the left common iliac vein, the sigmoid colon and the sacrum in a motorbike accident. The left iliac vein injury was treated using a Gore-Tex vein patch and an A-V fistula. The colon was restored after an intraoperative washout. The punched fragment of the sacrum was removed. An additional fracture of the proximal left humerus was managed with an osteosynthesis in a second operation. The principles of management of combined colon and vascular injuries are discussed and a short review of the literature is given.

[Quality management and strategic consequences of assessing documentation and coding under the German Diagnostic Related Groups system]. / Die Vidierkonferenz. Qualitätsmanagementmassnahme zur Sicherstellung der Dokumentations- und Kodierqualität.

INTRODUCTION: The introduction of the German Diagnostic Related Groups (D-DRG) system requires redesigning administrative patient management strategies. Wrong coding leads to inaccurate grouping and endangers the reimbursement of treatment costs. This situation emphasizes the roles of documentation and coding as factors of economical success. PURPOSE: The aims of this study were to assess the quantity and quality of initial documentation and coding (ICD-10 and OPS-301) and find operative strategies to improve efficiency and strategic means to ensure optimal documentation and coding quality. METHODS: In a prospective study, documentation and coding quality were evaluated in a standardized way by weekly assessment. RESULTS: Clinical data from 1385 inpatients were processed for initial correctness and quality of documentation and coding. Principal diagnoses were found to be accurate in 82.7% of cases, inexact in 7.1%, and wrong in 10.1%. Effects on financial returns occurred in 16%. Based on these findings, an optimized, interdisciplinary, and multiprofessional workflow on medical documentation, coding, and data control was developed. CONCLUSIONS: Workflow incorporating regular assessment of documentation and coding quality is required by the DRG system to ensure efficient accounting of hospital services. Interdisciplinary and multiprofessional cooperation is recognized to be an important factor in establishing an efficient workflow in medical documentation and coding.

[Computed tomography for the assessment of posterior pelvic injuries in patients with isolated fractures of the pubic rami in conventional radiography]. / Häufigkeit hinterer Läsionen bei vorderen Beckenringfrakturen Ergebnisse der Computertomographie bei der Erstdiagnose "isolierte vordere Beckenringfraktur" im konventionellen Röntgenbild.

To investigate the incidence of occult posterior injuries of the pelvic ring in patients with isolated fractures of the pubic rami, additional computed tomography (CT) was performed. Data from 70 patients were collected within a prolective study. Solitary fractures of the anterior pelvic ring based on conventional radiographic diagnosis were included. Spiral CT, slice thickness 5 mm, was carried out in all patients. In only 47% of cases was the diagnosis of isolated fractures of the pubic rami confirmed. A further 35 fractures of the sacrum and two partial disruptions of the sacroiliac joint were diagnosed using CT. All sacral fractures were incomplete, most were found at the anterior part of the bone. Furthermore, CT revealed three acetabular fractures. Dorsal injuries were significantly more frequent after high energy accidents. Clinical examination did not assist in the prediction of posterior injuries of the pelvic ring. There was no correlation between the extent of the anterior injuries in conventional x-ray and incidence of the posterior injuries in CT. None of the patients with dorsal injuries underwent operative treatment. In conclusion, CT is not required for the routine diagnosis of supposed isolated fractures of the pubic rami.

Knee arthrodesis with a unilateral external fixator.

The operative fusion of the knee joint remains a valuable technique in posttraumatic and infectious destruction of the knee. External fixation is the technique of choice. Due to the benefits of the monofixator in regard to stability, limited damage of soft tissues and high patient comfort, arthrodesis of the knee joint using an anteriorly placed unilateral external fixator is the procedure routinely used at our institution. From 1985 to 1994, 19 knee arthrodesis procedures were performed with a monofixator. Indications for operative fusion of the knee were an infectious destruction of the joint following osteosynthesis (tibial plateau) in 12 cases, posttraumatic arthrosis of the knee joint with chronic infection in 4 cases, flexion ankylosis of the knee in 1 patient, and destructive osteoarthritis of the knee complicated by an empyema in one case. In one patient, a rearthrodesis was performed for a non-union, following an arthrodesis attempt for infected knee arthroplasty. In all cases, stable fusion of the knee joint in a correct position with complete eradication of infection was obtained. Mean fixation time was 22 weeks. The fixator did not need to be removed prematurely.

Reconstruction of complete acromioclavicular separations (Tossy III) using PDS-banding as augmentation: experience in 64 cases.

Sixty-four patients with an acute type Tossy III acromioclavicular separation were treated surgically. Both the coracoclavicular ligaments and the ligaments of the acromioclavicular joint were reconstructed. An additional ligamenteous augmentation was performed, using completely resorbable 5 and 10 mm PDS bands. Thirty-nine patients (61%) were reexamined (follow-up time 2-45 months, mean 26 months). Results were good to excellent in 77% of cases. In 91% of patients, a range of motion with an abduction deficit of less than 20 degrees was obtained. Calcifications in the area of the coracoclavicular or acromioclavicular ligaments did not affect the final range of motion. Complications consisted of a subcutaneous infection in one case, a deep infection in another patient and one reluxation. PDS banding enables an early functional postoperative treatment. Implant removal is not required. Complications as breakage or migration of metal implants are avoided.

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases.

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.